pals algorithm - bradycardia and tachycardia 2016 · 2016-11-30 · title: microsoft word - pals...
TRANSCRIPT
PULSEPULSE
BRADYCARDIA TACHYCARDIA Identify and Treat underlying cause
• A -‐ maintain patent airway
• B -‐ assist breathing • C -‐ Oxygenate, cardiac monitors, NIBP, Oximetry, IV/IO, 12-‐Lead ECG Don't delay therapy
• D -‐ LOC, GCS, AVPU • E -‐ Expose pt, Temp
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11-‐2016 Edition
Consider Probable Causes H & T’s
• Hypoxemia • Hypovolemia • Hyper & Hypokalemia • H (Acidosis) • Hypothermia • Hypoglycemia • Tension Pneumothorax • Tamponade, Cardiac • Toxins • Thrombosis, Pulmonary • Thrombosis, Coronary • Trauma
Cardiopulmonary compromise continues?
• Hypotension • ALOC • Signs of Shock
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3a 3b
4a
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Based on AHA PALS 2015 Guidelines
NO
• Support ABCs • Give oxygen • Observe • Consider Expert Consultation
EPINEPHRINE 0.01 mg/kg
(0.1 mL/kg of 1:10,000 concentration)
Give every 3-‐5 mins.
ATROPINE 0.02 mg/kg
May repeat once Min. dose 0.1 mg Max. dose 0.5 mg
TCP (TRANSCUTANEOUS PACING) Demand Mode, 60-‐70 ppm,
2-‐3 mV or 20-‐30 mA
Treat underlying Causes (H/Ts)
START CPR
YES
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Narrow QRS: (SVT)
Wide QRS: (VT)
Narrow QRS: Vagal Maneuvers without delay
Wide QRS: may consider Adenosine if regular and QRS is monomorphic. Expert consultation.
Give Amiodarone or Procainamide
NO
SYNCHRONIZED CARDIOVERSION 0.5 – 1 Joule/kg Max. 2 Joules/kg
Sedate if needed but don’t delay Cardioversion
YES
Secondary Assessment
S.A.M.P.L.E.S.A.M.P.L.E. Bradycardia Persists?
If pulseless arrest develops, go to Cardiac Arrest Algorithm
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Cardiopulmonary compromise continues?
• Hypotension • ALOC • Signs of Shock
ADENOSINE 1st dose: 0.1 mg/kg RIVP (max: 6 mg) 2nd dose: 0.2 mg/kg RIVP (max: 12 mg)
AMIODARONE 5 mg/kg IV/IO given >20-‐60 mins.
diluted in D5W 100-‐250 mL
PROCAINAMIDE 15 mg/kg IV/IO over 30-‐60 mins. Do not routinely give with Amiodarone
Treat underlying causes
Infants: ≥ 220; Children: ≥180
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PULSELESS
VF/pVT PEA/ASYSTOLE
Defibrillate 2-‐4 J/kg max. of 10 J/kg
2 min. CPR A M I O D A R O NA M I O D A R O N
EE 5 mg/kg IV/IO bolus May repeat 2 times for refractory VF/pVT
Treat H & T’s
2 min. CPR Treat Reversible Causes Consider advanced airway
YES
SHOCKABLE?
NO
Is the rhythm shockable?
NO YES
PALS Systematic Approach
PRIMARY ASSESSMENT A.B.C.D.EA.B.C.D.E ..
Airway: Keep airway patent -‐ Position, Suction, OPA/NPA Breathing: Support Breathing -‐ Rescue Breaths: 1:3-‐5 sec (12-‐20/min) -‐ Cardiac Arrest with ETT: 1:6 sec. (10/min)
unsynchronized with compressions Circulation: IV/IO, Monitors, Bolus, Meds, Shock, Compress
Keep O2Sat >94-‐99% PETCO2 > 35-‐40 mm Hg Disability: LOC, AVPU, GCS, PERRLA Exposure: Temp, Signs of Trauma
START CPR (CAB) RATE: 100-‐120 per minute DEPTH: Infant 1 ½ inches (4 cm) Child 2 inches (5 cm) RECOIL: Allows refilling for
reperfusion Compression to Breaths Ratio:
1-‐Rescuer: 30:2 (5 cycles in 2 minutes)
2-‐Rescuers: 15:2 (10 cycles in 2 minutes)
Intervene
2 min. CPR Start IV/IO Start IV/IO
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NO
NO YES
INITIAL IMPRESSION -‐ Check for Scene Safety A -‐ Appearance B -‐ Breathing (WOB) C -‐ Circulation (Color)
Unresponsive?
YES
Activate Code/EMS
Check Breathing & Pulses 5-‐10 sec. Infant: Brachial Child: Carotid
Evaluate
Identify
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START CPR
SHOCKABLE?
2 min. CPR E P I N E P H R IE P I N E P H R I
N EN E 0.01 mg/kg
(0.1 mL/kg 1:10,000 Concentration)
Give every 3-‐5 mins.
2 min. CPR Start IV/Start IV/ IO IO
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E P I N E P H RE P I N E P H R
I N EI N E 0.01 mg/kg
(0.1 mL/kg 1:10,000 Concentration)
Give every 3-‐5 mins.
NO
YES
NO ROSC p. 290-‐298 Optimize ventilation and Oxygenation -‐ O2Sat >94-‐99%, PETCO2 35-‐40 mm Hg Assess for and Treat persistent Shock -‐ Bolus, Fluid maintenance, Vasopressors Correct H/Ts, BG, fever, & Shock If ALOC maintain Targeted Temp. Mgt. -‐ Out-‐of-‐hospital cardiac arrest: 5 days of normothermia 36-‐37.5° C or 2 days of hypothermia 32-‐34° C followed by 3 days of normothermia
YES SHOCKABLE?
SECONDARY ASSESSMENT S.A.M.P.L.E.
Signs & Symptoms, Allergies, Medications, Past Medical History, Last Meal/Fluids Taken, Events
Leading
DIAGNOSTIC ASSESSMENT Laboratory and Radiological Studies
Hypotensive Shock -‐ Epinephrine 0.1-‐1 mcg/kg per min -‐ Dopamine 10-‐20 mcg/kg per min -‐ Norepinephrine 0.1-‐2 mcg/kg per min Normotensive Shock -‐ Dobutamine 2-‐20 mcg/kg per min -‐ Dopamine 2-‐20 mcg/kg per min -‐ Epinephrine 0.1-‐0.3 mg/kg per min -‐ Milrinone Load: 50 mcg/kg over 10-‐60 mins; Infuse: 5-‐10 mcg/kg per min
-‐ Inamrinone Load: 0.75-‐1 mg/kg over 5 mins; Infuse 5-‐10 mcg/kg per min
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Primary Assessment Secondary Assessment Diagnostic Assessment
Based on AHA 2016 PALS Guidelines For Study Guide Only
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Go to Box 10 or 11 ROSC?
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