ACUTE & CRITICAL

CARE NURSING
Kristal Liza C. Besario, RN,MAN

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 Objective:
At the end of the discussion, the students will be
able to:
1. Differentiate Acute & Critical Care
2. Know and utilize concepts of Critical Care
Nursing
3. Identify intervention for patients who are
acute / critically ill
4. Demonstrate Skills & attitudes of a Critical Care
Nurse
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 ACUTE CARE
• is a branch of secondary health care where a
patient receives active but short-term
treatment for a severe injury or episode of
illness, an urgent medical condition, or during
recovery from surgery.

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 CRITICAL CARE
• is the field of nursing with a focus on the
utmost care of the critically ill or unstable
patients.
• Critical care nurses can be found working in a
wide variety of environments and specialties.
• These specialists generally take care of
critically ill patients who require mechanical
ventilation

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 SPECIFIC JOBS &
PERSONAL QUALITIES
• Critical Care Nurses are also known as ICU nurses.
• They treat patients who are chronically ill or at risk for deadly
illnesses.
• ICU nurse apply their specialized knowledge base to care for
and maintain the life support of critically ill patients who are
often on the verge of death.
• "perform assessments of critical conditions, give intensive
therapy and intervention, advocate for their patients, and
operate/maintain life support systems which include
mechanical ventilation
• these nurses must be very organized and structured.
• These nurses have quite a bit of good judgment or reasoning
when it comes to making important decisions.
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 TRAINING & EDUCATION
• Critical care nurses in the U.S. are trained in
Advanced Cardiac Life Support (ACLS) and
many earn certification in acute and critical
care nursing (CCRN) through the American
Association of Critical–Care Nurses.

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 SUBSPECIALITIES
• Geriatric patients are considered to be people over the
age of 65 and nurses that specialize in geriatrics work in
an adult Intensive Care Unit (ICU).
• Pediatric patients are children under the age of 18, a
nurse that works with very sick children would work in
a Pediatric Intensive Care Unit (PICU).
• A child is considered a neonatal patient from the time
they are born to when they leave the hospital. If a child
is born with a life-threatening illness the child would be
transferred to a Neonatal Intensive Care Unit (NICU).

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Like other areas of nursing, Critical Care is
driven by the Nursing Process.

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 CRITICAL CARE TEAM
• Physicians: Intensivists (critical care physician),
Radiologist, Neurologist, Nephrologist, and other
specialists
• Surgeons: trauma surgeons, thoracic surgeons,
cardiovascular surgeons, and other specialists
• Other providers: Nurse Practitioner (NP), Physician
Assistant (PA)
• Registered Nurse (RN) with special certifications in
critical care and ACLS (advanced cardiovascular life
saver)
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 CRITICAL CARE TEAM
• Respiratory Therapist (RT)
• Registered Dietitian (RD)
• Techs and aides: Certified Nursing Assistant (CNA), Patient
Care Technician (PCT), Primary Care Technician, and Trauma
Care Technicians
• Emergency transporters: paramedic, emergency medical
technician (EMT)
• Non-medical team members: law enforcement officer (police
and detectives) and patient advocates
• Supportive staff and administrators: patient transport
technician and others

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 SYNERGY MODEL
• Is framework that links practice to patient outcomes.
• It’s a patient-centered nursing practice model for complex
care developed by the American Association of Critical-
Care Nurses.
• The model outlines the components that are conducive to
the complex care arena and environment.
• It matches the nurses’ competencies to the needs of the
patient by assigning the sickest patients to the most
experienced nurse as they probably have the most
competencies and evaluates the relationship between
clinical practice and outcomes.
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 SYNERGY MODEL
• The focus is on patient-derived outcomes,
including functional change, behavioral
change, trust, satisfaction, comfort, and quality
of life.
• The model also addresses nurse-derived
outcomes: the nurse’s actions are evaluated.
The broad emphasis is over physiological
changes, absence of complications, provided
care, and treatment.
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 COMPONENTS OF SYNERGY MODEL
• Resiliency – ability to overcome challenges of all
kind
• Vulnerability – inability to withstand the effects of
hostile environment
• Complexity - complicated
• Resource availability
• Participation in care
• Participation in decision-making
• Predictability
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 ADMISSION CRITERIA
• What it means to be CRITICAL?
The American Association of Critical Care Nurses defines
admission criteria to be for those who are at high risk for
“actual or potential life-threatening health problems
(2005).”
A critical illness or injury is an acute impairment of one or
more vital organ systems in which the patient’s survival is
jeopardized (Department of  Health and Human Services).
Critically ill patients have complex physiologic and
hemodynamic perturbations

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 COMMON SITUATIONS FOR
ADMISSION
• Trauma perpetrations: MVA, contusions,
abrasions, fractures, hemorrhage
• Cardiovascular perpetrations: myocardial
infarction
• Neurological perpetrations: stroke
• Neurological findings: altered level of
consciousness

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COMMON SITUATIONS FOR ADMISSION

• Pulmonary findings: altered breathing

patterns, dyspnea, low oxygen saturation, use
of accessory muscles
• Cardiovascular findings: hypotension or
hypertension, bradycardia or tachycardia
• Integumentary findings: mottled skin

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 NUTRITIONAL NEEDS
• The role of nutrition for the critically ill patient
is vital to the recovery process
• Fever from serious illness increases the
metabolic demands of the body
• Serious burns require increased caloric and
protein needs to heal

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CRITICAL CARE ENVIRONMENT

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 CRITICAL CARE ENVIRONMENT
• The Importance of a Healthy Critical Care Environment
• Staff Stress in a Critical Care Setting
1. Technology: state-of-the-art technology also requires
state-of-the-art education to train those responsible
for using complex equipment
2. Poor communication: communication has a direct
impact on patient safety and the tone of the work
environment
3. Unstandardized practice: inconsistency leaves gaps in
the continuum of care

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The Six Standards of a Healthy Work Environment from the AACN

• Skilled communication
• True collaboration: True collaboration is
necessary to take truly quality care.
• Effective decision making:
 Must understand how the hospital culture works.
 Must know what’s going on with the patient to
answer questions succinctly through critical
values.

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The Six Standards of a Healthy Work Environment from the AACN

 After implementing an intervention, it must be

evaluated to determine if it was effective or
ineffective and then plan for the next step.
 This also includes the ability to anticipate the
provider’s actions. This involves an thorough
understanding of the patient’s history,
diagnosis, treatments, and other aspects

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The Six Standards of a Healthy Work Environment from the AACN

• Appropriate staffing
• Meaningful recognition
• Authentic leadership (Vollers, Roberts,
Dambaugh, & Brenner, 2009)

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Communication in Critical Care:
• The most vital outcome of skilled and
effective communication between the Critical
Care Nurse and the healthcare provider is
patient safety

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Communication in a Critical Care Setting

• Skilled communication is the lifeblood of the

critical care setting
• It involves multidisciplinary unity and collaboration
of nurses, healthcare providers, and other medical
professionals, along with administrative leaders,
the chief executive officer, and supporting staff
• Communication in the critical care setting has a
direct impact on patient outcomes
• The importance of the Critical Nurse’s
communication skills are ranked in the
same category as clinical skills
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 Communication in a Critical Care Setting

• It’s imperative for the communication between the provider

and nurses to remain strong
• The most vital outcome of skilled and effective
communication between the Critical Care Nurse and the
provider is patient safety
• Communication can come in the form of face-to-face
methods such as giving and receiving report, staff meetings,
and technological communication methods such as email,
phone calls, the Intranet (the internal network of the facility
that’s available only to employees, and possibly volunteers,
and students), and the content of the facility’s website

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 The Six Standards of the American Association of Critical-Care
Nurses

Standard # 1: Assessment
• Assessment: data is collected from a holistic perspective
• All potentially valuable sources are used to collect data,
including the patient, family, and other team members
through the use of interview, observation, analytical
models, and problem-solving tools
• The assessment process is driven by current and
anticipated needs
• Relevant assessment findings are communicated to
other team members and documented

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 The Six Standards of the American Association of Critical-Care
Nurses

Standard # 2: Diagnosis
• Assessment findings are used to develop and
prioritize the most appropriate nursing
diagnoses
• Diagnoses are validated through interactions
with the patient, family, and other team
members and are modified as needed
• Diagnoses are documented

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 The Six Standards of the American Association of Critical-Care
Nurses

Standard # 3: Outcomes Identification

• Identified outcomes take into consideration
the patient’s unique situation and are derived
from actual or potential diagnoses
• Outcomes are attainable, measurable,
include a timeframe, and are modified as
needed
• The identified outcomes are documented

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 The Six Standards of the American Association of Critical-Care
Nurses

Standard # 4: Planning
• A plan of care is made to achieve the desired outcomes
with the collaboration of the patient and family.
• It is focused on restoring health, promoting health,
minimizing the risk of complications and providing for
continuity of care. 
• This plan establishes priorities, and takes into
consideration the economic impact and resources
available to deliver the care. The nurse’s skills and
competencies must meet the patient’s needs
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 The Six Standards of the American Association of Critical-Care
Nurses

Standard # 5: Implementation
• The plan of care is delivered through safe
methods that involves the input of the patient
and family
• Elements may also include health teaching,
health promotion, and disease management
• All actions taken are documented

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 The Six Standards of the American Association of Critical-Care
Nurses

• Standard # 6: Evaluation
• Evaluation performed in a systematic way
using ongoing using evidence-based techniques
and involves the collaboration of the patient,
family, healthcare providers, as appropriate
• Results are documented and adjustments are
made as necessary to achieved the desired
outcomes

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Emphasized Principles in the ACCN’s Scope and Standards of Nursi
ng Care

• Use of current best evidence

• Collaboration with the patient, family,
healthcare provider, and other team members
as appropriate
• Actions to minimize the risk of complications
and deliver care in a safe and effective manner
• Documentation to record all actions taken

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 Objectives:
At the end of the discussion, the students will be
able to:
1. Discuss the skills & attitudes of critical thinking
2. Express the relationships among the nursing
process, critical thinking, the problem solving
process and the decision making process
3. Explore & apply ways of demonstrating critical
thinking.

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 CRITICAL THINKING
• Is essential to safe, competent, skillful nursing
practice.

• Nurses therefore need to embrace the

attitudes that promote critical thinking &
master critical thinking skills in order to
process & evaluate both previously learne &
new information

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 TOP 10 REASONS
TO IMPROVE THINKING
10. Things aren’t what they used to be or what
they will be
9. Patients are sicker, with multiple problems
8. More consumer involvement
7. Nurses must be able to move from one setting
to another
6. Rapid change & information explosion requires
us to develop new learning & workplace skills

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 TOP 10 REASONS
TO IMPROVE THINKING
5. Consumers & payers demand to see evidence of
benefits, efficiency and results
4. today’s progress often creates new problems that
can’t be solved by old ways of thinking
3. Redesigning care delivery & nursing curricula is
useless if students & nurses don’t have the
thinking skills required to deal with todays world
2. It can be done-it doesn’t have to be that difficult

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 TOP 10 REASONS
TO IMPROVE THINKING
1. Your ability to focus your thinking to get the
results you need can make the difference
between whether you succeed or fail in this
fast-paced world

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 Nurses use critical thinking skills in a
variety of ways:
• Nurses use knowledge from other subjects
and fields
• Nurses deal with change in stressful
environments
• Nurses make important decisions

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 CREATIVITY
• Is thinking that results in the development of
new ideas and products.

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 Skills in Critical Thinking
• CRITICAL ANALYSIS – the application of a set of
questions to a particular situation or idea to
determine essential information & ideas &
discard superfluous information and ideas
• INDUCTIVE REASONING – generalizations are
formed from a set of facts or observations
• DEDUCTIVE REASONING – is reasoning from
the general premise to the specific conclusion

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 ATTITUDES THAT FOSTER
CRITICAL THINKING
• Independence – they are not easily swayed by
the opinions of others but take responsibility
for their own views.
• Fair-Mindedness – assessing all viewpoints
with the same standards and not basing their
judgments on personal or group bias or
prejudice. The nurse listens to opinions of all
the members of a family, young and old.

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 ATTITUDES THAT FOSTER
CRITICAL THINKING
• Insight into Egocentricity – They actively try to
examine their own biases and bring them to
awareness each time they think or make a
decision.
• Intellectual Humility – they are willing to
admit what they do not know, they are willing
to seek new information & to rethink their
conclusion in light of new knowledge.

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 ATTITUDES THAT FOSTER
CRITICAL THINKING
• Integrity – they question their own knowledge &
beliefs of others.
• Perseverance – the nurse needs to continue to
address the issue until it is resolved.
• Confidence – they believe that well-reasoned
thinking will lead to trustworthy conclusions.
• Curiosity – they may value tradition but is not
afraid to examine traditions to be sure they are
still valid.
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 Standards of Critical Thinking
• CORE ATTRIBUTES OF CRITICAL THINKING
1. Reflection – determining what data are
relevant & making connections between that
data & the decisions reached.
2. Context – essential consideration in nursing
since care must always be individualized,
taking knowledge & applying it to real
people.

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 Standards of Critical Thinking
• CORE ATRIBUTES OF CRITICAL THINKING
3. Dialogue – refers to the process of serving as
both teacher & student in learning from
situations, questioning, marking connections,
and determining motivation.
4. Time – emphasizes the value of using past
learning it current situations that then guide
future actions.

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 Universal Intellectual Standards
STANDARDS Logicalness
Clarity SAMPLE QUESTIONS
Accuracy What is an example of this
How can I find out if that
Relevance is true
How does that help me
with this issue
Does that follow from the
evidence

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 Universal Intellectual Standards
STANDARDS Completeness
Breadth SAMPLE QUESTIONS
Do I need to consider
Precision another point of view
Significance Can I be more specific
Which of these facts is
most important
Have I missed any
important aspects

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 Universal Intellectual Standards
STANDARDS
Fairness
SAMPLE QUESTIONS
Depth Am I considering the
thinking of others
What makes this a difficult
problem

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 PROBLEM SOLVING
• The nurse obtain information that clarifies the
nature of the problem & suggest possible
solutions.

TRIAL & ERROR

INTUITION
RESEARCH PROCESS

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 DECISION MAKING
• They must evaluate the different types of
programs, as well as personal circumstances,
to make a decision appropriate to their
situation.

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 Sequential steps to the
decision making process
1. Identify the purpose
2. Set the criteria
3. Weight the criteria
4. Seek alternatives
5. Examine alternatives
6. Project
7. Implement
8. Evaluate outcome
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 Applying Critical Thinking to
Nursing Process
NURSING PROCESS Implementing
Assesing Evaluating
Goal Setting CLINICAL APPLICATION
Diagnosing
Planning

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 The Cardiovascular System
• Objectives:
1.  Assess patients with cardiovascular problems.
2. Identify the appropriate nursing intervention for patient with
cardiovascular problems
3. Utilize the nursing process in developing a nursing care plan
for patients with disturbances affecting the cardiovascular
system.
4. Identify the appropriate nursing and diagnostic examinations
for patients with cardiovascular problems
5. Design and implement a nursing care plan to an actual
patient with cardiovascular disorder/problems

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The Cardiovascular System

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 Functions of the Cardiovascular
System
• Cardiac Electrophysiology
• Cardiac Hemodynamics

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 Cardiac Electrophysiology
• Cardiac Conduction System – generates and
transmits electrical impulses that stimulate
contraction of the myocardium.

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Characteristics of Cardiac Conduction
Cells
• Automaticity
• Conductivity
• Contractility
• Excitability

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Components of the Conduction System

• Sinoatrial Node
• Atrioventricular Node
• Bundle of His
• L & R Bundle Branches
• Purkinje Fibers

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 Cardiac Action Potential
• Depolarization
• Repolarization

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 Refractory Periods
• Effective/Absolute Refractory Period
• Relative Refractory Period

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 Cardiac Hemodynamics
• An important determinant of blood flow in the
cardiovascular system is the principle that
fluid flows from a region of higher pressure to
one of lower pressure.

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• Cardiac Output
• Stroke Volume
 Preload
 Afterload
 Contractility

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 Diagnostic Test & Procedures
• To assists in identifying the cause of cardiac-
related signs & symptoms
• Identify abnormalities in the blood that affect
the prognosis of a patient with CVD
• To assess the degree of inflammation
• To screen for risk factors associated with CAD
• Determine baseline values before initiating
therapeutic interventions
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 Diagnostic Test & Procedures
• To ensure that the therapeutic levels of
medications are maintained
• To assess the effects of medication
• To screen generally for abnormalities

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 Cardiac Biomaker Analysis
• Plasma analysis of key isoenzymes and other
biomakers is part of a diagnostic profile for
acute MI
CK-MB
Myoglobin & Troponin T or I

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Blood Chemistry, Hematology & Coagulation
Studies
• Lipid Profile
• Cholesterol Level
• Triglycerides

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• CXR and Fluoroscopy
• ECG

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 PHYSICAL ASSESSMENT
Focused cardiac physical examination includes
evaluation of the following:
1. Effectiveness of the heart as a pump
2. Filling volumes and pressures
3. Cardiac output
4. Compensatory mechanism

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 PHYSICAL ASSESSMENT
1. General appearance & cognition
2. Inspection of the skin
3. Blood pressure (Pulse Pressure, Orthostatic
Hypotension)
4. Arterial Pulses (Pulse Rate, Rhythm, Quality
Configuration)
5. Effect of Vessel quality on pulse (Jugular
Venous Pulsation)
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 PHYSICAL ASSESSMENT
6. Heart Inspection & Palpation
a. Aortic Area
b. Pulmonic Area
c. Erb’s Point
d. Right Ventricular / Tricuspid Area
e. Left Ventricular / Apical Area
f. Epigastric Area

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 PHYSICAL ASSESSMENT
7. Chest Percussion
8. Cardiac Auscultation
a. Heart Sounds (S1, S2, & Gallop, Snaps &
Clicks, Murmurs, Friction Rub)
8. Interpretation of Cardiac Sounds
9. Inspection of Extremities
10. Other Systems (Lungs & Abdomen)

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 Other Test
• Cardiac computerized tomography (CT) or magnetic resonance
imaging (MRI). These tests can be used to diagnose heart
problems, including the extent of damage from heart attacks. In
a cardiac CT scan, you lie on a table inside a doughnut-shaped
machine. An X-ray tube inside the machine rotates around your
body and collects images of your heart and chest.
• In a cardiac MRI, you lie on a table inside a long tubelike
machine that produces a magnetic field. The magnetic field
aligns atomic particles in some of your cells. When radio waves
are broadcast toward these aligned particles, they produce
signals that vary according to the type of tissue they are. The
signals create images of your heart

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 Complications
DARTH VADER
Death
Arrhythmia/heart block
Ruptured myocardium
Thrombus (mural)
Heart failure/cardiogenic shock or arrest

Ventricular aneurysm/septal rupture

Another MI
Dressler's syndrome (and pericarditis)
Emboli
Regurgitant murmur/ventricular septal
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defect
 Management
MONA
Morphine
Oxygen
Nitrates
Aspirin

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 RHYTHM & MANAGEMENT
• Conduction System ***

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 RHYTHM & MANAGEMENT
• The Electrocardiogram
ECG monitoring purposes:
1. Monitor a patient’s heart rate
2. Evaluate the effects of disease or injury on the
heart function
3. Evaluate pacemaker function
4. Evaluate the response to medication
5. Obtain baseline data
6. Evaluate signs of MI, injury and infarction
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 RHYTHM & MANAGEMENT
• The Electrocardiogram
Electrodes – applied at specific locations on the
patient’s chest wall and extremities

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 RHYTHM & MANAGEMENT
• The Electrocardiogram
Leads – it records the electrical activity between
the two electrodes.
It allows for the viewing of the hearts electrical
activity in two different planes:
1. Frontal (coronal)
2. Horizontal (Transverse)

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 RHYTHM & MANAGEMENT
It allows for the viewing of the hearts electrical
activity in two different planes:
1. Frontal (coronal)
 Superior
 Inferior
 Right
 Left

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 RHYTHM & MANAGEMENT
Standard Limb Leads

• Leads I, II, & III

• Right arm electrode is always negative
• Left leg electrode is always positive

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 RHYTHM & MANAGEMENT
Standard Limb Leads

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 RHYTHM & MANAGEMENT
Leads aVR, aVL, and aVF
 a – Augmented
 V – Voltage
 R – Right arm
 L – Left arm
 F – Foot (Usually of the left leg)

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 RHYTHM & MANAGEMENT
Augmented Limb Leads
• aVR
• aVL
• aVF

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 RHYTHM & MANAGEMENT
• The Electrocardiogram
2. Horizontal (Transverse)
Directions
• Anterior
• Posterior
• Right
• Left

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 RHYTHM & MANAGEMENT
• The Electrocardiogram
Chest Leads
6 chest leads view the heart in the horizontal
plane
V1 V4
V2 V5
V3 V6

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 RHYTHM & MANAGEMENT
• The Electrocardiogram

Right Chest Leads – used to view the right

ventricle

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 RHYTHM & MANAGEMENT
• The Electrocardiogram

Posterior Chest Leads

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 RHYTHM & MANAGEMENT
• Electrocardiography Paper

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• P wave
 Produced by depolarization of
both atria
 Duration: 0.08 – 0.10 sec

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• QRS Complex
 Produced by depolarization of
both ventricles
 Duration : 0.06 – 0.10 sec

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• ST Segment
 Measures time between
Ventricular depolarization &
Beginning of repolarization

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• T Wave
 Reflects ventricular
Repolarization & relaxation

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• PR Interval
 Starts from beginning of
Atrial contraction to the
Beginning of ventricular
Contraction
 0.12 – 0.20 sec

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• QT Interval
 Measured from beginning
Of QRS to end of T wave
 0.38 sec

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 RHYTHM & MANAGEMENT
• Waveforms & Complexes
• PR Segment
 Part of the PR interval
 Horizontal line between
The end of the P wave and
The beginning of the QRS
Complex
 Normally isoelectric (flat)
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 RHYTHM & MANAGEMENT
• Segments & Intervals
• TP Segment
 End of T & onset of P

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 RHYTHM & MANAGEMENT
• ST Segment Deviation
Possible shapes of ST Segment elevation that
may be seen with acute MI
ST segment depression – Myocardial Ischemia

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 RHYTHM & MANAGEMENT
• U Wave – Electrolyte Imbalance
 Follows T Wave
 Most easily seen with slow heart rate
 Represents repolarization of Purkinje Fibers
 Prominent U-wave - Hypokalemia

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 RHYTHM & MANAGEMENT
• Hypokalemia
 ST depression
 Flattened T wave
 Inverted T wave

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 RHYTHM & MANAGEMENT
• Hyperkalemia
 Tall and peaked T wave
 Prolonged PR interval
 Widened QRS interval

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 How to analyze a Rhythm
• CONFIGURATION
• RATE
• RHYTHM

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 How to analyze a Rhythm
• CONFIGURATION
 Check for the presence of P wave
 Check for the characteristics of P wave
 Clear & upright = sinus
 P wave:QRS ratio = 1:1
 Unclear P wave, not definite,
Unidentifiable = atrial configuration
 Purely QRS Complex = ventricular configuration
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 How to analyze a Rhythm
• RATE
6 second strip = get the #’s of R waves x 10

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 How to analyze a Rhythm
• RHYTHM
 Regular – Cardia
 Irregular - Dysrhytmia/Arrhytmia

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 Heart Rhythm
1. Normal Sinus Rhythm

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 Heart Rhythm
2. Sinus Bradycardia

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 Heart Rhythm
3. Sinus Tachycardia

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 Heart Rhythm
4. Sinus Arrhytmia

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 Heart Rhythm
• Supraventricular Tachycardia
1. Atrial Tachycardia

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 Heart Rhythm
• Supraventricular Tachycardia
2. Atrial Flutter

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 Heart Rhythm
• Supraventricular Tachycardia
3. Atrial Fibrillation

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Kinds:
a. Unifocal PVC
b. Multifocal PVC

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Types:
1.PVC in Bigeminy

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Types:
2.PVC in Trigeminy

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Types:
3.PVC in Quadrigeminy

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Types:
4.PVC in Couplets

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 Heart Rhythm
• Ventricular Rhythms
1. Premature Ventricular Contraction
Types:
5.PVC in Triplets

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 Heart Rhythm
• Ventricular Rhythms
1. Ventricular Tachycardia
Types:
a. Monomorphic

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 Heart Rhythm
• Ventricular Rhythms
1. Ventricular Tachycardia
Types:
a. Polymorphic

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 Heart Rhythm
• Ventricular Rhythms
1. Ventricular Fibrillation

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 Heart Rhythm
• Ventricular Rhythms
1. Asystole

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 Heart Rhythm
• PEA

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 Quiz
1. You are called to the home of a 48 y/o woman
whose chief complaint is "I almost fainted when I
got out of bed." She has been ill for 2 days with
nausea, vomiting and diarrhea. She had a
temperature until this am when it finally broke. She
feels dizzy when she sits or stands up. Her skin is
cool and clammy. Her color is pale. Her pulse is 130.
Her BP is 88/64 and her Respirations are 18. Pulse
Ox reading is 96% on room air. She has no medical
history.
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 Quiz
1. She is placed on the cardiac monitor which
reveals the following rhythm. This rhythm is

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 Quiz
1. She is placed on the cardiac monitor which
reveals the following rhythm. This rhythm is
2. This rhythm is treated by
a. Administering adenosine 6mg IV fast push
b. Finding the underlying cause and correct it
c. Synchronized cardioversion @ 50J
d. Vagal Maneuvers

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 Quiz
1. She is placed on the cardiac monitor which reveals
the following rhythm. This rhythm is
2. This rhythm is treated by
3. Based on this patient's history, her tachycardia is
most likely caused by
a. Vertigo
b. Underlying Arrythmia
c. Dehydration
d. Heart Disease
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 Quiz
1. She is placed on the cardiac monitor which
reveals the following rhythm. This rhythm is
2. This rhythm is treated by
3. Based on this patient's history, her
tachycardia is most likely caused by
4. The next step in her treatment should be

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 Quiz
4. The next step in her treatment should be
a. O2
b. Normal Saline Solution Bolus
c. Dextrose 50%
d. Transcutaenous Pacemaker

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 Quiz
4. The next step in her treatment should be
5. Which of the following is TRUE regarding Sinus
Tachycardia.
a. Often represents heart rate above 200bpm
b. Always requires the administration of adenosine
c. It is always compensating for an underlying
cause
d. It is always a life threatening arrythmia

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 Quiz
4. The next step in her treatment should be
5. Which of the following is TRUE regarding Sinus
Tachycardia.
6. In what way does Sinus Tachycardia differ from
Normal Sinus Rhythm?
a. The heart rate is above 100bpm
b. The QRS is wider
c. The rhythm is irregular
d. The PR interval is longer
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Airway Management

Oxygenation & Ventilation

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 Lung Volume & Capacities
• Inspiratory Capacity – the volume of gas that can
be taken into the lungs in a full inhalation
• Functional Reserve Capacity – the volume left in
the lungs after a normal exhalation
• Vital Capacity – total amount of air that can be
exhaled after a maximal inspiration
• Total Lung Capacity – total volume of the lungs at
maximum inhalation
• Minute Volume – breaths/minute
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 Devices for assessing
oxygenation and ventilation
• Pulse Oximetry

• Calorimetric Captometer – continuous analysis

and recording of CO2 concentration in
respiratory gases
- Enables the early recognition of
hypoventilation, apnea and airway obstruction

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 Oxygen Delivery Devices
• Nasal Cannula
 Delivered 1-6L/min
 Oxygen concentration approximately 22%-45%
Advantages:
 Comfortable & well tolerated by patients
 No rebreathing of expired air
 Useful for patients who are predisposed to
carbon dioxide retention
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 Oxygen Delivery Devices
• Nasal Cannula
Advantages:
 Can be used for patients who require oxygen
but who cannot tolerate a nonrebreather
mask
Disadvantages:
 Can only be used in a spontaneously breathing
patient
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 Oxygen Delivery Devices
• Nasal Cannula
Disadvantages:
 Can only be used in a spontaneously breathing
patient
 Easily displaced
 Involves a drying of mucosa that may cause sinus
pain
 Oxygen flow rates of more than 6L/min do not
enhance delivered oxygen concentration
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 Oxygen Delivery Devices
• Simple Mask
 At 6-10L/min, this device can deliver an
inspired oxygen concentration of
approximately 35%-60%.
Advantages:
 Higher oxygen concentration

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 Oxygen Delivery Devices
• Simple Mask
Disadvantage:
 Not well tolerated by severely dyspneic
patient
 Requires a tight seal

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 Oxygen Delivery Devices
• Partial Re-Breather Mask
 Delivers approximately 35% to 60% oxygen
flow with rates of 6-10L/min
Advantages:
 Higher oxygen concentration delivered than
by nasal cannula

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 Oxygen Delivery Devices
• Partial Re-Breather Mask
Disadvantages:
 Potential suffocation hazard

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 Oxygen Delivery Devices
• Non – ReBreather Mask
 Can deliver up to 60%-80% oxygen at 10L/min
 Fill reservoir before use
Advantages:
 Higher oxygen concentration delivered than
by the other types

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 Oxygen Delivery Devices
• Non – ReBreather Mask
Disadvantages:
 Mask must be fit snugly on the patients face

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 Manual Airway Maneuvers
• Head Tilt Chin Lift

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 Manual Airway Maneuvers
• Jaw Thrust

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 Suctioning
• Possible Complications
1. Hypoxia
2. Arrhymias
3. Increased intracranial pressure
4. Local swelling
5. Hemorrhage
6. Tracheal trauma

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 Suctioning
• Possible Complications
7. Bronchospasm
8. Bradycardia & hypotension
9. Tachycardia
10. Hypertension

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 Airway Adjuncts
• Oral Airways
1. Oropharyngeal Airway

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 Airway Adjuncts
• Oral Airways
1. Oropharyngeal Airway

3 way insert
2. Hard Palate
3. Side of the mouth
4. Pushing the tongue with depressor directly

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 Airway Adjuncts
• Nasal Airway
1. Nasopharyngeal Airway

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 Airway Adjuncts
• Nasal Airway
1. Nasopharyngeal Airway

 For semi-conscious patient, oral trauma

 Size F-24-26, M-28-30
 Measure from nostril to earlobe

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 Techniques of
Positive Pressure Ventilation
1. Mouth-to-mouth Ventilation
2. Mouth-to-Barrier Device Ventilation
3. Mouth-to-Mask Ventilation
4. Bag-Mask Ventilation

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Cricoid Pressure “Sellick Maneuver”

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 Cricoid Pressure “Sellick Maneuver”

• Technique applied during ET intubation, used

by either prevent regurgitation, or to assist
with visualization of the glottis by a
practitioner attempting intubtaion.

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 Advance Airway
• Esophageal-Tracheal Combitube
- A blind insertion airway device often used in
the pre-hospital and emergency setting.

• Laryngeal Mask Airway

- Inserted into the pharynx to maintain patent
airway

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Endotracheal Tube

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 Endotracheal Tube
• The placement of a flexible tube into the trachea
Advantages:
1. Keeps a patent airway
2. Enables delivery of high concentration of oxygen
3. Protects airway from aspiration
4. Permits suctioning of airway secretions
5. Provides alternative route for administration of
certain drugs

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 Endotracheal Tube
• Indication for Emergency Endotracheal
Intubation
1. The inability of the provider to ventilate the
unconscious patient adequately with a bag-
mask device
2. The absence of airway protective reflexes

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 Endotracheal Tube
• Complication of Intubation
1. Trauma to the lips, teeth, and soft tissues of
the airway
2. Bronchial intubation
3. Laryngospasm
4. Post-intubation hoarseness and sore throat

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 Endotracheal Tube
• Preparation of Equipment
1. Inspect laryngoscope for serviceability
2. Tube size
3. Endotracheal tube cuff
4. Malleable stylet
5. Lubrication
6. Laryngeal spray
7. Inspect resuscitator for serviceability
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 Endotracheal Tube
• Confirmation of tube placement
1. Colorimetric Device
2. Esophageal Detector Device
3. Wave form capnography
4. Direct visualization of ET tube passing through the
vocal cords
5. Bilateral breath sounds
6. Absence of air movement during epigastric
auscultation
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 Basic Emergency
Pharmacology
• Sinus Bradycardia
1. Atropine Sulfate
Dose Interval No. of doses
0.5mg 3-5 minutes 6 doses
0.5mg
3mg

2. Dopamine-Epinephrine Infusion
2-5mcg/kg/min

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 Basic Emergency
Pharmacology
• Atrial Tachycardia - Adenosine
Dose Interval Num. of doses
6mg 2 mins 3 doses
12mg
12mg

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 Basic Emergency
Pharmacology
• Atrial Flutter
Name Dosage Interval No. of dosage
Verapramil 2.5 -5mg 15-30 minutes 3
5-10mg
20

Metoprolol 5mg 5 minutes 3

5mg
15mg-30mg

Amiodarone 300mg 10 minute

150mg/min infusion
2.2 gram/24 hours

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 Basic Emergency
Pharmacology
• V-tach /V-fib
1. Epi – initial 1mg – subsequent 1mg 3-5 mins
2. Vasopressin 40 units replacement of 1st and
2nd dose of epi
3. Amiodarone – 2 consecutive results of
pulseless Vtach/Vfib
4. Lidocaine – 1-1.5mg/kg – 0.5-0.75mg/kg – 5-
10minute interval- 3mg/kg (if amiodarone is
not available)

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