superficial thickness

Superficial thickness

First-degree

Full thicknessThird- or fourth-

degree

Partial thickness —

deepSecond-degree

Partial thickness — superficial

Second-degree

Epidermis involvement

Dermis and underlying

tissue

Deep (reticular) dermis

Superficial (papillary

Erythema minor pain, lack of blisters

Hard, leather-like eschar, purple fluid, no sensation

(insensate)

Whiter appearance, with decreased pain. Difficult to

distinguish from full thickness

Blisters, clear fluid, and pain

Nomenclature

Traditional nomenclature

Depth Clinical findings

BURN

Require only symptomatic treatment.

Usually heals in 7 days.

No blister formation.

Skin is red, painful, and tender.

Involves only the Epidermal layer of the skin.

Leaves no scars.

I= 1st DEGREE BURN

The deeper layer of the dermis, hair follicles, sweat glands and sebaceous glands are spared

II= 2nd DEGREE BURN1- SUPERFICIAL – PARTIAL THICNESS The burn extends to the dermis

The epidermis and superficial (papillary layer) dermis are injured

Blistering of the skin

Exposed dermis is red, moist at blister base

Very painful to touch

Good perfusion of dermis with intact capillary refill

Heal in 14 – 21 days

Scaring usually minimal

II= 2nd DEGREE BURN2- DEEP – PARTIAL THICKNESS

Extends into the deep reticular layer of the dermis

There is damage in the hair follicles, sweat glands, & sebaceous glands

Caused by steam, hot liquids, flameSkin may be blisteredThe burned areas don’t blanchNo capillary fillingAbsent pain sensationHealing takes 3 W – 2 monthsScaring is commonSurgical debridement & skin grafting may be necessary to obtain maximum function

III= 3rd DEGREE BURN

Involves the entire skin thickness

All epidermal and dermal layers are destroyed

Caused by flame, hot oil, steam and contact e’ hot object

Skin is charred, pale, painless, leathery

Injuries will not heal spontaneously

Surgical repair and grafting are necessary

Injuries will leave significant scaring

9%

Front18%

Back18%

9%9%

18%18%

ESTIMATION OF BURN %(ADULT)

RULE OF 9 & ESTIMATION OF BURN SIZE

CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY

1= MINOR

Partial thickness burn less 15% of BSA in the 10 – 50 – year old age group

Partial thickness burn less than 10% BSA in children under 10 and adults more than 50

Full thickness burn of less than 2% BSA in any one with out associated injuries

These burn imply out patient treatment

2 =MODERATE

CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY / cont

Partial thickness burn of 15 – 25 % BSA in 10 – 50 year – old age group

Partial thickness burn of 10 – 20 % BSA in children under 10 or adults over 50

Full thickness burn of less than 10% in any one

Partial thickness burn of the hands, face, feet, perineum, or circumferential burn of an extremity are excluded

3 =MAJOR

CLASSIFICATIONS OF BURN ACCORDING TO SEVERITY / cont

Partial thickness burn greater than 25% BSA in the 10 – 50 – year – old age groupPartial thickness burn greater than 20% BSA in children younger than 10 and adults over 50Full thickness burn greater than 10% BSA in any oneBurn involving face, feet, hands and perineumBurn complicated by inhalation burnBurn crossing major jointsCircumferential burns of an extremityElectrical burnsBurn complicated by # or other traumaBurns in infants & elderly

FLUID REPLACEMENT

PARKLAND FORMULA

use crystalloids

ADULTS

RL 4ml X patient Wt ( kg ) X % BSA over initial 24 h

½over the 1st 8 hrs from the time of burn

½over the subsequent 16 hrs

FLUID REPLACEMENT

PARKLAND FORMULA

use crystalloids CHILDREN

they have an increased body surface area – to - wt ratio, so they have greater fluids requirement

RL 3 ml X patient Wt ( kg ) X % BSA over initial 24 hrs plus maintenance fluid

½over the 1st 8 hrs from the time of burn

other ½ over the subsequent 16 hrs

Maintenance

Based upon the child’s wt

100 ml/kg for the 1st 10 kg

then 50 ml/kg up to 20 kg

then 2o ml/kg for any wt above 20kg

DIGOXIN TOXICITY• S/S• Acute & chronic• DX• FAB

HYPERKALEMIA • Is life threatening Hyperkalemia present ?• ECG changes• high risk ( RF,On dialysis, medication)• Serum K > 5.5mEq/l

IV 0.9%Nacl

YDOC > Alkalinizing agents > Sodium bicarbonateIncrease pH, which results in a temporary K shift from the ECS to ICS• Adult: 1 mEq/kg slow IV push not to exceed 50-100 mEq• Children: 1-2 mEq/kg IV over 5-10 min; repeat in 10 min prn

Stabilize the myocardium > IV Calcium gluconate • Adult: 10 mL of 10% sol IV over 10 min (under ECG monitor)•Children: 100 mg/kg (1 mL/kg) of 10% sol IV over 10 min; not to exceed 10 mL

Shift K into the cells

DW & InsulineAd: 5-10 U simple insuline and 25-50 g D (50-100 ml 50% DW)children: 0.5g Dw 25% and 0.1u/kg IV slowly

Albuterol (Ventolin) NEB

Adult: 5 mg mixed with 3 mL NS high-flow Nebulizer q20min Children: 2.5 mg/dose with 3 mL isotonic saline nebulized

Enhance elimination of K

N

N or HighLow

Pt volume status Kayexalate: 25-50 g mixed with 100 mL of 20% sorbitol PO/PR

Is urine output present?

N

NO

RESPONSE

Y

Attempt loop diuretics(lasix 40-100mg)

Hemodialysis

Simple febrile seizures are: Temperature greater than 38 C Age – 6 months to 6 years isolated Generalized tonic – clonic seizures lasting less than 15 minutes do not recur within 24 hours or within the

same febrile illness No CNS infection or inflammation No systemic metabolic abnormality No history previous afebrile seizure

HYPOGLYCEMIA

1- Serum glucose level < 50 mg/dl.2- Symptoms consistent with the diagnosis.3- History of DM4- Patient with altered mental status

Yes

Is patient responsive ? No

• 1g/kg/IV 50% D/W• IV infusion of 10% D/w• 200 mg hydrocort when (adrenal crisis, no response to treatment)

IV line Present ?

• Glucagon: 1gm IM,SC• NG tube >> sweet Drink

Y

N

• Asess and monitor patient Response• Check RBS q 15 min

• continue to monitor• Search for causes• Ensure patient safety

• Establish IV access• 1g/kg/IV 50% D/W• Continuous infusion of 10% D/w• Glucagon: 1gm IM,SC

Recheck RBS in 15 min

• 20 – 30 gms of oral carbohydrate• Assess response

Is patient NPO

Yes

Yes

NO

Is patientResponsive

Retreat with 1gm/kg

CarbohydratePO, IV

• Monitor Pt• If eating, feed meal within 30 min• Evaluate etiology• Educate Pt how to prevent future episode

Is RBS greaterThe 70 mg/dl

Yes

Recheck RBS in 30 min

Is RBS greater than

60 mg/dl

No

Is patient NPO

• Retreate with 20-30gm carbohydrate• continue monitoring Pt

No

Yes

NO

YEs

No

S/S OF HYPOGLYCEMIA

NEUROGLYCOPENICSYMPTOMS

HYPEREPINEPHRINEMICsymptoms

-Alternation in LOC -Lethargy, confusion

- Agitation- Unresponsiveness

- Seizures- Focal neurological deficits

- Coma

-Anxiety, nervousness -Irritability

-Nausea, vomiting -Palpitation, tremor

- Sweating ,- Change in pupils size

-Salivation -Bradycardia

Due toHypoglycemia

Due torelease of adrenaline

HYPOTHERMIA

IT IS DEFINEDAS A CORE TEPERATURE LESS THAN 35C ( 95F )

1. T wave inversion2. PR, QRS, QT prolongation3. Muscle tremor artifacts4. Osborne ( J ) wave5. Dysrhythmias

- Sinus bradycardia - AF or Flutter - Nodal rhythm - AV block - PVC,s - VF - Asystole

ECG CHANGES IN HYPOTHERMIA

J wave: it is a positive reflection at the junction of the QRS and S – T segment.

CORE TEPERATURE LESS THAN 35C ( 95F )Primary: Secondary

Resulting from a medical illnessSee D/D

Radiation, Conduction, Convection& Evaporation

Mechanisms of heat loss

Due to environmental exposure, with no underlying medical condition

REWARMING TECHNIQUES

1. Passive warming:Removal from cold environmentUse of insulating blankets

GENERAL & SUPPORTIVECARE

2. Active external warmingRadiant heat, Warmed blanketWarm water immersion, heated objects

3. Active core re – warming= warm NS (42*C) throughNG tube, folly’s catheter, peritonial catheter. Rectal tube= Warm IV fluids

ABC Assessment, RR, pulse oxymetry, effort

V/S: core temperature, HR, BP

adequateYes

No

O2

INTUBATIONLMA, ETT

CORE TEMP < 35*C

Warm IV fluids, ECG monitoring, soft handling

TREATMENT OF THE CAUSE (See D/D)

Treatment of dysrhythmiasaccordingly

YES

Paracetamol poisoning1. toxic dose

2. Paracetamol level

3. Activated charcoal

4. Lavage

5. NAC IV dose

Time of ingestion

< 2 hours > 8 hours 2 – 8 hours

Activated charcoal

< 150 mgs/kg >150mgs/kg < 150 mgs/kg >150mgs/kg

NAC

Treat possible , probable and high risk group with NAC.

Paracetamol level at presentation

Paracetamol level at 4 hours

PROTOCOLS FOR NAC ADMINISTRATION(Do not Delay NAC treatment while waiting for paracetamol level)

• ORAL:72 h treatment= Loading dose: 140 mg/kg, Subsequent Doses: 70mg/kg q 4h for 17 doses.• IV: 20 h treatment= Loading dose:150 mg/kg over 15 min, Subsequent Doses: 50 mg/kg over 4h followed by 100mg/kg over 16h

Paracetamol Poisoning

Patient assessment in ACLS

And care priority

ABC: when patient either responsive of not with intact circulation

CAB: when patient not responsive with no pulse

Antidotes for Toxins in Emergency Overdose Patients

Antidote Toxin Dose and comments Naloxone Opiates Naloxone2 mg; less to avoid narcotic withdrawal,

more if inadequate response; same dose in children

Bicarbonate

Tricyclics 44–88 mEq in adults; 1–2 mEq/kg in children; IV push, not by slow infusion

Flumazenil Benzodiazepines 0.2 mg, then 0.3 mg, then 0.5 mg, up to 5 mg; not to be used if patient has signs of TCA toxicity; not

approved for use in children but probably safe Calcium Calcium channel

blockers1 g calcium chloride IV in adults, 20–30 mg/kg/dose in children, over a few minutes with continuous monitoring

Glucagon b-blockers, calcium channel

Blockers

5–10 mg in adults, then infusion of same dose per hour

Physostigmine Anticholinergics 1–2 mg IV adults, 0.5 mg in children over 2 min for anticholinergic delirium, seizures, or dysrhythmias

Atropine Organophosphates, carbamates

Test dose 1–2 mg IV in adults, 0.03 mg/kg in children. Titrate to drying of pulmonary secretions

N-acetylcysteine

Acetaminophen 140 mg/kg, then 70 mg/kg q4h; IV form still investigational

Antidotes for Toxins in Emergency Overdose Patients

Antidote Toxin Dose and comments Ethanol Methanol, ethylene

glycolLoading dose 10 ml/kg of 10%; maintenance dose

0.15 ml/kg/hr of 10%; double rate during dialysis Fomepizole Methanol, ethylene

glycol15 mg/kg every 12 hr

Pyridoxine. Isoniazid 5 g in adults, 1 g in children, if ingested dose unknown. Antidote may cause neuropathy

Thiamine Ethylene glycol chronic ethanol ingestion

100 mg IV

Digoxin-specific FAB

fragments.

Digitalis glycosides 10–20 vials if patient in ventricular fibrillation. Otherwise, dose is based on serum digoxin concentration or amount ingested

Sodium nitrite Cyanide, H2S 10 ml of 3% (300 mg; 1 ampule) in adults; 0.33 ml/kg in children, slowly IV

Deferoxamine Iron15 mg/kg/hr IV, higher doses reported to be safe

protamine sul Heparine

Vitamine k warfarine

Specific anti venom

Snakes & yellow scorpions

Odors in Overdose History ODOR POSSIBLE INTOXICANT

Bitter almond Cyanide

Fishy Zinc or aluminum phosphide

Fruity ethanol, acetone, chloroform

Garlic Arsenic, organophosphates

Glue Toluene, solvents

Pears Chloral hydrate, paraldehyde

Rotten eggs Hydrogen sulfide, NAC

Shoe polish Nitrobenzene

wintergreen Methyl salicylate

Activated charcoal does not adsorb:A. ironB. lithiumC. sodiumD. leadE. cyanideF. hydrocarbonsG. causticsH. alcohols

Causes and Differential Diagnoses of Potentially Catastrophic Illness Presenting with Vaginal Bleeding

Assess ABC, V/S, Start IV, Blood for Lab, Cross Match, Cardiac Monitoring, O2 therapy, history

Pain Assessment ( PQRST method) provoke, paliate, quality, radiation, site, time (onset-duration-frequency)

Ectopic pregnancy Abruptio placentae Placenta previa Postpartum hemorrhage Uterine rupture

D I F E R E N T I A L D I A G N O S I S

P H Y S I C A L F I N D I N G S

Anxiety/diaphoresis,Tachycardia,

Tenderness on pelvic and lower abdominal

exam. Vaginal bleeding

Hypovolemic shock, Hypotension, Abdominal and uterine tenderness. Variable dark red uterine

bleeding

Hypovolemic shock, Hypotension, Gravid

uterus, abdominal exam usually benign

Enlarged, doughy uterus (uterine atony). Vaginal bleeding without uterine

bleeding (vaginal lacerations

Hypovolemic shock, Hypotension Tender

abdomen with guarding

PELVIC US FINDINGAdnexal mass Ovarian

massPlacental separation Low lying placenta NORMAL, Uterine mass Peritoneal fluid

Lower abd pain, always present .Variable character. sudden onset,. Occasional

radiation into back or flank. unilateral

Uterine tenderness and irritability. Intermittent or

steady abdominal cramping. Back pain

Usually very little pain.Often minimal. Can be

severe with uterine inversion.

Uterine pain without contraction

Supporting History

First-trimester pregnancy, amenorhea,

irregular mensprior ectopic pregnancy, PID, STD, tubal ligation.

Over 20 w gestationIncreased maternal age,

HTN smoking, abdominal trauma.

Over 20 weeks gestation. Incidence

increased with multiparity and prior

C-section.

Difficult, traumatic delivery. Previous CS

retained placnta Multiple gestations, hydramnios, multiparity. uterine atony

Previous cesarean section.

4321

SpontaneousTo voiceTo painNone

EYE OPENING

54321

OrientedConfusedInappropriate wordsIncomprehensive wordsNone

VERBAL RESPONSE

654321

Obeys commandLocalizes painWithdraw (pain)Flexion (pain)Extension (pain)non

MOTOR RESPONSE

G.C.S

15MAXIMUM SCORE

Severe < 8Moderate 9 – 12Mild 13 - 15

How to choose appropriate ET Tube size for age??

(Age/4)+4

(16/age)+4

Snake bite

human bite

Child abuse

Anion gap calculation and metabolic acidosis

Na+ − (Cl- + HCO3−)

• 8 to 16 mEq/L plasma when not including [K+]

1. Lactic acidosis2. Ketoacidosis

Diabetic ketoacidosisAlcohol abuse

3. Toxins:MethanolEthylene glycolPropylene GlycolLactic acidUremiaAspirinPhenforminIronIsoniazidCyanide

4. Renal failure, causes high anion gap acidosis by decreased acid excretion and decreased HCO3

− reabsorption. Accumulation of sulfates, phosphates, urate, and hippurate accounts for the high anion gap.

High anion gap metabolic acidosis

2[Na+] + [Glucose]/18 + [ BUN ]/2.8

Normal human reference range of osmolality in plasma is about 285-295 milli-osmoles per kilogram.

High quality CPR

1. Rate >> at least 100 compression/min

2. Depth >> at lest 2 ½ inches

3. Allow chest recoil

4. Do not interupt compression

5. Do not hyperventilate

TRIAGECOMPONENT

Focused PhysicalEvaluation

Across the roomassessment

Triage history & Physical assessment

Triage decision

-Visual assess -General appearance

Acuity levels1,2,3,4,5

Subjective Objective

ChiefComplaint

DescriptionOf symptoms

Hx of past &Present illness

AMPLEAssessment Of the Presenting event

Include:• Appearance• ABC, VS• Physical exam• GCS• AVUP

Pain Assessment“PQRST” Method

Patient dying? Intubated/apnic/pulseless

OR Unresponsive 1

N

Y

Shouldnt wait??High risk situation Or

Confused/lethargic/ disorientation?Or Severe pain/distress

How many different resources are needed?

N

2None One

Two or more

45

A

D

C

B

2-8y >140 >30

3m-2y >160 >40

>8y >100 >20 Age HR RR SaO2<90%

Danger zone vitals

E

S

I

ALGORITHM

Y

3

ESI ResourcesRESOURCES NOT RESOURCES

Labs (blood, urine) History & physical(including pelvic)

ECG, X-rays, CT-MRI-ultrasoundangiography

Point-of-care testing

IV fluids (hydration) Saline or heplock

IV, IM or nebulized medications PO medications

Specialty consultation Phone call to PCP

1. Simple procedure (laceration repair, Foley cath)2. Complex procedure(conscious sedation)

Simple wound care (dressings, recheck) Crutches, splints, slings

Toxidromes (a toxic “fingerprint)

Refers to the collection of signs and symptoms.

It include grouped, physiologically based abnormalities of vital signs General appearance Skin, eyes, mucous membranes Lungs, heart, abdomen Neurologic examination

Helpful in establishing a diagnosis when the exposure is not well defined.

Certain clinical findings may narrow the etiologic possibilities

Common Toxic Syndromes (Toxidromes) Anticholinergic Common

signs

Delirium with mumbling speech, tachycardia, dry flushed skin, dilated pupils, myoclonus, slightly elevated temperature, urinary retention, decreased bowel sounds. Seizures and dysrhythmias may occur in

severe cases.

Common causes

Antihistamines, antiparkinsonians, atropine, scopolamine, amantadine, antipsychotics, antidepressants, antispasmodics, mydriatics, muscle relaxants.

Sympathomimetic  

Common signs

tachycardia (or bradycardia with pure a-agonist), hypertension, hyperpyrexia, diaphoresis, Delusions, paranoia, piloerection, mydriasis,

hyperreflexia. Seizures, hypotension, and dysrhythmias. Common causes

Cocaine, amphetamine, methamphetamine and its derivatives, ephedrine, pseudoephedrine. In caffeine and theophylline overdoses, similar findings, except for the organic psychiatric signs, result from

catecholamine release.

Common Toxic Syndromes (Toxidromes) Opioid/sedative/ethanol   Common

signs

Coma, respiratory depression, miosis, hypotension, bradycardia, hypothermia, pulmonary edema, decreased bowel sounds, hyporeflexia, needle marks. Seizures may occur after overdoses of some narcotics

(e.g., propoxyphene) Common causes

Narcotics, barbiturates, benzodiazepines, glutethimide, methyprylon,

methaqualone, meprobamate, ethanol, clonidine, guanabenz

Cholinergic   Common

signs

Confusion, central nervous system depression, weakness, salivation, lacrimation, urinary/fecal incontinence, gastrointestinal cramping, emesis, diaphoresis, muscle fasciculations, pulmonary edema, miosis,

bradycardia/tachycardia, seizures Common causes

Organophosphate and carbamate insecticides, physostigmine,

edrophonium, some mushrooms

HR ?

FAST SLOW

What is ventricular rate ? (correspond to pulse rate)

NORMAL

NARROW OR WIDE??

0.10 sec

0.17 sec

P

ST

Teaching Moment When an impulse originates anywhere in the

atria or above the ventricles:1. SA node2. Atrial cells

3. AV node4. Bundle of His

and then is conducted normally through the ventricles, the QRS will be narrow (0.08 - 0.12 s).

Classification of Arrhythmias

Slow pulse rateBradyarrhythmias

Fast pulse rateTachyarrhythmias

Depending On HR/min &QRS Duration/sec

SlowNarrow

Slow Wide

Fast Narrow

Fast Wide

Interventions to treat Rhythm disturbances

1. Mechanical

Vagal maneuvers

Pericardiocentesis

Chest decompression

Valsalva maneuver

2. Pharmacological

Adrenaline

Amiodarone

Adenosine

Mg sulphate

Lidocain

Atropine

3 .Electrical

Defibrilation

Synch cardioversion

Pacing

Treatment mode selection depends on the patient’s general status:

1. Presence or absence of pulse

2. Patient’s stability

Pulse present??YESNO

Stablepatient??

YESNO

mechanical

Pharma

Failed

FailedElectrical

Shockable rhythm ??

YESNO

VF &Pulsless VT

CPR

AsystolePEA

When you decide to use the electrical intervention,

please remember the 3 S’s

1.Sedate the patient when needed (Medazolam)

2.Select the mode (DC or synchronous mode)

3.Select the dose (Jules)

Rhythm Disturbances“Arrhythmias“

May be shockablewhen

• Pulse is present • Unstable patient

Non shockable(No pulse)

Shockable(No pulse)

Ventricular Fibrillation

Pulseless V T

Ventricular Tachycardia Asystole

PEASupraventricular Tachycardia

ARRHYTHMIAS

Svt Vt Vf/pulseless VT Bradycardia Asystole

BRADYCARDIA S/S MANAGEMENT

YES

Is It 2nd Degree II AV BlockOr 3rd Degree AV Block

NO YES

Observe

Prepare For Trans-venous Pacer

Use TCP AS Bridge Device

BRADYCARDIA

ALGORITHM

Serious Signs & Symptoms? Signs of poor perfusion caused by Bradycardia

5 T’s 5 H’s

Assess CAB, Secure Airway, V/SStart IV, History, Physical Exam,

12 Lead ECG, Cardiac Monitoring Pulse Oxymetry, O2 therapy

No

• Atropine 0.5 Q3 – 5 min

• TCP

• Dopamine 2 – 10 ug/kg/min

• Epinephrine 2 – 10 ugm/min

Intervention Sequence:

Toxins Tamponade, cardiacTension pneumothoraxThrombosis, MI / PETrauma (Increased ICP)

HypovolemiaHypoxiaHydrogen ion (acidosis)Hyper/hypokalemiaHypothermiaHypoglycemia

Attach to monitor or defibrillatorobtain IV access rapid NS infusion

take blood samples for Lab

PEA ALGORHYTHMUnresponsive patient

CAB: No pulse >> start CPR 30:2(MOVE )

Epinephrine 1 mg IV

Continue CPR

Quick exam and history for cause5H, 6Ts

PROBLEMS

HypoxiaVentilation

HypothermiaIncrease core tempe

Tension PneumothoraxNeedle Decompression

Tamponade CardiacPericardiocentesis

HypovolemiaVolume Infusion

Hydrogen ion (acidosis)NaHCo3

Hyper >> Ca Gluconate Insuline/Glucose, Na Hco3

Tablets (Drug Over Dose)lavage, Charcoal, Anti Dote

Thrombosis, coronary MI(MONA, HIBA, PTCA, CABG)

Epinephrine 1 mg IV EO cycle ORm1 dose of Vasopressin 40Uto replace 1st t or 2nd dose of EPI

Hand and Foot infections

F B

I NGESTION

Notice anything else?

•A case of iron

deficiency?

ThanksWith my

best wishes

If asystole or PEA go to protocol --------------------- If pulse present, start post CPR care

Give 5 cycles of CPR (2 min)

Shockable

Check rhythmShockable rhythm?

Give 5 cycles of CPR (2 min)

Continue CPR while charching defibrillator Give one shock Resume CPR Epinephrine 1 mg Q 3-5 min IV/IO/ET Vasopressin 40u IV/IO/ET

IV/IO, ETT

Give 1 shock Biphasic device 200J Monophasic device 360JResume CPR immediately

Check rhythmShockable rhythm? No

SHOCKABLE

No

Continue CPR Give one shock Amiiodaron 300 mg IV/IO once then Consider additional 150 mg IV/IO

Continue CPR Give one shock Lidocaine 1 – 1.5 mg/kgm IV/ IO/ET, then 0.5 – 0.75 mg/kgm max 3 doses

Continue CPR Give one shock Procainamide 17 mg/kg IV Infusion Over 30 min Na Hco3 1mEq/kg

Continue CPR Give one shock Mg Sulphate 1 – 2 g IV/IO In TDP or Refractory VF

Pulseless arrest BLS algorithm: call for help Give O2 Attach monitor/Defibrillator when available

VF/pulless VTAsystole/PEA

Non Shockable

Shockable

Check rhythmShockable rhythm?