2. Algorithms  Bradycardia with a Pulse Stable Cardiopulmonary status Cardiopulmonary Compromise  Tachycardia with Pulses and Poor Perfusion Sinus Tachycardia Supraventricular Tachycardia Ventricular Tachycardia  Pulseless Arrest Ventricular Fibrillation vs. Ventricular Tachycardia Asystole vs. PEA  Septic Shock

3. Steps involved when called to evaluate a patient  Help can be called for at any time!!! The sooner the better!  #1 LOOK AT YOUR PATIENT!! Sick or not sick  #2 Examine  #3 Cardiac Monitor  #4 Check wires/tubing  #5 Call for help and Establish Roles  #6 Identify Algorithm  #7 Resuscitation Supplies/Meds

4. Sick or Not Sick?

5. Sick or Not Sick

6.  http://www.youtube.com/watch?v=XJ- ON24aO9s&feature=BFa&list=PLF7E5E 6EAB1933606 http://www.youtube.com/watch?v=XJ- ON24aO9s&feature=BFa&list=PLF7E5E 6EAB1933606

7. Examine  Get history (RN/family concerns, HPI, hospital course)  Vital signs (trends and current)  Physical Exam (ABC’s) Airway Breathing Cardiovascular

8. Physical Exam  Airway Can patient speak or cry? Look: for respiratory distress (i.e. grunting, flaring retractions), choking, cyanosis Listen: air movement in neck and chest, quality (stridor, wheeze, etc..), I:E, RR Feel: movement from mouth, nose, chest rise, crepitus Assess: can airway be maintained with basic maneuvers/positioning, suction

9. Physical Exam  Breathing Is patient moving sufficient air in and out to maintain effective oxygenation and ventilation? Look: RR, trachea position, symmetry of chest rise, accessory muscles, skin color Listen: symmetry and quality, adequacy of air movement, intrathoracic sounds (stridor, crackles, wheeze) Feel: subcutaneous air, tenderness, instability of chest wall Assess: stable or not? Respiratory failure? BMV? Intubate? Trumpets?

10. Physical Exam  Cardiovascular Adequate circulation to support end-organ function? Look: ○ poor perfusion: cyanosis, mottling, pallor, altered mental status ○ Chest trauma: asymmetry of chest expansion ○ Jugular Venous Distention Listen ○ Heart rate: tachycardic vs. bradycardic vs. normal ○ Heart tones: murmur, rub, gallop ○ Breath sounds: rales vs. wheeze ○ Diminished Breath sounds Feel ○ Central pulses, temperature of skin, capillary refill Assess ○ Adequate vs. inadequate vs. absent

11. Cardiac Monitor  Know what the numbers on the monitor mean  Make sure connections are correct and wires/leads actually attached to the patient Lead placement: White is right, Smoke (black) over fire (red) Waveform Heart rate from leads and pulse oximeter should correlate  If patient on oxygen, make sure connected appropriately to wall with no kinks and cannula/mask placed appropriately

12. Establish Roles  Code Team Team Leader Airway Physician Float Physician Medication Nurse Bedside Nurse Circulating Nurse Documenter Assistants

13. Identify Algorithm Pulse vs. No Pulse PulseNo Pulse Shockable Ventricular Fibrillation Ventricular Tachycardia Not Shockable Asystole Pulseless Electrical Activity

15. What makes a Rhythm Shockable?  The heart is active, but in a life-threatening and dysfunctional pattern. In Ventricular Tachycardia, the heart is unable to pump blood effectively as it is beating too quickly to fill. This will ultimately lead to ventricular fibrillation. At this point the electrical activity in the heart becomes chaotic – again preventing the heart from pumping effectively. Over time, the fibrillation will decrease and the heart will become asystolic from lack of appropriate oxygenation.

16. What makes a Rhythm Shockable?  Defibrillation – for UNORGANIZED rhythms Therapeutic delivery of an unsynchronized electrical current through the myocardium over a brief period to terminate the dysrhythmia Does not jump start the heart Purpose is to depolarize the ventricular cells simultaneously (including fibrillating cells)  asystole  natural pacemakers will resume normal activity

17. What makes a Rhythm Shockable?  Synchronized Cardioversion – for ORGANIZED Delivery of a shock to the heart to terminate a rapid dysrhythmia that is times to avoid vulnerable periods in the cardiac cycle (peak to end of T wave) Heart cells will contract simultaneously  interrupting and terminating the abnormal electrical rhythm without damaging the heart  allowing the sinus node to resume normal pacemaker activity

18. Identify Algorithm Pulse vs. No Pulse Bradycardia Cardiopulmonary system stable? Yes ABC’s Compromise CPR Tachycardia Pulse

20. Identify Algorithm Pulse vs. No Pulse BradycardiaTachycardia Narrow QRS (<.0.8 seconds) Sinus Tachycardia Supraventricular Tachycardia Wide QRS (>0.08 seconds) Ventricular Tachycardia Pulse

22. Rhythms

23. Rhythm