Technical Writing for Success
3rd EditionDarlene Smith-Worthington, Sue Jefferson
468 solutions
Edge Reading, Writing and Language: Level C
David W. Moore, Deborah Short, Michael W. Smith
304 solutions
Technical Writing for Success
3rd EditionDarlene Smith-Worthington, Sue Jefferson
468 solutions
Technical Writing for Success
3rd EditionDarlene Smith-Worthington, Sue Jefferson
468 solutions
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Elements of Effective High-Performance Team Dynamics
1. Clear Roles and Responsibilities
2. Knowing Your Limitations
3. Constructive Interventions
4. Knowledge Sharing
5. Summarizing and Reevaluating
6. Closed-Loop Communication
7. Clear Messages
8. Mutual Respect
Clear Roles and Responsibilities
Every member should know his/her role and responsibilities.
Resuscitation Triangle Roles
Compressor
AED/Monitor/Defibrillator
Airway
Leadership Roles
Team Leader
IV/IO Medications
Timer/Recorder
Knowing Your Limitations
Know your limitations, team leader should also know your limitations. Ask for advice when unsure.
Constructive Intervention
Leader may need to intervene if action may be inappropriate at the time. It should be tactful. Avoid confrontation.
Knowledge Sharing
Encourage an environment of knowledge sharing. Ask for good ideas for DDX. As if anything has been overlooked.
Summarizing and Reevaluating
Summarize information out load in a periodic update to the team. Review status of resuscitation attempt an announce plans for next steps
Closed-Loop Communications
Give clear
message, orders, or assignments to team members.
Receive clear response from team members
Listen for conformation of response
Clear Message
concise communication spoke with distinctive speech in controlled tone of voice
Mutual Respect
Share a mutual respect for each other and work together
Systematic Approach
-If pt appears unconscious
- Use BLS Assessment for initial evaluation
- Then use Primary and Secondary assessments for more advanced evaluation and treatment
-If patient appears conscious
- Use the Primary Assessment for initial evaluation
BLS Assessment
Check Responsiveness
Shout for nearby help/activate Emergency response/AED/defibrillator
Check breathing and pulse
Defibrillation
Check Responsiveness
Tap and shout "Are you ok?"
Shout for nearby help/activate Emergency response/AED/defibrillator
Shout for nearby help
activate emergency response system
Get and AED if one is available, or send someone to get
one
Check breathing and pulse
Check for absent or abnormal breathing by looking or scanning the chest for monument. for about 5-10 seconds
Pulse check should be performed simultaneously with breathing check to minimize delay in detection of cardiac arrest and initiation of CPR
Check pulse for 5-10 sec
If no pulse within 10 sec begin CPR with chest compressions
If there is a pulse start rescue breathing at 1 breath every 5-6 seconds. Check pulse every 2 minutes
Defibrillation
If no pulse, check for shockable rhythm
Provide shocks as indicated
Follow each show immediately with CPR beginning with compressions
How long do you try to limit interruptions in chest compressions
No longer than 10 seconds
Coronary Perfusion Pressure (CPP)
Aortic relaxation (diastolic) pressure - Right atrial relaxation (diastolic) pressure
ROSC
Return of Spontaneous Circulation
When is ROSC most likely to occur
When CPP of 15 mmHg or greater was achieved during CPR
Chest Compression Concepts
Compression of at least 2 inches
Compress the chest at rate of 100-120/min
Allow compete chest recoil after each compression
The Primary Assessment
Airway
Breathing
Circulation
Disability
Exposure
Airway
Maintain patent airway in unconscious patient using head tilt-chin lift, OPA or NPA
Used advanced airway management if needed
Breathing
Give O2 when indicated
Maintain O2 Sat of 94% or greater
Monitor adequacy of ventilation and oxygenation
Avoid excessive ventilation
Circulation
Monitor
CPR quality
- Quantitative waveform capnography. if PETCO2 <10 mmHg, attempt to improve CPR quality
Attach monitor/defibrillator
Provide defibrillator/cardioversion
Obtain IV/IO
Give appropriate drugs
Give IV/IO fluids as needed
Check glucose and temp
Check perfusion issues
Disability
Check for neuro function
Quickly assess responsiveness, Level of consciousness, pupil dilation
AVPU: Alert, Voice, Painful, Unresponsive
Exposure
Remove clothing to perform a physical exam, looking for obvious sings of trauma, bleeding, burns, unusual markings, or medical alert brackets
Secondary Assessment
involves differential diagnosis, including focused history and search for underlying case.
SAMPLE: Signs/Symptoms, Allergies, Medications, PMH, Last meal consumed, Events
H's & T's
Potential reversible causes of cardiac arrest as well as emergency cardiopulmonary conditions
H's
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/hyperkalemia
Hypothermia
T's
Tension pneumothorax
Tamponade (cardiac)
Toxins
Thrombosis (pulmonary)
Thrombosis (coronary)
Most common causes of Pulseless Electrical Activity (PEA)
Hypovolemia and Hypoxemia
Hypovolemia
Common cause of PEA, initially produces a rapid narrow-complex tachycardia, and typically increases diastolic and decreased systolic pressure. As blood loss continues, blood pressure drops, eventually becoming undetectable, but narrow QRS complexes and rapid rate continue (PEA)
Respiratory Distress
Clinical state characterized by abnormal respiratory rate or effort
Respiratory Failure
Clinical state of inadequate oxygenation, ventral or both. Often the end stage of Respiratory Distress.
Respiratory Arrest
Cessation of breathing. Usually caused by events such as drowning or head injury .
Provide tidal volume approx 500-600 mL (6-7 mL/kg)
Excessive ventilation can cause
Gastric inflation
Regurgitation and aspiration
Increased intrathoracic pressure
Decreased venous return to heart
Diminished cardiac output and survival
Bag-Mask Ventilation
Deliver approximately 600 mL tidal volume to produce chest rise over 1 second
Oropharyngeal Airway (OPA)
Used in unconscious patient if chin lift or jaw thrust fails
Should NOT be used in conscious or semiconscious patient
How to select proper size OPA
Place OPA against side of face, when flange of OPA is at corner of moth, the tip should be at the angle of the mandible
Nasopharyngeal Airway (NPA)
Used as alternative to OPA
May be used in conscious, semiconscious or unconscious patients
How to select proper size NPA
Compare butter circumference of NPA with inner aperture of nare. Length of NPA should be same as distance from tip of patients nose to the earlobe.
Soft Suctioning
Aspiration of thin secretions fro oropharynx and nasopharynx
Performing intratracheal suctioning
Suctioning thought in-place airway (ie NPA) to access back of pharynx in pt with clenched teeth
Rigid Suctioning
More effective suction of the oropharynx, particularly if there is thick particulate matter (vomit)
Types of Advanced Airway devices
Laryngeal mask airway
Laryngeal tube
Esophageal-tracheal tube
ET tube
Ventilation rate of Advanced airway device
Cardiac Arrest: Once every 6 seconds
Respiratory Arrest: Once very 5-6 seconds
ACS Algorithm
STEMI Chain of Survival
Rapid recognition and reaction to STEMI warning signs
Rapid EMS dispatch and transport and prearrival notification to receiving hospital
Rapid assessment and dx in the ED (or cath lab)
Rapid treatment
Administer O2 and drugs for ACS/Suspected STEMI
Oxygen
Aspirin
Nitroglycerin
Opiates (e.g. Morphine)
Oxygen
give if O2<90%
Aspirin
-160-325 mg of non-enteric coated. Have patient
chew them
-Give if pt has not taken ASA, allergy, or GI bleeding
Nitroglycerin
- 1 SL tablet or spray every 3-5 minutes.
-May repeat does twice (3 total doses)
- Administer only if hemodynamically stable
- SBP >90 mmHg or now lower than 30 mmHg below baseline
- HR is 50-100/min
Contraindications:
- Inferior wall MI and RV infarction
- Hypotension, bradycardia, or tachycardia
-
Resecent phosphodiesterase inhibitor use
Morphine
Given for chest discomfort unresponsive to nitro
EKG
Obtain within 10 minutes of arrival and assess the patient
It is the center of decision pathway in management of ischemic chest discomfort and the only means to identify a STEMI
Reperfusion goals for STEMi patients
Fibrinolytic within 30 minutes of arrival or perform PCI within 90 minutes of arrival
The 1st 10 minutes of assessing and stabilizing patient
Check vitals
Establish IV
Brief focused H&P
Complete fibrinolytic checklist
Obtain labs
EKG
Portable Chest x-ray (less than 30 minutes after patients arrival in ED)
STEMI
ST-segment elevation in 2 or more contiguous leads or new LBBB.
J-joint elevation greater than 2mm in leads V2 and V3 and 1mm or more in all other leads by new or presumed new LBBB
2.5 mm in men younger than 40
1.5 mm in all women
NSTE-ACS
Ischemic ST-segment depression 0.5 mm or greater or dynamic T-wave inversion w/ pain or discomfort
Low-/intermediate-risk ACS
Normal or non diagnostic changes in T segment or T wave that are inconclusive and return future risk stratification
St-segment deviation in either direction of less that 0.5 mm or T-wave inversion less than or equal 2mm.
Mainstay tx for STEMI
Early reperfusion therapy achieved with primary PCI or fibrinolytic
Door to PCI Goal
90 minutes
if at non-PCI-capable hospital, 120 minutes
Door to Fibrinolytics
30 minutes
Fibrinolytic Agent
Clot buster, administered to pt with J-point ST segment elevation >2mm in leads V2 and V3, and 1 mm or more in all other leads or by new LBBB
examples: rTPA, reteplase, tenecteplase
Major types of Stroke
Ischemic Stroke- MC
Hemorrhagic stroke
Stroke Chain of survival
Rapid recognition and reaction to stroke warning signs
Rapid EMS dispatch
Rapid EMS system transport and prearrival notification
Rapid diagnosis and tx in hospital
8 D's of Stroke Care
1. Detection
2. Dispatch
3. Delivery
4. Door
5. Data
6. Decision
7. Drug/Devices
8. Disposition
NINDS in-hospital goals for assessment of suspect stroke
1. Immediate general assessment by the stroke team, emergency physical , or expert within 10 minutes of arrival, order surgery non contrast CT
2. Neurologic assessment by stroke team or designee and CT scan performed in 25 minutes of hospital arrival
3. Interpretation of the CT scan within 45 minutes of ED arrival
4. initial of fibrinolytic therapy in appropriate patients, within 1 hour of hospital arrival and 3 hours from symptom onset
5. Door to admission time of 3 hours
Cincinnati Prehospital Stroke Scale
Facial droop (have patient smile or try to show teeth)
Arm Drift (have patient close eyes and hold both arms out, with palms up)
Abnormal speech (have the patient say "you can't teach an old dog new tricks")
Immediate General Assessment and Stabilization
Assess ABCs
Provide Oxygen
Establish IV access and obtain blood samples
Check Glucose
Perform Neuro exam
Activate stroke team
Order CT scan
Obtain 12 lead EKG
Non contrast CT Scan
Can differentiate between ischemic and hemorrhagic stroke.
Most important test for a patient with acute stroke
If Hemorrhage is present
Pt not candidate for fibrinolytic
No Hemorrhage
Fibrinolytic, but if C/I give ASA
Fibrinolytic Therapy
Given to adults with acute ischemic stroke within 3 hours of onset of symptoms, or within 4.5 hours of onset of symptoms for selected patients
Inclusion Criteria for fibrinolytic
Dx of ischemic stroke causing neuro deficits
Onset of symptoms <3 hours
Age >18 years
Exclusion criteria for Fibrinolytic
Head trauma or stroke w/i 3 months
Symptoms of subarachnoid bleed
Arterial puncture in previous 7 days
History of previous intracranial hemorrhage
Elevated BP (>185 SBP and >110 DBP)
Active internal bleeding
Acute bleeding diathesis
Glucose <50
CT
demonstrates multi lobar infarction
Inclusion Criteria for fibrinolytic 3-4.5 hr
ischemic stroke with neuro deficit
Onset of symptoms 3-4.5 hours before tx
Exclusion Criteria for Fibrinolytic 3-4.5 hr
Age >80
Severe Stroke (NIHSS score >25)
Taking oral anticoagulant regardless of INR
History of both DM and
prior ischemic stroke
Monitor Blood Glucose
Consider giving IV or SQ insulin when glucose is greater than 185 mg/dL
Hypertension managent in rtPA candidates
Blood pressure must be 185 mmHg or less systolic and 110 mmHg or less Diastolic to limit risk of bleeding
Medications for treatment of HTN in stroke pt
Labetalol
Nicardipine
Labetalol dose
10-20 mg IV over 1-2 minutes, may repeat X 1
Nicardipine
IV 5mg/hr, titrate up to 2.5 mg/h every 15-20 minutes, max 15 mg/hr
Adult Cardiac Arrest Algorithm
Antiarrhythmics
Amiodarone
Lidocaine
Magnesium Sulfate
Amiodarone Dose
300 mg IV/IO bolus, then consider additional 150 mg IV/IO once
Class III Antiarrhythmic
Lidocaine Dose
Given if Amiodarone is unavailable
1-1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg IV/IO at 5-10 minute intervals
Max dose of 3 mg/kg
Magnesium Sulfate
1-2 g IV/IO diluted in 10 mL (D5W, NS) given as IV/IO bolus, typically over 5 to 20 minutes
Persistently low PETCO2 values less than 10mmHg
suggest ROSC is less likely to occur
Sudden spike in ETCO2 of 35-40 mmHG
Suggest ROSC has occurred
In Asystole consider stopping CPR if ETCO2 is
Less than 10 mmHg after 20 minute of CPR
Symptomatic Bradycardia
HR less than 50 w/ symptoms
Cornerstone of managing bradycardia
Differential beween S/S that are caused by the slow HR vs those that are unrelated
Correctly diagnose presence and type of AV blocks
Use Atropine as 1st line drug of choice
Decide when to intimate Transcutaneous pacing (TCP)
Decide when to start Eii or dopamine
Know when to cal expert consult
In addition: You must know the techniques and cautions for using TCP
Sinus Bradycardia w/ borderline first-degree AV block
Second-degree AV block type 1 (wenkebock)
Second-degree AV block type 2 (Mobitz)
Complete AV block w/ ventricular escape pacemaker
Third-Degree AV bock w/ junctional escape pacemaker
Adult Bradycardia With a Pulse Algorithm
Atropine
0.5 mg IV may repeat to a total dose of 3 mg
Dopamine Infusion
2 to 20 mcg/kg/min
Epinephrine Infusion
2 to 10 mcg/min
Avoid atropine in
Type II second-degree or third-degree AV blocks . These bradyarythmias are not likely to respond to reversal of cholinergic effects, tx is TCP or B-adrenergic support
Transcutaneous Pacing (TCP)
Delivers pacing impulses to heart throughout the skin by use of cutaneous electrodes.
When To use TCP
1. Hemodynamically unstable
bradycardia
2. Unstable clinical condition like due to bradycardia
3. Pacing readiness in the setting of AMI as follows:
-Symptomatic sinus bradycardia
-Mobitz type II 2nd degree AV Block
-Third-degree AV block
- New Left, right, or alternator BBB, or bifacicular block
4. Bradycardia with symptomatic ventricular escape rhythms
Precaution for TCP
Contraindicated in severe hypothermia
not recommended for Asystole
Conscious patients require analgesia if time allows
Do not assess carotid pulse to confirm mechanical capture, electrical stimulation causes muscular jerking that may mimic the carotid pulse
Technique for TCP
1. Place pacing electrodes on chest
2. Turn the pacer on
3. Set the demand rate to approximately 60/min (can be adjusted up or down based on pt clinical
response once pacing is established)
4. Set the current milliamperes output 2mA above the sole at which consistent capture is observed
Sinus tachycardia
Atrial fibrillation
Atrial flutter
Supraventricular tachycardia
Monomorphic ventricular tachycardia
Polymorphic ventricular tachycardia
2 Keys to management of tachycardia
1. Rapid recognition that the patient is significantly symptomatic or even unstable
2. Rapid recognition that the S/S are caused by the tachycardia
HR less than 150 is suggestive of
unlikely that symptoms of instability are caused by the tachycardia
HR greater than 150
usually inappropriate response to physiologic stress (fever, dehydration eat) or other underlying condition
Adult Tachycardia with a Pulse Algorithm
Unstable tachycardia
Requires immediate cardioversion, even in the absence of EKG
Most wide-complex tachycardias are...
Ventricular in origin
If pt unstable w/ pulse w/ regular uniform wide-complex vt
Treat with synchronized cardioversion and initial shock of 100J (monophasic waveform)
If no response to 1st shock, increase the dosage in a stepwise fashion
Arrhythmias w/ polymorphic QRS appearance (polymorphic VT)
Treat as VF w/ high-energy unsynchronized shock
Unsynchronized Shock
The electrical shock will be delivered as soon as operator pushes the shock button to discharge the device. These shocks use higher energy levels
Synchronized Shock
Uses a sensor to deliver a shock that is synchronized with a peak of the QRS complex
When to use Synchronized Shocks
Unstable VT
Unstable a-fib
Unstable a-flutter
Unstable regular monomorphic tachycardia w/ pulse
When to use unsynchronized shocks
Patient who is pulseless
Patient demonstrating clinical deterioration
When you are unsure whether monomorphic or polymorphic VT is present
Tx of choice when pt has symptomatic reentry SVT or VT with pulses
Synchronized cardioversion
Assessment of tachycardia w/ present pulse
Perform BLS assessment and Primary and Secondary assessments.
Determine if significant symptoms or sings are present and if they are due to the tachycardia
If S/S of tachycardia are due to the tachycardia
Pt is unstable and immediate cardioversion is indicated
If pt develops pulseless vt
deliver unsynchronized high-energy shocks and follow Cardiac arrest algorithm
Polymorphic VT
Treat the rhythm as VT and deliver high-energy unsynchronized shocks
Patient has stable tachycardia w/ pulse
BLS, Primary, Secondary assessment
- Look for sings of increased WOB and hypoxia
- Give O2; monitor O2 sat
- Support airway, breathing, circulation
-Obtain an EKG early to identify the rhythm; check BP
-Identify and treat
reversible cause
Drugs to avoid in pt w/ Irregular Wide-complex tachycardia
AV nodal blocking agents such as Adenosine, CCB, Digoxin and possibly B-Blockers
Therapy for narrow QRS w/ regular rhythm is
Attempt Vagal maneuvers
Give adenosine
Vagal maneuvers
are preferred initial intervention for terminating narrow-complex tachycardia that are symptomatic (but stable) and supraventricular in origin
Adenosine
given if Vagal maneuvers fail
6mg rapid IV push over 1 second
followed by 20 mL saline flush
If SVT does not convert within 1-2 minutes
-Give second dose of adenosine 12 mg rapid IV push
Adenosine should generally not be given to
Asthma or COPD patients
Synchronized cardioversion for Narrow Regular
50-100 J
Synchronized cardioversion for Narrow Irregular
120-200 J
Synchronized cardioversion for Wide regular
100 J
Synchronized cardioversion for Wide irregular
Defibrillation dose NOT synchronized
Antiarrhythmic Infusions for Stable Wide-Complex Tachycardia
Procainamide
Amiodarone
Sotalol
Procainamide
20-50 mg/min until arrhythmia suppressed, hypotension ensures, QRS duration increased >50%, or maximum dose 17 mg/kg given
Maintenance infusion: 1-4 mg/min
Avoid of prolonged QT or CHF
Amiodarone (Infusion dose)
1st dose: 150 mg over 10 min
Repeat as needed if VT recurs
Follow by maintenance infusion of 1mg/min for first 6 hours
Sotalol
100 mg (1.5 mg/kg) over 5 min.
Avoid if prolonged QT
Drugs for post-cardiac arrest care
Epinephrine infusion
Dopamine infusion
Norepinephrine infusion
Adult Immediate Post-Cardiac Arrest Care Algorithm
Ventilation rate should be started at
10/min and titrated to achieve a PETCO2 of 35-40 mmHg or a PaCO2 of 40-45 mmHG
Targeted Temperature Management
Adults with ROSC after cardiac arrest, by selecting and maintaining a constant temperature between 32-36 degree C (89.6-95.2 degree F) for at least 24 hours
Treat Hypotension (SBP Less than 90 mmHg)
IV bolus
Norepinephrine
Epinephrine
Dopamine
IV Bolus for Hypotension
1-2 L normal saline or lactated Ringer's
Norepinephrine
0.1-0.5 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg
Epinephrine (for hypotension)
0.1-0.5 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg
Dopamine
5-10 mcg/kg/min IV infusion titrated to achieve minimum SBP >90 mmHg or MAP >65 mmHg
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