St. Lukes College of Medicine-William H.

Quasha Memorial Batch 2012

Lecture Notes

ER

Block I

AUTOMATED EXTERNAL DEFIBRILLATOR

Dr.

Case Scenario: You are on a airplane. A flight attendant asks would a health care provider please come to the middle gallery? At the middle gallery 2 flight attendants are doing chest compressions and pocket mask ventilation on a 55 year old man. What would you do next? SUDDEN CARDIAC ARREST: Most commonly a victim in vcardiac arrest is in rhythm known as ventricular fibrillation The purpose of CPR is to manually circulate blood and oxygen through the body, not to fix an electric problem Manual circulation only accomplishes about 10 to 30% of the normal cardiac output. Therefore CPR enables the heart to restart. Each minute that passes when someone is in cardiac arrest is equal to 10% of their of survival. The survival rate for a victim in cardiac arrest in a prehospital setting is 3 to 5%. However, IF: You could access the victim within a few minutes CPR is started immediately You could have a defibrillator available to deliver an electric shock within those first few minutes. Then: Your victim has a 50 to 74% chance of surviving. According to ACLS 2006: 50 to 74% survival rate for victims of witnessed Vfib if CPR and defibrillation is given within 3 to 5 minutes. o Immediately bystander CPR alone can double or triple the VF survival rate at any interval to defibrillation o Early defibrillation with AED can double survival over that resulting from CPR alone. PROBLEMS WITH DEFIBRILLATORS Its not everywhere and not accessible outside the hospital You have to be a paramedic or physician to read and interpret the victims heart rhythm Defibrillators are large and heavy Defibrillators are very expensive Defibrillators are only available when trained rescuers get to the scene THE SOLUTION Now with the advances in technology there are machines called automated External Defibrillators OR AED o Portable o Light weight o Durable o Cost effective ($2300) o Minimal amount of training and time to learn how to use. AUTOMATED EXTERNAL DEFIBRILLATORS (AED) An AED is a computerized defibrillators that can o Analyze the heart rhythm of a person in cardiac arrest. o Recognize the shock able rhythm VFIb Vtac o Advise the operator whether the rhythm should be shocked INDICATIONS: AEDS should be used if a victim has signs of cardiac arrest. o Unresponsive o Not breathing o No pulse or other signs of circulation

OPERATIONS OF AED: 4 UNIVERSAL CONTROL STEPS: Power on the AED Attach pads Analyze rhythm Shock (if advised) Attachment of pads: Attach to the patient o Select the correct pads size for the victims size and age o Open package o Expose adhesive surface o Attach to the patient (upper right sternal border and cardiac apex) o Attach cables to AED Analysis Put placer in analyzer mode o Announce to the team members, analyzing rhythm- Stand clear o Verify that there is no patient movement and that no one is in contact with the patient. Press the analyze control (some AED omit this control Shock Press the shock button Of VF/VT is present, the device will charge to 150 to 360 joules and would signal that a shock is indicated. Announce shock is indicated- stand clear Verify that no one is touching the patient Press the shock button when signaled to do so. Repeat these steps until VF/VT is no longer present The device will signal no shock indicated AED safety With every analysis and shock make sure that no one touches the patient. Give verbal warning to bystanders o Im clear o Youre clear o Everybodys clear Visual: check all clear Physical: add hand gestures Only then press to shock

SPECIAL SITUATIONS Remove the victim from standing water and dry the chest first before giving defibrillation Do not place an AED electrode directly over the implantable defibrillator. Place the pad at least 1 inch to the side of any implantable device. Remove transdermal medication patches AED IN CHILDREN AED may be used in children 1 to 8 years old who have no signs of circulation Ideally the device should deliver pediatric dose (2 to 4 J/Kg BW) Currently there is insufficient evidence to support a recommendation for or against the use of AED in children <1year old.

St. Lukes College of Medicine-William H. Quasha Memorial Batch 2012

Lecture Notes

ER
CHEST PAIN

Block I

CHEST PAIN

Dr.

INCLUSION > 19 year old male + female. Nontraumatic chest pain of any character EXCLUSION < 19 year old, raumatic chest pain TRIAGE NURSE If these symptoms are present, obtain STAT ECG o Chest pain or severe epigastric pain, non traumatic in origin, with components typical of myocardial ischemia or MI. Central or substernal compession or crushing chest pain Pressure tightness, heaviness, squeezing, constricting, cramping, burning, aching sensation Unexplained indigestion, belching, epigastric pain Radiating in the neck, jaw, shoulders, back, one or both arms Associated dyspnea Associated nausea or vomiting Associated diaphoresis TRIAGE PHYSICIAN High risk history o Chest or left arm pain or discomfort as chief symptom reproducing prior documented angina o Known history of CAD, including MI o Prolonged ongoing (>20 min) rest pain o Age >75 years Moderate Risk history o Chest or left arm pain or discomfort as chief symptom o Age greater that 70 years o Male sex o Diabetes mellitus o Prior MI, peripheral or cerebrovasacular disease or CABG, prior Aspirin use o Prolonged (>20min) rest angina, now resolved with rest or by sublingual NTG o Nocturnal angina o Extracardiac vascular disease Low risk History o Probable ischemic symptom in absence of any of the intermediate likelihood characteristics o Recent cocaine use o Increased angina frequency, severity or duration o Angina provoked at lower threshold o New onset angina with onset 2 weeks to 2 months prior to presentation Physical Examination o New or worsening murmur o Hypotension o Bradycardia/tachycardia o Diaphoresis o Pulmonary edema o S3 or new /worsening rales RULE OUT OTHER LIFE THREATENING CAUSES OF CHEST PAIN o Aortic dissection o Pulmonary embolism o Perforating ulcer o Tension pneumothorax o Boerhaaves syndrome (rupture of esophageal wall) WITHIN 10 MINUTES: STABILIZE PATIENT: o Take vital signs, O2 saturation at baseline o Assess pain score o 02 inhalation o Intubation (as needed)

o Start IV fluids DIAGNOSTICS o 12 LEAD ECG o Troponin o CKMB o CXR o 2D echo with Doppler (as needed) THERAPEUTICS o Nitrates o Aspirin 325 mg/tab (chewed and swallowed) o Clopidogrel 75 mg /tab- 4 tabs PO o Clexane 0.4 mg SQ o Morphine Sulphate 2mg IV WITHIN 30 MINUTES: DIAGNOSTICS o Stress test o Diagnostic angiography THERAPEUTICS o Beta blockers o ACEinhibitors o Low molecular wt. heparin o GIIIb/IIIa inhibitors o Statins DISPOSITION STEMI pathway o Fibrinolysis, ideal within 4 hrs, best if done within 70 minutes o Percutaneous coronary intervention (PCI). Ideal 90 minutes door to balloon o NSTEMI/unstable angina pathway o Admitted to CVU/telemetry o Admitted to regular room/ ward o Observe at the ER o Died at the ER o Transfer to another hospital o Discharged CLINICAL PEARLS MONA greets chest pain at the door o Morphine sulfate o Oxygen o Nitroglycerin o Aspirin Time in myocardium ECG immediately ECG will dictate nest step in management STEMI Reperfusion Goals: Restore flow to myocardium as quickly as possible, prevent further clot formation, control pain.