1. EMERGENCY MEDICINE TRAINING
RESUSCITATION
Presented By:
Dr. Murad Karajah
Thursday,1st of Dec,2011

2. Adult Cardiopulmonary Resuscitation
• Survival from in-hospital cardiac arrest
has been reported to be 17%
• The survival is dependent on the actions
of many people, acting as a team
 The most important new recommendation
chest compressions.
And change A-B-C to C-A-B

3. Adult Cardiopulmonary Resuscitation
 patients with a witnessed VF arrest, or
time is< 5 minutes, ear ly
def ibr i l lat ion is the prefer red
However, in patients un witnessed VF
arrest, or an arrest of unclear length of
time Ini t ial CPR has been shown
to improve outcomes

4. The New Guidelines Recommend
 It is now recommended that rescuers should
make chest compressions , at a rate at least 100
compressions per minute
 Another recent change to the guidelines for
CPR has been the recommendation of a ratio of
30 compressions to 2 ventilations
The only exception is for rescuer CPR
delivered to newborn and pt with respiratory
arrest .
 The chest compressions should depress the
adult sternum at least 2 inches, rather than the
previous recommendation of 1 ½ to 2 inches

5. The New Guidelines Recommend
• If an advanced airway is in place delivery of
respirations should occur without pauses in
compressions at a rate of 8–10 per minute

6. The New Guidelines Recommend
Airway Management And Ventilation
• Rescue breathing and airway management are
of less importance than uninterrupted chest
compressions
• Insertion of (ETT) may not be the critical
airway/ventilation management intervention
• All breaths, whether delivered by (BVM) or
advanced airway device should be done over 1
second and at a rate of approximately 12BPM.
Hyperventilation should be avoided

7. Approach To Cardiac Arrest And
Life-Threatening Arrhythmias
• Cardiac arrest is characterized by an
abrupt LOC because of absence of
blood flow
• The most common electrical
mechanisms of cardiac arrest are the
ventricular tachyarrhythmia's

8. Adult BLS Healthcare Providers
• Patient unresponsive or gasping
First: call help or send some one to do this
Second: check pulse if present give 1 breath q 5
sec check P q 2 min
no pulse start Compression 30 then 2 breath
3d check rhythm- if shockable give one shock
then CPR 2 min
not shockable start CPR 2 min then check again
rhythm until patient start to move or ALS
provider take over
Un Shockable rhythm – a systole – pulseless
electrical activity

9. Adult Cardiac Arrest Shout for help/active EMS
START CPR
GIVE O2
ATTACH MONITOR
ASYSTOLE
PEA
VF/VT
SHOCK
RHYTHM
SHOCHABLE
CPR 2 min
EPINEPHRINE
every 3-5 min
Consider advanced AW
Give shock then CPR for 2 min
Iv access
YES
YES
NO
NO
CPR 2 min
Iv epinephrine every 3-5
min
Consider advanced AW
CHECK RHYTHM
TREAT
REVERSIBLE
CAUSE
If rhythm shockable give 3d
shock
Then start amiodarone
Treat reversible cause
Rhythm
SHOCKABLE
CPR

10. Post Cardiac Arrest Care
 After return to spontaneous circulation
 optimize ventilation and oxygenation by
 O2 sat < 94%
 Don’t hyperventilate
 Considered intubation
 Treat hypotension
 give IV fluids bolus
 If no response give vasopressore infusion
 Do ECG 12 leads
 Patient not follow commands consider induced
hypothermia
 Signs of AMI cardiac reperfusion is indicated

11. CPR Quality
• Push hard (>=2inches [5cm]) and fast (>=100/min) and allow complete chest recoil
• Minimize interruptions in compressions
• Avoid excessive ventilation
• Rotate compressor every 2 minutes
• If no advanced airway, 30:2 compression-ventilation ratio
• Quantitative waveform capnography
-If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality
Return of spontaneous Circulation (ROSC)
• Pulse and blood pressure
• Abrupt sustained increase in PETCO2 (typically>40 mm Hg)
• Spontaneous arterial pressure waves with intra-arterial monitoring
Shock Energy
• Biphasic: Manufacturer recommendation (120-200 J);if unknown, use maximum available. Second and subsequent
doses should be equivalent, and higher doses may be considered.
• Drug Therapy
• Monophasic:360 J
• Epinephrine IV/IO Dose:1 mg every 3-5 minutes
• Vasopressin IV/IO Dose:40 units can replace first or second dose of epinephrine
• Amiodarone IV/IO Dose: First dose:300 mg bolus. Second dose: 150 mg.
Advanced Airway
• Supraglottic advanced airway or endotracheal intubation
• Waveform capnography to confirm and monitor ET tube placement
• 8-10 breaths per minute with continuous chest compressions
Reversible causes
• Hypovolemia -Tension pneumothorax
• Hypoxia -Tamponade, cardiac
• Hydrogen Ion (acidosis) - Toxins
• Hypo-/hyperkalemia -Thrombosis,pulmonary
• Hypothermia -Thrombosis,coronary

12. Adult Bradycardia
yes
symptomatic
NO
No symptoms
Just observation
Under monitor
symptoms:
Hypotension
Mental changes
Shock
Chest pain
Acute heart failure
HR >50 bpm
Identify the cause
Started ABCs IV access
Give O2 Monitor ECG
12 Leads
Give atropine If not effective transfer
for pacing Or adrenalin Or dopamine

13. Adult Tachycardia With Pulse
Wide
QRS < 0.12
Synchronized
cardioversion
yes
NO
NO
YES
IDENTIFY AND TREAT
UNDERLYING CAUSE
ABCS
O2 therapy
Iv access
BP monitoring
Symptoms :
Hypotension
Chest pain
Mental status changes
Shock
IHD
Acute heart failure
Considered
adenosine
Antiarrhythmic
IV access
Vagal
maneuver
B blocker
Ca blocker
HR<150

14. Doses/Details
Synchronized Cardioversion
Initial recommended doses:
• Narrow regular: 50-100 J
• Narow irregular: 120-200 J biphasic or 200 J monophasic
• Wide regular: 100J
• Wide irregular: defibrillation close (NOT synchronized)
Adenosine IV Dose
First dose: 6 mg rapid IV push: follow with NS flush.
Second dose:12 mg if required.
______________________________________
Antiarrhythmic Infusions for Stable Wide=QRS Tachycardia
Procainamide IV Dose:
20-50 mg/min until arrhythmia suppressed. hypotension ensues.
QRS duration increases>50%.or maximum dose 17 mg/kg given.
Maintenance infusion:1-4 mg/min. Avoid if prolonged QT or CHF.
Amiodarone IV Dose:
First dose: 150 mg over 10 minutes.
Repeat as needed if VT recurs.
Follow by maintenance infusion of 1 mg/min for first 6 hours.
Sotalol IV Dose:
100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

15. Approach to patient with arrhythmia
Identify and treat underlying cause
 Maintain patent airway: assist breathing as
necessary
 Oxygen if hypoxic
 Cardiac monitor
 Monitor blood pressure
 Iv access
 12 leads ECG
 don't delay therapy

16. Persistent tachyarrhythmia
causing
• Hypotension
•
• Acute altered mental status
•
• Acute heart failure
• Ischemic heart disease
• Signs of shock

17. Sinus Bradycardia

18. First degree AV Block
• Causes
Medication
Ischemic heart disease
Hypothyroidism
• Sinus bradycardia
• P wave before QRS
• PR interval < 0.2 sec

19. Second Degree AV Block:
Type 1 – Wenkenbach
Causes
Inferior MI
Digoxin toxocity
P
• consists of progressive
prolongation of the PR
interval until
a nonconducted P wave
occurs
PR

20. Second-Degree AV Block, Type II
• Most patients will require
permanent pacemaker
• the PR interval remains
constant with intermittent
conduction
of atrial impulses
Conduction block below the
AV node.

21. Third Degree AV Block:
Complete AV Block
• These patients require
transvenous pacer
placement for
stabilization
• occurs when there is no
AV conduction. P waves
• and QRS complexes exist
independently of each
other
• ventricular escape beats
typically occur at a rate of
about 40 beats/min.

22. Sinus Tachycardia
Causes include
• pain, fear, anxiety,
• fever, hypovolemia,
• pulmonary embolism,
hyperthyroidism,
• CHF, ischemia,
• sepsis,
• alcohol, nicotine, caffeine,
catecholamine's,
atropine, anticholinergic
toxicity, and herbal weight
• accelerated sinus node
discharge at a rate
Higher than 100 beats/min.
Normal
• P wave
• PR interval, and
• QRS complex

23. SVT – Supraventricular Tachycardia
CAUSES
• IHD
• catecholamine's,
• COPD, digoxin toxicity,
rheumatic heart disease,
• (MVP), alcohol,
electrolyte abnormalities,
• accessory pathways such
as (WPW).
• ectopic pacemaker or
reentry
Most SVTs are AV nodal
reentrant tachycardia's
• narrow QRS complexes
• P waves are often
absent

24. Management of SVT
• Carotid massage
• A denosine,
• Beta blockers,
• Calcium-channel blockers,
• Amiodarone,
• Procainamide,
• Synchronized cardioversion. If the
patient’s condition is unstable

25. Atrial Fibrillation
Causes
• hypertension,
• rheumatic heart disease,
• coronary artery disease
hyperthyroidism,
• COPD,
• CHF, and
• alcohol intoxication
• multiple areas of atrial
myocardium continuously
Discharging and contracting
The atrial rate is between
400 and 600
• ventricular contraction
rate <100 beats/min, it is
• termed atrial fibrillation
with rapid ventricular
response

26. Management of atrial fibrillation
 If the duration of atrial fibrillation is less than 48 hours or no
thrombus is present on TEE - Treatment
• chemical (pharmacological)
• or electrical cardioversion.
 If the patient’s condition is unstable, immediate sedation and
synchronized cardioversion is indicated(100–200 J is usually
effective).
 If the duration of AF more than 48 hrs the treatment focused
to rate control
• Calcium-channel blockers and beta blockers are first-line
agents
• Then plan for cardioversion after 3-4 wk of anticoagulation

27. Atrial Flutter
Causes
• CAD
• AMI.
• CHF,
• pulmonary embolus
• myocarditis,
• digoxin toxicity
• a localized area of ectopy
in the atrium
• regular atrial rate
between 250 and 350
beats/min
• The degree of AV block
is usually 2:1 but may be
greater

28. Management of flutter
• Treatment is directed at controlling the
ventricular rate.
Calcium-channel blockers and beta blocker
are first-line
• Chemical and electrical cardioversion may
also be considered. If
• the patient’s condition is unstable,
immediate sedation and synchronized
• cardioversion is indicated (0.5–1 J/kg is
usually effective).

29. Ventricular Tachycardia (Monomorphic)
Polymorphic Ventricular Tachycardia – Torsade de •
Pointes
• VT occurs when more than three depolarization's
occur from a ventricular focus.
• VT less than 30 seconds duration is termed
nonsustained ventricular tachycardia.
• QRS complex is generally wide and regular
• rate higher than 100 beats/min (usually 150–200)

30. Management of VT
• The most common causes of VT are ischemic heart disease .
Other common causes include
• MVP, HOCM, hypoxia, electrolyte abnormalities,
• Treatment is administered according to ACLS guidelines.
• Amiodarone and lidocaine are first-line agents for stable VT.
• Magnesium, procainamide, and bicarbonate can also be
considered
• for refractory VT. If the patient’s condition is unstable,
immediate sedation and synchronized cardioversion are
indicated.

31. VENTRICULAR FIBRILLATION
• Treatment is administered
according to
ACLS guidelines.
• there are no organized
depolarization or
contractions of the ventricles.

32. ACUTE CORONARY SYNDROM
Symptoms suggest IHD
Emergency assessment :out clinic
Monitor-IV access- bed rest
Aspirine-O2 therapy – nitroglycerin – morphine
Obtain ECG –
If ST elevation transfer urgent to hospital
If considering fibrinolysis give prehospital
Time should be recorded
ED assessment- <10 min
review rapid history ,physical exam , ECG, Monitor, cardiac enzyme,O2
Portable x ray , coagulation study
Review complete fibrinolytic checklist
Treatment in the emergency department :
O2 therapy >94% , morphine , NTG , ASA

33. ECG finding
Normal or non
specific
changes
ST or new LBBB
Strongly suggest acute
myocardial injury
ST or T wave inversion
High risk for unstable
angina or NSTEMI
Start therapy
Don’t delay reperfusion Trop or high risk patient
consider early invasive
strategy if :
Recurrent chest pain
Recurrent st depression
Ventricular tachycardia
Hemodynamic instability
Signs of heart failure
Observation
Serial ECG
Enzymes
Non invasive
<12hr
Time of cardiac test
symptoms
<12 hr
Reperfusion
Door to Pallone
PCI 90 min
Door to
fibrinolysis 30
min
Start treatment by
-NTG - -Heparin
-ASA - B blocker
- Clopidogrel - ACEI/ARB
Statin therapy
Any changes
consider
invasive test

34. ADULT SUSPECTED STROK
Candidate for
Fibrinolytic
Consult neurologist&
Neurosurgery
Need admission
SIGNS&SYMPTOMS
Active EMS
ASSESSMENT AND ACTION
ABCs and give o2
Obtain iv access
Check glucose
Obtain 12 leads ECG
Order if possible urgent brain CT
Alert hospital
Hemorrhagic Yes Ischemia No
CT showed
bleeding
Give Rtpa
And give ASA
Heparin after
24 h
Yes No
ASA

35. Thank You