Download - Pals dru dri,defib,dys 2011
![Page 1: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/1.jpg)
Dysrhythmias, Drugs, Drips, and Defibrillation
Pediatric ConsiderationsTerri M. Repasky MSN, RN, CEN, EMT-PClinical Nurse Specialist - Emergency
![Page 2: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/2.jpg)
Dysrhythmias
• Rhythm disturbances are an uncommon cause of cardiovascular arrest in children
• In pediatrics we use three classes of rhythms
![Page 3: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/3.jpg)
Rhythm group by pulse rate
• Slow pulse = bradyarrythmia
• Fast pulse = tachyarrhythmia
• Absent pulse = collapse rhythms
![Page 4: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/4.jpg)
Slow Pulse
![Page 5: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/5.jpg)
Fast Narrow Pulse
![Page 6: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/6.jpg)
Fast Wide Pulse
![Page 7: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/7.jpg)
NO Pulse
![Page 8: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/8.jpg)
Things to Consider
• Is the patient stable or unstable ?
• Is the patient’s condition causing the rhythmOR is the rhythm causing the condition?
• Is the rhythm causing the patient to be unstable ?
![Page 9: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/9.jpg)
Assessment of Cardiovascular Function
• Ventilation and Oxygenation
• Heart Rate
• End-organ perfusion
• Peripheral pulses
• Skin signs
• LOC
• Blood pressure
![Page 10: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/10.jpg)
Pulses Blood Pressure
• Compensated Shock
• Hypotensive Shock
![Page 11: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/11.jpg)
Blood Pressure
Cardiac Output = Heart Rate x Stroke Volume
![Page 12: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/12.jpg)
Back to Pulses
• Is it fast, slow, or absent?• Is perfusion compromised?• Are the ventricular complexes wide or
narrow?• Is there a diagnostic pattern to the EKG?
![Page 13: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/13.jpg)
Sinus Tachycardia
![Page 14: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/14.jpg)
Supraventricular Tachycardia
![Page 15: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/15.jpg)
Fast Pulse Narrow Ventricular Complex
• Sinus Tachycardia• Supraventricular Tachycardia
![Page 16: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/16.jpg)
Fast Pulse Narrow Ventricular Complex
• Sinus Tachycardia
• Possible history of fever, pain, volume loss (diarrhea, vomiting, bleeding, trauma), anxiety, meds
• Supraventricular Tachycardia
• Nonspecific history of irritability, lethargy, poor feeding, tachypnea, sweating, pallor or hypothermia
![Page 17: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/17.jpg)
Fast Pulse
• Tachycardia appropriate for the clinical condition
• Tachycardia excessive for the clinical condition
![Page 18: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/18.jpg)
Fast Pulse
• Tachycardia appropriate for the clinical condition
• Sinus Tachycardia (ST)
• Tachycardia excessive for the clinical condition
• SupraVentricular Tachycardia (SVT)
![Page 19: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/19.jpg)
Fast Pulse Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT) or
• Sinus Tachycardia (ST) ???
![Page 20: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/20.jpg)
Fast Pulse Narrow Ventricular Complex (QRS)
• Is it Supraventricular Tachycardia (SVT) or
• Sinus Tachycardia (ST) ???
History and Heart Rate are big clues
![Page 21: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/21.jpg)
Fast Pulse Narrow Ventricular Complex
Heart Rate Probable SVT> 180 Children> 220 Infants
![Page 22: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/22.jpg)
Fast Pulse Tachycardia excessive for the clinical condition
(not Sinus Tach)
Stable, Perfusing Patient
• Narrow QRS (probable SVT)
• Wide QRS (probable VT)
• Vagal Maneuvers• Adenosine• Expert Consultation• Amiodarone or
Procainamide• Treat possible contributing factors
• Expert Consult• Amiodarone or
Procainamide• Treat possible contributing factors
![Page 23: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/23.jpg)
Fast Pulse Tachycardia excessive for the clinical condition
Unstable Patient, Poor Perfusion
• Narrow QRS (probable SVT)
• Wide QRS (probable VT)
• Synchronized Cardioversion• (may try Adenosine if it does not delay electrical cardioversion)
![Page 24: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/24.jpg)
Fast Pulse Tachycardia appropriate for the clinical condition
• Consider the cause….
• Treat the cause !
![Page 25: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/25.jpg)
Slow PulseStable Patient
Sinus Bradycardia Heart Blocks
• Consider the cause– Prolonged hypoxemia– Drugs
![Page 26: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/26.jpg)
Slow Pulse
• Consider the cause:
• 6 H’s and 5 T’s Hypovolemia Hypoxemia“Hydrogen Ion” Hypothermia Hypoglycemia Hyper /Hypokalemia
![Page 27: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/27.jpg)
Slow Pulse
• Consider the cause:
• more H’s:Head Injury Heart Block
Heart TransplantHeart Disease
![Page 28: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/28.jpg)
Slow Pulse
• Consider the cause:
• 5 T’sTamponade Tension
PneumothoraxToxins Thrombosis
Trauma
![Page 29: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/29.jpg)
Slow Pulse Unstable Patient, Poor Perfusion
• Oxygenation and Ventilation• Chest Compressions (if heart rate still <60 despite O2 & vents)
• Epinephrine• ? Atropine• Pace Maker
![Page 30: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/30.jpg)
Slow Pulse
• Epinephrine vs Atropine
![Page 31: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/31.jpg)
NO Pulse
• Asystole• Ventricular Fibrillation (VF)• Pulseless Ventricular Tachycardia (VT)• Pulseless Electrical Activity (PEA)
![Page 32: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/32.jpg)
No Pulse
• CPR ? Defibrillate• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes
![Page 33: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/33.jpg)
No PulseAsystole or PEA
• CPR• Ventilate with 100% oxygen• IV or IO access• Epinephrine q 3-5 minutes• Treat Cause!• Perform flat line protocol
![Page 34: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/34.jpg)
No Pulse
• Flat Line Protocol–Check Leads–Check in a different lead–Increase gain or size
![Page 35: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/35.jpg)
No Pulse
•Consider cause:
6 H’s and 5 T’s
![Page 36: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/36.jpg)
No PulsePulseless Ventricular Tachycardia or Fibrillation
• CPR• Defibrillate (as soon as available)• Resume CPR• Rhythm Check (Q2mins), if VF/VT
• Defibrillate• Give Meds• Resume CPR
• Alternate Epi with Amiodarone
![Page 37: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/37.jpg)
Summary of Therapy by Pulse Rate
Fast(adequate perfusion) Vagal Maneuvers, Adenosine or
Amiodarone/Procainamide(poor perfusion) Cardioversion
Slow Ventilation / Oxygenation CompressionsEpi.
Absent CPRVF / VT: DefibrillationPEA/EMD: Identify & treat the cause
Epinephrine
![Page 38: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/38.jpg)
Warning:
Treat the Patient Not the Rhythm
![Page 39: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/39.jpg)
Drugs & Drips
Fluids “Drips” are use for:Volume Replacement & Delivery of Medications
![Page 40: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/40.jpg)
Drips: Fluids of Choice
• Isotonic Crystalloids–Normal Saline–Lactated Ringer’s
• What if your patient is hypoglycemic?
![Page 41: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/41.jpg)
Drugs: Sites for Administration
Peripheral veinsIntraosseousCentral veinsEndotracheal
![Page 42: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/42.jpg)
When would you use an IO ?
![Page 43: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/43.jpg)
When would you use an IO ?
Cardiopulmonary ArrestShock
Intractable seizures
![Page 44: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/44.jpg)
When would you use ET ?
• What drugs can you give down the ET tube?
• L or L• E A• A N• N E
![Page 45: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/45.jpg)
How do I do that? • Dilute the drug with 3-5 ml of NS• Instill directly into tube • Deliver positive pressure breaths
• Or Insert a catheter into ET tube • Instill drug via catheter• Flush with 3-5 ml of normal saline• Deliver positive pressure breaths
1
2
![Page 46: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/46.jpg)
Drugs Dosages: ET / IO
• IO: same dose as IV
• ET:– Epinephrine dose is 10 times greater
0.1 mg/kg (use 1:1,000 strength)– Other drug are increased 2-3 times IV dose
![Page 47: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/47.jpg)
“ Defib.”
Joules per kilogram
![Page 48: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/48.jpg)
Post Arrest Shock
Optimize Ventilation and Oxygenation
Titrate O2 saturation to 94% - 99%
Advanced Airway
Waveform Capnography
Treat shock&
Contributing Factors
![Page 49: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/49.jpg)
Review
• Dysrhythmias - fast, slow, none
• Drugs - Oxygen, Epinephrine
• Drips - Normal Saline
• Defibrillation - rare but know how !
![Page 50: Pals dru dri,defib,dys 2011](https://reader036.vdocuments.pub/reader036/viewer/2022062522/58abfd0a1a28abb6718b4f23/html5/thumbnails/50.jpg)
• Questions ????