Basic life support (BLS) The goals of resuscitation interventions for patient in respiratory or cardiac arrest to restore and

support effective oxygenation, ventilation, circulation with return impact neural functions. Classification and recommendation and level of evidence 1.Class 1(benefits>>>risks): the procedure, treatment, diagnostic test and assessment should be performed and administered. 2.Class 2A (benefits>>risks): it is reasonable to perform and administered procedure, assessment, diagnostic test, and treatment. 3.Class 2B (benefits>= risks): the procedure and treatment, assessment, and diagnostic test may be considered 4.Class 3 (risks>= benefits) : should not perform or administer treatment, assessment and procedure.. Classification of survey: 1.Primary survey : include basic life support(BLS) 2.secondary survey: advance cardiac life support(ACLS) The BLS primary survey performed by any trained health care providers without advanced interventions and depend on basic ABCD before contact of BLS should check the responsive of the victims, activation EMS and get AED health care provider should assess breathing before get rescue breathing with mask health care provider should assess pulse before initiate chest compression health care provider should assess shockable rhythm before initiate DC shock

Open airway by non invasive method (head tilt and chain left) if patient with neck and head trauma thrust the jaw without extension the head Basic primary survey includes: 1)A(airway) Open airway by non invasive method (head tilt and chain left) if patient with neck and head trauma thrust the jaw without extension the head

2)B(breathing) Look, listen, feel if victims breathing or not, adequate breathing or not If patient breath put he\she in recovery position If victims absent breathing give two rescue breathing each breath in one second and must observe it is rises the chest Do not ventilate fast(rate) or much(volume) to prevent hyperventilation 3)C(circulations) Palpate in adult if carotid pulses are present or not by apply three fingers on carotid artery in the groove area behind the sternomastoid muscles, check should for 5 second and no more then 10 second and unilateral check. Palpate in infant brachial or femoral pulses If no pulses in adult or infant pulse less then 60 beat\min initiate chest compression with adult 30:2 and infant with one rescuer 30:2 or 15:2 if have 2 rescuer Push hard, push fat 100 beat\min( in five cycle 150:10 in two minute) Site of chest compression in adult between nipple in below half of sternum and infant below the nipple level Chest compression method: in adult put on heal of the hand in the site of chest compression and other hand on it. In infant used two thump and both adult and infant make 1\4 depth or 3-5cm.

During chest compression should avoid any interruptions as check pulse, analysis rhythm, airway management and switching the rescuer all of these aspect done after 5 cycle or 2 min to provide adequate level of circulation blood and oxygenation to brain and vital organs If pulses is present and absent breathing give adult 1 breath in 5-6 second and 1 breath in 3-5 second in infant and check pulses every 2 minute 4)D(defibrillation) If patient with shockable rhythm initiate and prepare DC shock Each DC shock or cardioversion must initiate CPR 5 cycle or 2 minute Recovery positions Recover position important in victims because it is provide airway open, remove fluid in the mouth of victims This position called lateral position, and provide spin straight, and put hand in position that maintain any chest compression 1.during responsive victims In adult ask victims is shocking give abdominal thrust (epigastrial thump) or chest thrust if obese or pregnant victims repeat technique until obstruction remove or victims become un responsive In infant confirm infant difficult of breathing, silent cough, cyanosis give 5 back slaps and 5 chest thrust until remove obstruction or victims become unresponsive 2.during unresponsive victims

begin CPR in 5 cycles or 2 minute and look in mouth if big foreign body causes obstruction and able to remove it ACLS secondary survey 1)A(airway) Observe airway is patent and find indication of invasive airway devices used Maintain airway patent in unconscious patient by noninvasive (head tilt and left chain) and invasive airway as OPA (oropharyngeal airway) or NPA (nasopharyngeal airway) Used laryngeal mask airway(LMA) or combitube or ETT 2)B(berating) Observe: oxygen is adequate or not, proper placement of airway devices, are exhaled CO2 or oxyhemoglobin saturated. Assessment adequate oxygenation depend on chest rises during ventilation, oxygen saturation, capnometry or capnography Confirmation of airway placement through : physical examination(5 point air entry, measure CO2 exhaled, esophageal detector devices. 3)C(circulation) Obtain IV, IO and attached monitors leads to analyze rhythm , heart rate Give drug and fluid Observe BP and take blood sample, cross matching 4)Defibrillations Give patient DC or cardioversion is the rhythm is shockable rhythm 5)Assess 6 H's and 6 T's

 H's: hypoxia, hypovolemia, hydrogen (acidosis), hypo\hyper kalmeia, hypoglycemia, and hypothermia. T's: toxin, tamponade(cardiac), tension( pneumothorax), thrombosis, and trauma 6)Assessment of disability Assess GCS , mental status Assess extremities injuries, excessive bleeding Insert Foleys catheters and gastric tube CODE of CPR Role of team member: 1)Organize the group 2)Monitor individual performance of team member 3)Provide excellent team behaviors 4)Train and coach 5)Facilities and understanding all algorithms 6)Focus in competence patient care Role of team member 1)Clear about role and take fulfill responsibilities about her\his tasks 2)Well practiced in resuscitation skill and knowledgeable about algorithm 3)Committed to success Element of effective resuscitation team dynamics 1)Used close loop communications Team leader give massage\order and assignment good eye contact with team member Team leader confirm order and the team member confirm this order before done by repeat the order and after the procedure done by say the procedure done, or the drug given 2)Used clear massages

 All order which delivered by team leader must clear in calm manner without shouting or yielding and speak complete sentences Team member repeat order before done and after done clearly 3)Clear role and responsibilities Each person must know her\his responsibilities to prevent take many manner for one team member, missing the primary role of team member, freelancing one of team member Team leader must clearly identify each team member role Team member must ask if any difficult in her\his task 4)Know one's limitations The team leader should be aware of limitation of each team member The leader should not practiced the team member for new task during CPR to prevent any negative effect Team member should not take new task during CPR 5)Knowledge sharing 6)Constrictive intervention Team leader must intervenes the actions in tactfully manner Team leader should not confront any team member and after CPR criticism him Team leader can suggest alternative drugs, and ask about who is responsible of mistakes 7)Relevance of summarizing The leader to reevaluate the patient status, make massages friendly, and provide deferential diagnosis 8)Mutual respect All team leader and team member must leave Ego regardless any additional training or experienced that the team leader or team member experienced or have it. Leader speak friendly, and controlled of tone voice and avoid shouting

ACLS cases Respiratory arrest Respiratory arrest: complete absent or clearly inadequate respiration to maintain effective oxygenation and ventilations associated with present pulses When patient com with respiratory arrest do the following Ask the patient are you all right Activate emergency responses 911 or AED Patient with asphyxia arrest must do 5 cycle CPR then contact with emergency responses Initiate BLS Patient with respiratory arrest give 1 oxygenation every 5-6 second but patient with respiratory arrest give 1 breath every 10-12 sec Then check pulses in both cases after 2 minute Increase rate (amount) of oxygenation or increase volume lead to increase intra thoracic pressure (decrease venous return and decrease CO), increase gastric inflation, patient aspiration Advance airway management: Include 6 criteria: 1. given and supply oxygen saturation 90% 2. open airway 3. provide basic ventilation management 4. used OPA or NPA management 5. suctions 6. provide ventilation with advance airway management Opening airway

 Upper airway obstruction caused by loss of throat muscles weakness or tongue fall back and occluded the airway Airway open by head tilt and chin left or jaw thrust without head extension if trauma occurs Unconscious patient (no gag reflex, no cough) can placement OPA or NPA to maintain airway potency Is you seen foreign body obstruction airway able by used finger to remove this foreign body Basic air way management: Various devices supplementary oxygen 21-100% Divided to two type 1.non invasive : as oxygen supply cylinder, nasal canula, face mask, ventori mask 2.invasive as OPA, NPA Nasal canula: low flow rate oxygenation provide oxygen up to 44% put in patient nose ratio describe as increase 1L\min increase concentration 4% start at 1l\min maintain oxygen saturation 21-24% 1 L\min 2 L\min 3L\min 4L\min 5L\min 6L\min 12-24% 25-28% 29-32% 33-36% 37-40% 41-44% Face mask low rate oxygenation put in patient nose and mouth with reservoir bag or without reservoir bag with reservoir bag used when 1. patient seriously ill and require high oxygenation concentration 2. avoid ETT in acute intervention as pulmonary edema, COPD , acute asthma 3. have indication of ETT but have high gag reflex , or high clenched teeth in case of high clenched teeth can used tight fitting mask

 Face mask supplement 60% oxygen concentration in flow rate 6L\min(with ratio 1 L\min increase concentration 10% 6L\min 7 L\min 8 L\min 9L\min 10L\min 60% 70% 80% 90% 95-100 Ventori mask More controlled of oxygenation delivery from 24-50% concentration used for patient with COPD or chronic increase CO2 level with sever hypoxemia 4-8L\min 10-12L-min 24-40% 40-50% Bag mask ventilation Consist of self inflating bag and non rebreathing valve used when connect with advance airway tube or face mask to provide positive ventilation pressure Used of bag mask ventilations without advance airway tube causes gastric inflations Bag mask procedure 1. fix on face and press against face 2. provide head tilt 3. mouth to mask ventilation (make C shape of thump and index of one of your hand and press on mask ) Oropharyngeal airway(J shape) used to prevent airway obstructions by the tongue and facilitate suctioning used for unconscious patient after head tilt chain left or thrust the jaw should not used for conscious patient because it is stimulate gag reflex and vomiting technique of OPA insertion: clear mouth and pharynx form secretions select the size of the OPA by put the tip of airway on the corner of the mouth and must reach the angle of mandible and when you insert it must glottis opening

 insert airway that is turned backward then after inserted rotate it 180 degree or same shape insertion by used tongue blade Nasopharyngeal airway used when conscious or semiconscious patient or patient with trauma in mouth or high gag reflex or cough select the size and used lubricants insert gently to prevent lacerate the adenoid tissue and causes bleeding and aspiration Advance airway management Combitube Alternative tube to provide adequate oxygenation and have fetal risk complications Consist of two inflatable tube(100cc and 15 cc) balloon cuff and blind insertion without visualized vocal cord (inserted in esophagus and trachea) Laryngeal mask airway (LMA) Composed of tube with cuffed mask , blind insertion until feel resistance Not used for patient with regurgitation or aspiration (class 3 survey) Endotracheal tube (ETT) during ETT insertion for patient without gagreflex or cough or unconscious patient ask other team member to cricoids pressure Cricoids pressure maintain gastric regurgitation and facilitate insertion of ETT, when pressure in cricoids used thump and index fingers Cricoids : the first prominent below thyroid cartilaginous (Adam's apple) Importance of ETT: 1. keep airway opening and deliver high oxygen rate 2. protect aspiration 3. facilitate suctioning

4. alternate for medication if IV or IO impossible indication of ETT 1. cardiac arrest and bag mask ineffective 2. responses patient but unable to oxygenation 3. patient unable to protect airway(coma, cardiac arrest ETT medication administration protocol 1. Medication given to patient by ETT is: atropine, vasopressin, epinephrine, and lidocain. 2. ETT medication must mixed with 10 cc saline or distal water (saline increase liability absorption in airway especially atropine drugs) 3. The dose of ETT medication high dose than IV or IO equal 2-2.5*(IV or IO dose). 4. after ETT medication given 2 ventilation must be performed to facilitate absorptions Complication of ETT If ETT insertion in esophagus causes patient suffer to brain death and die Confirmation of ETT 1. listen to the 5 point (2 apex, 2 base of the lung, epigastric region) associated with bag mask deliver oxygenation 2. observe chest wall rises 3. gastric sound: gargling sound indicate of the ETT in esophagus exhaled CO2 detectors devices Purpose of defibrillations : to return spontaneous rhythm and maintain spontaneous perused rhythm After defibrillation in the first minute the rhythm spontaneously slowing and no create pulses so must immediate initiate CPR cycle after defibrillation Agonal gap it is a gap in the first minute after sudden cardiac arrest (no responses, no pulses) May used DC shock monphasic or biphasic or AED(automated external defibrillators) if the DC shock machine not known monphasic or biphasic used 200 j

 Monphasic start with 360j and biphasic constant used of 200j VF and pulseless VT Considered victims who unresponsive to BLS and no responsive to the first shock Drugs used in VF and VT vasopressin, epinephrine, amidrone, lidocain, magnesium sulfate VF and VT algorithm include 1. shockable : VT, VF 2. non shock able : PEA and a systole algorithm start by BLS and call helpful team Shockable rhythm (VT, VF) 1. shock : DC shock or defibrillators as protocol 2. immediate 5 cycle CPR and still CPR until defibrillation is charge 3. give other one shock and perform 5 cycle CPR 4. give vasopressin and epinephrine as protocol 5. shock and 5 cycle CPR performed immediate and check rhythm 6. used anti arrhythmias drugs as amidrone, lidocain or magnesium sulfate if torsad de pointes 7. then perform 5 cycle CPR 8. repeated if still VT or VF 9. move to other algorithm if change rhythm Non shockable rhythm (PEA and a systole) 1. 2. 3. 4. 5. 5 cycle CPR vasopressin and epinephrine as protocol considered atropine 5 cycle CPR and check rhythm if still repeated same algorithm but if change used the other algorithm depend on the new rhythm strip produced

during CPR management H's, and T's

 the recommendation of shockable is 3 times non shockable rhythm the QRS are narrowed and regular if temperature less than 30 and patient with VF or VT used hypothermia algorithm (rewarming procedure) then initiate CPR because temperature 30 make unresponsive body to drugs or pacing or defibrillation drug given must followed by 20 cc fluid and rise hand for 10-20 second to facilitate delivery of drugs hypovolemia is the most causes of PEA causes narrow QRS and sinus tachycardia causes of hypovolemia 1. hemorrhage, pulmonary embolism, cardiac tamponade, ischemia 2. peripheral vascular dilation and myocardial dysfunction after given over weighted drugs if you face unclear situation as fine VF or asystole differentiations considered fine VF is a prolong arrest so must initiate 5 cycle CPR then can judged what is the rhythm asystole CPR continued 20 minute out side asystole no need CRP if you witness a systole can perform CPR immediate Drugs of VF, VT Vasopressin Given IV\IO or in ETT Vasopressin given as first or second dose not given as third or more associated with epinephrine Non adregenic peripheral vasoconstrictions Epinephrine Given in dose I mg and repeated it q 3- 5 min

Alpha adregenic : effect to make vasoconstrictions of cerebral and coronary artery to increase MAP and aortic pressure Amidrone: Antiarrhythmia drugs used when patient un responsive to shock Affect of Na, K, Ca channel and considered alpha and beta adregenic blocker During CPR given 300 mg then 150 mg repeated every 3-5 min Maximum amount of amidrone 2.2 gm\24 hr with recurrent VF\ or VT based on cumulative toxicity Recurrent VF\VT prescribed given amidrone as the following 1. 150 mg in 10\min (bolus dose) 2. 360mg\nex 6 hr (1mg\min)and slow infusion 3. 540mg \18 hr (0.5 mg\min) as maintenance dose During amidrone given observe hypotension, bradycardia, GI toxicity Lidocain Antiarrhythmia drugs used if amidrone is not available During CPR given 1-1.5 mg\kg first dose then 0.5-0.75 mg\kg (3 dose) repeated every 5-10 minute The maximum dose of lidocain 3 mg\kg Lidocain followed 1-4 mg\min after CPR Magnesium sulfate Used for patient with torsad de pointes and prolongation of QT interval or patient with severe low magnesium level Given in dose 1-2 gm diluted in 10 ml D5w need (5-20 minute) Atropine IV \IO or ETT given 1 mg every (3-5 min) and give just 3 doses

H's Hypovolemia Hypoxia Hydrogen ions (acidosis) Hyperkalmeia

Indicators Narrow complex, rapid rate, flat jugular vein Slow rate, cyanosis, ABG DM, renal failure, small amplitude QRS complex T wave taller, smaller p wave, QRS wide, RF, DM, dialysis U wave in ECG QT prolong , QRS wide J or Osborn wave Bradycardia

Treatment Volume infusion Oxygenation Sodium bicarbonate glucose pulse insulin, calcium chloride, Sodium bicarbonate, dialysis Infusion potassium, added magnesium

Hypokalemia Hypothermia

Bradydisarrhythmia: arrhythmia disorders with heart rate less than 60 bpm, may found 40-50 bpm in athletes persons Bradycardia with escape rhythm: bradycardia dependant of ventricle rhythm but considered normal myocardial function but with abnormal conduction Functional or relative bradycardia : heart rate 70 bpm in case as cardiogenic shock or septic shock Rhythm of bradycardia: sinus bradycardia, first \second (1, 2)\ third heart block. Complete heart block considered collapse and need TCP Drug of bradycardia : atropine, dopamine(infusion), epinephrine (infusion) Symptoms of bradycardia Chest discomfort and angina pain and SOB Decrease level of consciousness

 Dizziness, syncope, lighteners Weakness, fatigue Sing of bradycardia Orthostatic BP Diaphoresis Pulmonary edema, CHF, PVC Management of bradycardia 1. BLS primary survey and ACLS secondary survey include: A: maintain airway potency B: give patient oxygen and monitor oxygen saturation C: IV access, ECG, Vitals sings D: conduct with the problem and search with contributing factors 2. If poor perfusion must prepare TCP(transcoetaneous pacemaker ), Sins and symptoms of poor perfusion: altered mental status, hypotension, chest pain, and sings of shock. 3. if patient with adequate perfusion still monitored and observation 4. if patient with poor perfusion must initiate the following prepare TCP give patient atropine as protocol of bradycardia give patient epinephrine and dopamine as protocol of bradycardia 5. treat causes under H's and T's and provide consultation Transcoetaneous pacemaker (TCP) TCP produce electrical depolarization and cardiac contraction and impulses, it is also contain defibrillators When apply TCP confirm it is mechanical and electrical capture Patient with hemodynamic instability and AV block type 2 and 3 with wide QRS complex must considered TCP immediately.

 Ischemic patient should not increase heart rate in TCP to not increase demand of oxygen and increase size of ischemia and infarctions Indication of TCP 1. Hemodynamic instability with bradycardia (hypotension, altered mental status, angina, pulmonary edema). 2. Sinus bradycardia, AV blocks, AMI. RBBB, LBBB 3. bradycardia with ventricular escape rhythm 4. tachycardia caused by drugs therapy or cardioversion to organized heart rate Contraindication of TCP 1.hypothermia, asystole 2.conscious patient until delay sedation( benzodiazepines, analgesic) 3.carotid pulse not assess for patient with TCP because TCP produce jerky movement and produce mimic carotid pulse activity When must used TCP if ineffective atropine patient become more symptomatic IV access not quickly established TCP technique Connect the electrical way to machine and connect electrode (one way toward patient and one toward the machine Turn on Put mood fixed(async) or demand(sync) Select heart rate (60 bpm) or as order Set cardiac output until capture occurs Drugs for bradycardia

Atropine: Atropine is the first line given for symptomatic bradycardia but also then can initiate TCP and other drugs in atropine not respond Atropine given in dose 0.5 mg until prepare TCP If TCP ineffective can given atropine according (0.04*KG) with maximum dose 3 mg Atropine not give for patient with ischemia because it is increase oxygen demand by increase heart rate and increase ischemia and increase area of infarction Epinephrine If TCP is ineffective use Dose 2-10 mic\min Dopamine Dopamine alpha and beta adregenic action and can be added to epinephrine or given alone If TCP is ineffective use dose 2-10 mic\min (Chroutropic or heart dose) Pulmonary edema 1.assess BP and insert IV access and foleys catheter 2.give patient morphine, oxygen, nitroglycerin, lasix nitrocin given in dose 10-20 mic\min IV if systolic BP more than 100mm.hg dopamine or dobutamin to enhance pump action (2\10 mic\min) IV norepinephrine 0.5-3 mic\min IV Hypothermia cases Hypothermia patient who is temperature less then 36 1.remove wet garment 2.protect against heat lost and chills by use isolating blanket 3.put patient in horizontal position 4.avoid rough movement and excess activity

5.monitor cardiac rhythm, core temperature, responsive, breath If patient breathe and pulse present management as the following: 1.mild hypothermia( T between 34-36) passive rewarming active external rewarming: hot fluid, hot blanket) 2.moderate hypothermia (T between 30-34) passive rewarming active external rewarming of the truncal area (trunk) 3.sever hypothermia (T <30) IV access with normal saline (T:43) Warmed hummed oxygen (T:42-46) Peritoneal lavage (KCL free from fluid) Esophageal rewarmed tube Extra corporeal rewarming( external body) If breath and pulse absent 1.CPR 5 cycle 2. DC shock 200 biphasic 3.then CPR 5 cycle 4.IV access with normal saline (T:43) 5.Warmed hummed oxygen (T:42-46) 6.Peritoneal lavage (KCL free from fluid) 7.Esophageal rewarmed tube 8.Extra corporeal rewarming( external body) Tachycardia cases Tachycardia increase obtaining in ECG with decrease QT interval Management of tachycardia must start to assess the following: 1. symptomatic or asymptomatic 2. stable or unstable 3. QRS complex wide or narrow 4. rhythm regular or irregular / Unstable tachycardia

Tachyarrhythmia : rhythm of the heart rate more than 100 bpm symptomatic or asymptomatic Tachycardia may be considered stable or unstable Tachycardia lead to decrease cardiac output and lead to CHF and pulmonary edema, and decrease blood flow to vital organs Rhythm of unstable tachycardia: atrial fibrillation, atrial flutter, subraventricular tachycardia (SVT), monomorphic VT, polymorphic VT and wide QRS complex tachycardia with uncertain type. Drugs used in case of unstable tachycardia: cardioversion, sedation Symptoms of unstable tachycardia: SOB, chest pain Altered mental status Weakness, fatigue Fainting( pre syncope), syncope Sins of unstable tachycardia Hemodynamic instability (hypotension and sings of shock) Hypotension Ischemia in ECG PE and CHF Poor peripheral perfusion manifested by: altered mental status, cold extremities, decrease urine output Management of unstable tachycardia: 1.maintain BLS and ACLS as the following A: airway patent B: give oxygen and suction and measure oxygen saturation C: vital sings, ECG, IV access 2.observe sings and symptoms of unstable tachycardia as the following (altered mental status, hypotension, sings of shock, syncope, fainting) 3.prepare cardioversion immediate( no choice)and considered sedation

4.some times patient with unstable tachycardia and wide QRS complex as a complex situations so must considered as case of VT Stable tachycardia Heart rate exceed 100 bpm and not exceed 180 bpm as sinus tachycardia , also if heart rate 120-130 bpm when patient rest Sinus tachycardia considered physiological condition increased by fever, blood loss, exercise Drugs of stable tachycardia is adenosine and may used Antiarrhythmia drugs Management of stable

Management of stable tachycardia: 1.maintain BLS and ACLS as the following A: airway patent B: give oxygen and suction and measure oxygen saturation C: vital sings, ECG, IV access 2.management as classification of stable tachycardia A.stable with narrow QRS complex and regular HR (QRS narrow<0.12 second) As sinus tachycardia Initiate vegal maneuvers( carotid massage and vlasava maneuver) If not conversion give patient 6mg adenosine (first dose(bolus dose with 20 cc normal saline and rise the head and wait 2 minute) If not conversion give patient 12 mg adenosine (second dose) bolus dose with 20 cc normal saline and rise the head and wait 2 minute)

If not conversion give patient 12 mg adenosine (third dose) bolus dose with 20 cc normal saline and rise the head and wait 2 minute) If patient become unstable prepare immediate cardioversion If patient conversion It is probable to reentry SVT : treated with adenosine or long AV bloke agent as diltazm or Beta blocker If patient not conversion Possible to convert to atrial flutter , ectopic atrial tachycardia, or junctional tachycardia can initiated by long AV blocker as diltazm and B-blockers drugs AV blocker not given to patient with CHF, PE Then provide expert consultation

B.stable with narrow QRS complex and irregular HR (QRS narrow<0.12 second) Irregular narrow as atrial fibrillation(AF) and atrial flutter , multifocal atrial tachycardia (MAT), AV nodal reentry (SVT) Considered AV blocker drugs as diltazm and bblocker( not given in case CHF, PE) If patient become unstable prepare immediate cardioversion C.stable with wide QRS complex and regular HR (QRS wide >0.12 second) As monomorphic VT or uncertain rhythm used amidrone (150mg in 10 minute) and can repeat it until maximum dose 2,2 g\day Prepare elective cardioversion If SVT occurs prepare adenosine

If patient become unstable prepare immediate cardioversion D.stable with wide QRS complex and irregular HR (QRS wide >0.12 second) As AF and WPW or polymorphic VT Expert consultation Avoid AV node blocker (adenosine, digoxine, verpamil, diltazm Considered amidrone If torsades de pointes considered magnesium sulfate (1-2 g in 5-60 min infusion If patient become unstable prepare immediate cardioversion Cardioversion and defibrillations Not recommended in case junctional tachycardia, MAT, ectopic because it is rising the depolarization and increase rate

Mode of defibrillation is tow type 1. synchronized : used sensors to deliver shock synchronized with QRS complex by press sync bottom given in low energy 2. Asyncronized: shock deliver any where In cardiac cycle but must given in high energy As case of polymorphic VT and VF or accelerate tachycardia the sensors can not select QRS complex in cardiac cycle so can not delivers cardioversion. Indication of cardioversion: 1. Sinus tachycardia: physiological effect as responses to extrinsic factors that need to increase CO, as person with high sympathetic tones and high neural activity, exercise

2. atrial flutter : ( if person with heart rate 150 bpm and under Antiarrhythmia drugs and complain of systemic cardiac disease considered stable) 3. heart rate >150 bpm and unstable hemodynamic 4. patient seriously ill with cardiac disease and lower heart rate increase ventricular rate than 150 bpm not considered to cardioversion paddle can not used for synchronized just for monitoring and fibrillation (not used in same time monitor and cardioversion) patient treat by cardioversion in the following cases 1. patient with stable tachycardia with wide QRS complex and regular rhythm 2. patient with unstable tachycardia with pulses when patient become unstable initiate cardioversion as the following(synchronized) 1. atrial fibrillation , SVT, monomorphic VT start at 100j-200j-300j-360j in monphasic 2. atrial flutter: start at 50j-100j-200j-300j-360j in case of polymorphic VT and VF initiate defibrillations Drugs of stable tachycardia Adenosine given in 3 doses 6g-12mg-12mg Adenosine given and must followed by 20 ml directly normal saline and rise the hand for 20 second Adenosine not used to block AV and terminate approximately 90% of reentry arrhythmia within 2 minutes Adenosine not terminate atrial fibrillation and atrial flutter but blocks AV conductions Adenosine interaction with other drugs if given in large dose as caffeine, theobromide, and theophillin

Addsenosine start with 3 mg as minimal dose if patient under treatment drugs as ( dipyrimadole or carbamazepine) or patient with heart transplantation Contraindication of adenosine : 1.wide QRS complex 2.patient with airway disease( cause bronchial spasm) Acute stroke cases stroke : a general term refer to acute neurotically impairment follow interruptions of blood supply to a specific area in brain type of stroke 1. ischemic stroke: 85% of total case of stroke caused by occlusion of an artery region in brains 2. hemorrhagic stroke: 15% of total cases where blood vessels rupture into surrounding tissue hemorrhage patient with hypertension or with atrial fibrillation considered high risk and can not monitored sings of stroke ECG is not take apriority over obtaining CT scan but ECG can give resent MI or atrial fibrillation which may lead to stroke Do not delay CT because ECG just you can perform 12 ECG until CT is prepared Drugs of stroke: 1. fibrinolytic therapy (tPA): tissue palsmogen activators 2. glucose50 3. labetol 4. nitropursside 5. nicardipine 6. aspirin the main purpose of fibrinolytic therapy is reperfusion acute ischemia (minimize brain injury and maximize patient recovery) diagnosis and treatment of stoke depend on 7 D's as the following

1. detection : onset sings and symptoms of stroke 2. dispatch of EMS 3. delivery: advanced pre hospitals notification 4. door : urgent triage in ED 5. data : computed tomography (CT) initiated 6. decision : treatment of fibrinolytic or not 7. during administration drugs and monitoring period of assessment and management 1. 10 min :immediate general assessment in and order CT 2. 25 min :neurological assessment CT 3. 45 min :interpretation CT 4. 60min: administer fibrinolytic therapy after hospital treatment and assessment 5. 3hr: treatment of fibrinolytic therapy after sings onset appears Algorithm of stroke: 1.identify the possible sings and symptoms: sudden weakness and numbness in face, arm, leg in one side sudden confusion trouble spelling or understanding sudden trouble seeing in one or both eyes sudden trouble walking dizziness, loss balance and coordination sever head ache without unknown causes 2.clinical assessment : support ABC give oxygen (maintain oxygen >92% to prevent hypoxemia and increase ischemia brain injury established timing check glucose alert hospital and bring witness from family or caregiver clinical assessment depend on: 1. Cincinnati assessment Dropped : ask patient to observe teeth or smile

 Arm weakness : ask patient to close eyes and hold both arms out Abnormal speech : ask patient to speak and observe slurred or not 2. Los Angeles assessment : ask about : Age>45 History of seizure or epilepsy Symptoms duration <24 hr Patient on weal chair or bedridden Blood glucose between 60-400 mg\dl Unilateral exam of 1.facial smile : equal shape, R weak, left weak 2.grips : equal , weak grips , no grips 3.Arm strength: equal, falls. 3.within 10 min: immediate general assessment : be alert stroke risk of aspiration, upper airway obstructions, hypovolemia oxygen and vital sings IV access available Treated glucose if hyperglycemia Neurological assessment Order CT 12 lead ECG until prepare CT but not delay CT 4.within 25 min: immediate neurological assessment : review patient history establish symptoms onset : assess level of consciousness, aphasia, orientation level, motor strength perform neurological examination interpretation CT 5.within 60 min: given drugs( fibrinolytic therapy) if not hemorrhage stroke indicate of acute ischemia stroke so fibrinolytic candidate depend on family, fibrinolytic checklist protocol if no hemorrhage and have contraindication of fibrinolytic give aspirin orally and rectally

if no contraindication given , in have contraindication give patient aspirin do not give patient anticoagulant or antiplatelet before 24 hr until if fibrinolytic contraindication if hemorrhagic stroke consultation neurosurgery or transfer to other hospitals admit to the stroke unit and observe glucose level, blood pressure , neurological status Hypertension management: 1.systole >220 and diastole >121-140 able to reduction BP 10-15% of total BP labetol 10-20 mg IV for 1-2 min and can be repeated to maximum dose 300 mg Nicardipine 5 mg\hr infusion (start at 2,5mg\hr and repeated every 5 min until maximum dose 15mg\hr 2.diastole >140 Able to reduction BP 10-15% of total BP Nitropursside 0.5 mic\min IV infusion with continuous monitor BP Care in intensive care unit: 1.support airway , oxygen, ventilation, nutrition 2.avoid GW fluid infusion 3.give patient 70-100 ml\hr normal saline 4.monitor hyperglycemia >200 5.treat fever ( Acetaminophen) Fibrinolytic therapy: tPA is given within 3 hr of onset symptoms major complication of tPA is intracranial hemorrhage, andioedema, transient hypotension may be considered IV therapy or intra arterial therapy if IV therapy have contraindication tPA checklist Inclusion criteria ( mean yes given)

age > 18 clinically diagnosed stroke time of onset symptoms <3 hr Exclusion criteria (mean not given) evidence of ICH CT obtain multi lober ischemia (1\3 of total cerebral hypo density) History of ICH Uncontrolled hypertension >185\110 Aneurysm, neoplasm, male formation in arteriovenous system Seizure Active internal bleeding or acute trauma Acute bleeding disorder as ( platelet <100,000, heparin received with 48 hr (activate APTT, INR>1,7 or PT > 15 second Intracranial or intraspinal surgery or serious head trauma within 3 months Relative exclusion criteria Surgery within 14 days GI or urinary bleeding AMI within 3 months Glucose level <50 >400