Medical Archive

Introduction

• Systems of Care
  • Cardiopulmonary resuscitation
    • A systematic approach
    • Measurement
    • Benchmarking and feedback
  • Acute coronary syndromes
    • Introduction
      • Starts “on the phone” with activation of EMS
    • EMS components
    • Hospital-based components
  • Acute stroke
  • Post-cardiac arrest care
    • Targeted temperature management
    • Hemodynamic and ventilation optimization
    • Immediate coronary repercussion with PCI
    • Glycemic control
      • Should not attempt to alter glucose concentration within a lower range (80-110mg/dL)
    • Neurologic care and prognostication
  • Education, implementation, and teams
• Effective High-Performance Team Dynamics
  • Roles of the leader and members of a high-performance team
  • Elements of effective high-performance team dynamics
• The Systematic Approach
  • The BLS assessment
  • The primary assessment
  • The secondary assessment
  • Diagnosing and treating underlying causes

Respiratory arrest case

The BLS assessment

Assess and reassess the patient
Ventilation and pulse check

The primary assessment

Airway management in respiratory arrest
Ventilations

Management of respiratory arrest

Overview

Giving supplemental oxygen

Opening the airway

Common cause of airway obstruction
Basic airway opening techniques
Airway management

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Providing basic ventilation

Basic airway skills
Bag-mask ventilation

Basic airway adjuncts: oropharyngeal airway

Basic airway adjuncts: nasopharyngeal airway

Technique of NPA insertion

Suctioning

Introduction
Soft vs rigid catheters
Oropharyngeal suctioning procedure
Endotracheal tube suctioning procedure

Providing ventilation with an advanced airway

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BURP maneuver

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Tracheostomy

• Procedures
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  • Transverse incision: sternal notch 1cm ?, transverse cervical skin incision
  • Vertical incision: ? 2-3 ???? vertical midline incision (??? 4th ???? ??)
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Precautions for trauma patients

Acute coronary syndrome case

Introduction

Rhythms for ACS
Drugs for ACS

Goals for ACS patients

Managing ACS: The acute coronary syndromes algorithm

Overview of the algorithm
Important considerations
Application of the ACS algorithm

Identification of chest discomfort suggestive of ischemia

Signs and conditions
starting with dispatch

EMS assessment, care, and hospital preparation

Introduction
Monitor and support ABCs
Administer oxygen and drugs

	Indications	Dose and route
Oxygen	Dyspneic, or hypoxemic Has obvious signs of HF Has an SO2 <90%, or the SO2 is unknown.	Target: SO2 ?90%
Aspirin	Has not taken aspirin  No history of true allergy No recent GI bleeding If rtPA is administered – hold for at least 24 hours	160-325mg of non-enteric-coated aspirin. Chewable > PO (absorbed better, particularly if morphine has been given) 300mg of rectal suppositories for patients with N/V, active PUD, or other disorders of the UGIT.
Nitroglycerin	Only if the patient remains hemodynamically stable: SBP >90mmHg or no lower than 30mmHg below baseline and the HR is 50 to 100/min No recent PDEi use within the previous 24 hours Neither inferior wall MI nor RV infarction	1 sublingual NTG tablet(or spray) every 3-5 minutes May repeat the dose total of 3 doses.
Morphine		In STEMI when chest discomfort is unresponsive to nitrates. In NSTE-ACS, use with caution because of an association of increased mortality.

Immediate ED assessment and treatment

Introduction
The first 10 minutes
Patient general treatment

Classify patients according to ST-segment deviation

STEMI

Early reperfusion therapy
Use of PCI
Use of fibrinolytic therapy
Adjunctive treatments

Acute stroke case

Introduction

Potential arrhythmias with stroke
Drugs for stroke

Approach to stroke care

Goals of stroke care
Critical time periods
Application of the suspected stroke algorithm

Identification of signs of possible stroke

Warning signs and symptoms
Activate EMS system immediately
Stroke assessment tools

Critical EMS assessments and actions

Introduction
Critical EMS assessments and actions

In-Hospital, immediate general assessment and stabilization

Introduction
Immediate general assessment and stabilization

Immediate neurologic assessment by stroke team or designee

CT scan: Hemorrhage or no hemorrhage

Decision point: hemorrhage or no hemorrhage

Fibrinolytic therapy

Evaluate for fibrinolytic therapy
Potential adverse effects
Patient is a candidate for fibrinolytic therapy
Extended IV rtPA window 3 to 4.5 hours
Intra-arterial rtPA

Endovascular therapy

Intra-arterial rtPA
Mechanical clot disruption/stent retrievers
Systems of care

General stroke care

Begin stroke pathway

Monitor blood glucose

Monitor for complications of stroke and fibrinolytic therapy

Hypertension management in rtPA candidates

• Patient otherwise eligible for acute reperfusion therapy except that blood pressure is >185/110 mm Hg:
  • Labetalol 10-20 mg IV over 1-2 minutes, may repeat × 1 time, or
  • Nicardipine IV 5 mg/h, titrate up by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h; when desired blood pressure is reached, adjust to maintain proper blood pressure limits
  • Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate
• If blood pressure is not maintained at or below 185/110 mm Hg, do not administer rtPA.
• Management of blood pressure during and after rtPA or other acute reperfusion therapy:
  • Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours.
• If systolic blood pressure 180-230 mm Hg or diastolic blood pressure 105-120 mm Hg:
  • Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min, or
  • Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/h every 5-15 minutes, maximum 15 mg/h
• If blood pressure not controlled or diastolic blood pressure >140 mm Hg, consider sodium nitroprusside.

Cardiac arrest: VF/pulseless VT case

Measurement
Benchmarking and feedback
Change
Rhythms for VF/pulseless VT
Drugs for VF/pulseless VT

Managing VF/pulseless VT: The adult cardiac arrest algorithm

Application of the adult cardiac arrest algorithm: VF/pVT pathway

Routes of access for durgs

IV > IO > ET

Vasopressors

Antiarrhythmic agents

Extracorporeal CPR (for VF/pulseless VT/asystole/PEA)

Ultrasound (for VF/pulseless VT/asystole/PEA)

Cardiac arrest: pulseless electrical activity case

Description of PEA

Managing PEA: The adult cardiac arrest algorithm

Cardiac arrest: asystole case

Approach to asystole

Managing asystole

Application of the adult cardiac arrest algorithm: asystole pathway

Terminating resuscitative efforts

Bradycardia case

Description of bradycardia

Managing bradycardia: The bradycardia algorithm

Application of the bradycardia algorithm

Transcutaneous pacing

Tachycardia: Stable and unstable

The approach to unstable tachycardia

Managing unstable tachycardia: The tachycardia algorithm

Application of the tachycardia algorithm to the unstable patients

Introduction

Assess appropriateness for clinical condition

Identify and treat the underlying causes

Decision point: Is the persistent tachyarrhythmia causing significant signs or symptoms?

Perform immediate synchronized cardioversion

Determine the width of the QRS complex

Cardioversion

Introduction

Unsynchronized vs synchronized shocks

Potential problems with synchronization

• If the R-wave peaks are undifferentiated or of low amplitude
• An unwary practitioner
• Synchronization can take extra time

Recommendations

Energy doses for cardioversion

Synchronized cardioversion technique

Unstable AF: 200J
Unstable mVT: 100J
Other unstable SVT/Aflutter: 50-100J
Unstable pVT: treat as VF with high-energy shock

Approach to stable tachycardia

Managing stable tachycardia: The tachycardia algorithm

Application of the tachycardia algorithm to the stable patient

Immediate post-cardiac arrest care case

Managing post-cardiac arrest care: The post-cardiac arrest care algorithm

Application of the immediate post-cardiac arrest care algorithm

Introduction

Optimize ventilation and oxygenation

SaO2 goal: >94%
Arterial pH goal: 7.3~7.3
PaCO2 goal: 35~40mmHg. Do not hyperventilate

Treat hypotension

STEMI is present or high suspicion of AMI

Coronary reperfusion

Following commands? – NO: comatous

Optain brain CT

EEG monitoring

Targeted temperature management

• ONLY intervention that demonstrated to improve neurologic recovery after cardiac arrest.
• Protocols
  • Monitor core temperature
    • Using esophageal thermometer, bladder catheter in nonanuric patients, or a pulmonary artery catheter. Axillary and oral temperatures are inadequate.
  • Concurrent PCI and hypothermia are reported to be feasible and safe.
• Induction
  • Achieve target temperature as quickly as possible (in most cases, within 3-4 hours)
• Maintenance
  • At least 24 hours
  • Goal temperature of 32-36C.
• Rewarming
  • Begun 24 hours after the time of initiation of cooling.
  • 0.3~0.5C/hr

Advanced critical care

Post-cardiac arrest maintenance therapy