Resuscitation Manual PDF

The authors of the original 2005 version are unknown. 2023 revised version: Tarlan Nathalie Sharifi With the contribution of: Andrew Chan Chantal Piché Christine Echegaray-Benites Eduardo Martinez Del Valle Emilie Cheruet Genevieve Pelletier Jeanne Corriveau M.Sc, CPC Josée Larocque Marie-Josée Jobin Melanie Bouchard Melanie Giroux Melissa Waldner Olivia Guay Pierre Chassé In the document, you will find the following icons: IMPORTANT INFORMATION DANGER / ALERT DOCUMENTATION Medication names in purple. TABLE OF CONTENTS Introduction.................................................................................................................................................................... 8 1. Role and responsabilities........................................................................................................................................... 9 Management of Physical Environment................................................................................................................................ 9 Management of Patient Priorities....................................................................................................................................... 9 Management of Human Resources..................................................................................................................................... 9 2. Family presence....................................................................................................................................................... 10 3. Airway management............................................................................................................................................... 11 Objectives.......................................................................................................................................................................... 11 Introduction...................................................................................................................................................................... 11 Life-threatening airway conditions.................................................................................................................................... 11 Signs of partial or total airway obstruction....................................................................................................................... 11 Therapeutic interventions................................................................................................................................................. 11 Reassessment of the airway.............................................................................................................................................. 15 Oxygen delivery devices.................................................................................................................................................... 16 Extraglottic airway devices (EAD)...................................................................................................................................... 18 Tracheal Intubation........................................................................................................................................................... 20 Mechanical Ventilation...................................................................................................................................................... 21 Rapid Sequence Intubations (RSI)...................................................................................................................................... 21 Care of the intubated patient............................................................................................................................................ 28 Carbon Dioxide Monitoring via Capnometry and Capnography........................................................................................ 31 The Difficult Airway........................................................................................................................................................... 37 Nasotracheal Intubation.................................................................................................................................................... 37 Cricothyrotomy................................................................................................................................................................. 39 Tracheostomy.................................................................................................................................................................... 40 Noninvasive Ventilation (BIPAP and CPAP)........................................................................................................................ 41 Mechanical Ventilation...................................................................................................................................................... 42 High Flow Therapy using the AirvoTM2............................................................................................................................... 46 Heliox................................................................................................................................................................................. 51 4. Respiratory emergencies......................................................................................................................................... 53 Objectives.......................................................................................................................................................................... 53 Pneumothorax................................................................................................................................................................... 53 Hemothorax...................................................................................................................................................................... 54 Tension pneumothorax..................................................................................................................................................... 54 Needle thoracostomy (needle decompression)................................................................................................................ 55 Chest Tubes and Chest Drainage Systems......................................................................................................................... 55 Pulmonary Edema............................................................................................................................................................. 59 Pulmonary Embolus........................................................................................................................................................... 59 Status Asthmaticus............................................................................................................................................................ 61 Life-Threatening Asthma Exacerbations............................................................................................................................ 61 Smoke Inhalation............................................................................................................................................................... 61 5. Acid-base disorders.................................................................................................................................................. 63 Introduction...................................................................................................................................................................... 63 Metabolic acidosis............................................................................................................................................................. 63 Metabolic alkalosis............................................................................................................................................................ 63 Respiratory acidosis........................................................................................................................................................... 64 Respiratory alkalosis.......................................................................................................................................................... 64 Arterial Blood Gas: Steps for Interpretation...................................................................................................................... 64 Venous blood gas.............................................................................................................................................................. 65 6. Myocardial infarction.............................................................................................................................................. 67 Introduction...................................................................................................................................................................... 67 Acute Coronary Syndrome Algorithm................................................................................................................................ 69 ECG Interpretation............................................................................................................................................................ 70 Cardiac Biomarkers............................................................................................................................................................ 72 Management of patients with AMI................................................................................................................................... 72 7. ACLS.......................................................................................................................................................................... 75 Introduction...................................................................................................................................................................... 75 Adult cardiac arrest algorithm........................................................................................................................................... 76 Adult bradycardia algorithm.............................................................................................................................................. 77 Adult tachycardia with pulse algorithm............................................................................................................................. 78 Adult post-cardiac arrest care algorithm........................................................................................................................... 79 Cardiac arrest in pregnancy algorithm.............................................................................................................................. 80 ACLS medications.............................................................................................................................................................. 81 8. Pacemaker therapy.................................................................................................................................................. 83 Introduction...................................................................................................................................................................... 83 Indications for Emergency Pacing..................................................................................................................................... 83 Transcutaneous Pacing...................................................................................................................................................... 83 Transvenous Pacing........................................................................................................................................................... 83 Pacemaker Nomenclature................................................................................................................................................. 84 Procedure for transcutaneous pacing............................................................................................................................... 85 Magnet Application for Implantable Cardioverter Defibrillators (ICDS)............................................................................ 87 9. Cardioversion........................................................................................................................................................... 88 Introduction...................................................................................................................................................................... 88 Synchronized Cardioversion Procedure............................................................................................................................. 88 Adult tachycardia with a Pulse Algorithm.......................................................................................................................... 91 Complications.................................................................................................................................................................... 91 10. Extracorporal membrane oxygenation (ecmo).................................................................................................... 93 Inclusion Criteria................................................................................................................................................................ 93 Veno-Arterial (VA) ECMO.................................................................................................................................................. 93 Veno-Venous (VV) ECMO.................................................................................................................................................. 94 Room Layout..................................................................................................................................................................... 95 Nursing Role...................................................................................................................................................................... 96 Documentation................................................................................................................................................................. 96 Transfer............................................................................................................................................................................. 96 Debriefing.......................................................................................................................................................................... 96 Complications.................................................................................................................................................................... 97 11. Ventricular assist device........................................................................................................................................ 98 Introduction...................................................................................................................................................................... 98 Indications......................................................................................................................................................................... 98 Devices.............................................................................................................................................................................. 98 Collective orders................................................................................................................................................................ 98 Nursing Role...................................................................................................................................................................... 98 Vital Signs.......................................................................................................................................................................... 99 Emergency Management................................................................................................................................................ 100 Complications.................................................................................................................................................................. 100 Cardiac Monitoring.......................................................................................................................................................... 101 HeartWare....................................................................................................................................................................... 101 HeartMate III:.................................................................................................................................................................. 106 12. Shock.................................................................................................................................................................... 111 Definition......................................................................................................................................................................... 111 Categories of Shock......................................................................................................................................................... 111 Stages of Shock................................................................................................................................................................ 111 Composite Physical Examination Findings in Shock......................................................................................................... 112 Clinical Manifestations of Shock...................................................................................................................................... 112 Classification of Shock..................................................................................................................................................... 113 Diagnostic Studies to Evaluate a Patient in Shock........................................................................................................... 116 Therapeutic Interventions............................................................................................................................................... 116 13. Fluid resuscitation................................................................................................................................................ 118 Introduction.................................................................................................................................................................... 118 Basic Principles of Fluid Resuscitation............................................................................................................................. 118 Symptoms of Hypovolemia.............................................................................................................................................. 119 Replacement Fluids......................................................................................................................................................... 119 Blood products................................................................................................................................................................ 121 Drugs............................................................................................................................................................................... 123 14. Massive transfusion protocol.............................................................................................................................. 125 Purpose........................................................................................................................................................................... 125 Population....................................................................................................................................................................... 125 Elements of clinical activity............................................................................................................................................. 125 Targeted Treatment End Points...................................................................................................................................... 126 Pharmacological Management........................................................................................................................................ 127 Documentation............................................................................................................................................................... 127 Trauma Pack Distribution Schedule................................................................................................................................. 128 15. Arterial line........................................................................................................................................................... 129 Introduction.................................................................................................................................................................... 129 Indications....................................................................................................................................................................... 129 Contraindications............................................................................................................................................................ 130 Modified Allen’s Test (MAT)............................................................................................................................................ 130 Insertion.......................................................................................................................................................................... 131 Procedure for zeroing...................................................................................................................................................... 133 Square wave test............................................................................................................................................................. 134 Accidental removal.......................................................................................................................................................... 136 Blood sampling via arterial line....................................................................................................................................... 136 16. Neurological Emergencies................................................................................................................................... 138 Objectives........................................................................................................................................................................ 138 Anatomy of the brain...................................................................................................................................................... 138 Neurological Vital Signs................................................................................................................................................... 138 Increased Intracranial Pressure....................................................................................................................................... 139 Stroke.............................................................................................................................................................................. 142 Status Epilepticus3........................................................................................................................................................... 152 Meningitis15..................................................................................................................................................................... 153 Neurological Disorders.................................................................................................................................................... 155 17. Trauma................................................................................................................................................................. 157 Introduction.................................................................................................................................................................... 157 Biomechanics, kinematics and mechanism of injury....................................................................................................... 157 Forms of energy.............................................................................................................................................................. 158 Types of energy force...................................................................................................................................................... 159 Types of injuries.............................................................................................................................................................. 161 Mechanism of injury and potential injury patterns in MVCs........................................................................................... 162 Assault............................................................................................................................................................................. 166 Penetrating trauma......................................................................................................................................................... 166 Primary survey [ABCDEFG].............................................................................................................................................. 171 Reevaluation.................................................................................................................................................................... 173 Secondary survey [HI]...................................................................................................................................................... 173 Just keep reevaluating – VIPP.......................................................................................................................................... 174 Selected head injuries..................................................................................................................................................... 175 Brain hemorrhage and hematomas................................................................................................................................. 176 Craniofacial injuries......................................................................................................................................................... 177 Spinal cord injuries (SCI).................................................................................................................................................. 180 Mechanisms of injury to the vertebral column............................................................................................................... 181 Vascular system response (Neurogenic shock)............................................................................................................... 184 Assessment findings........................................................................................................................................................ 184 Nervous system response (Spinal shock)......................................................................................................................... 184 Nursing care of the patient with spinal cord or vertebral column injury......................................................................... 185 Thoracic injuries.............................................................................................................................................................. 187 Chest wall injury.............................................................................................................................................................. 187 Rib and Sternal Fracture.................................................................................................................................................. 187 Lung injury....................................................................................................................................................................... 189 Heart injury...................................................................................................................................................................... 192 Abdominal injuries........................................................................................................................................................... 193 Liver................................................................................................................................................................................. 193 Spleen.............................................................................................................................................................................. 194 Hollow organs.................................................................................................................................................................. 194 Pelvic fractures................................................................................................................................................................ 195 Complications of trauma................................................................................................................................................. 196 Post resuscitation care considerations............................................................................................................................ 197 SPECIAL POPULATION...................................................................................................................................................... 198 Selected injuries and emergencies.................................................................................................................................. 201 Comorbidities in older adult population.......................................................................................................................... 210 Summary......................................................................................................................................................................... 210 18. Lethal triad in trauma......................................................................................................................................... 212 Hypothermia................................................................................................................................................................... 212 Acidosis............................................................................................................................................................................ 212 Coagulopathy.................................................................................................................................................................. 212 19. Exposure injuries.................................................................................................................................................. 214 Introduction.................................................................................................................................................................... 214 Heat Stroke...................................................................................................................................................................... 214 Frostbite.......................................................................................................................................................................... 215 Hypothermia................................................................................................................................................................... 216 Burns............................................................................................................................................................................... 218 20. Intoxication.......................................................................................................................................................... 223 21. Organophosphate poisoning............................................................................................................................... 232 Introduction.................................................................................................................................................................... 232 Epidemiology................................................................................................................................................................... 232 Pathophysiology.............................................................................................................................................................. 232 Clinical features............................................................................................................................................................... 232 Diagnostic........................................................................................................................................................................ 233 Management................................................................................................................................................................... 233 22. Carbon monoxide poisoning............................................................................................................................... 235 Symptoms: Mild to Moderate CO toxicity....................................................................................................................... 235 Symptoms: Severe CO toxicity......................................................................................................................................... 235 Treatment........................................................................................................................................................................ 235 23. Endocrine emergencies....................................................................................................................................... 237 Acute hypoglycemia........................................................................................................................................................ 237 Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State2, 3................................................................................. 239 Thyroid Storm:4............................................................................................................................................................... 244 Myxedema Coma............................................................................................................................................................. 246 24. References............................................................................................................................................................ 249 INTRODUCTION The nursing study guide is a document prepared with the collaboration of experience nurses working in the Emergency Department (ED) at the Royal Victoria Hospital (RVH) and the Montreal General Hospital (MGH). This manual will provide you guidelines to care for patients suffering from critical illness and also present you the current applicable procedures seen in the Emergency Department. This present manual is a valuable reference document but doesn’t constitute a complete training itself. The Preceptors will acknowledge the competency of the Critical care room nurse candidates after completion of the mandatory Resuscitation Course including theoretical and skills evaluation. The Critical care nurses are responsible to provide the appropriate care for the critical ill or injured patients that are brought to that room. To improve your knowledge and skills it is strongly recommended to obtain additional course certifications such as BCLS, ACLS and TNCC. The Resuscitation Room nurses must also be aware of the current MUHC policies and procedures (techniques) that are applicable in the resuscitation room such as:  AMI, thrombolytics  Blood warmer  C-spine immobilization; neck collar and backboard  Care of intubated patient  Cardiopulmonary resuscitation  Central lines insertion  Chest tubes insertion  Conscious sedation  CPAP - BiPAP  CVP  Heimlich Valve  Specific IV medications protocols  Stroke, thrombolytics  Tracheostomy  Transvenous pacing  Warming / Cooling blanket  15 lead EKG Enjoy your reading! 1. ROLE AND RESPONSABILITIES Management of Physical Environment MOTO: Be Prepared! Equipment Ensure that all equipment is available and functional. (Bag-valve mask, O2 + suction, intubation box, ventilator, monitor, defibrillator, BP cuffs, O2 Sat , IVAC pumps, etc.) Medications Ensure that you have an adequate supply of all medications as per check-list. Check expiry dates. Check all equipment necessary for administering medication. Check if the medication protocol and dilution book are present. Supplies Check all supply carts for necessary equipment. Stock on daily basis. Ensure equipment on trauma cart ready. Management of Patient Priorities Knowledge base ABCD’s, Medications (action, S/E, method of administration), Management of life-threatening respiratory, cardiology, neurologic, and metabolic emergencies. Be responsible for your own learning! Technical proficiency and organization skills Important and will increase your level of comfort. Goal is to continually develop these. Recognize your strengths and weaknesses and work to improve yourself. Prioritize! Know your Limits! Know your Resources! Communication/Interpersonal skills Crisis management situation as patients critically ill. Provide as much information to patient and family as possible. Maintain calm and empathetic matter. Evaluate pros and cons of family presence on an ongoing basis. Management of Human Resources Leadership It is your responsibility to be in charge of managing the activity surrounding the care of all your patients. Take initiative, delegate and be assertive PRN. Know when you need help! Teamwork Code 1 Nurse / Trauma Leader RN - Person in charge, nursing notes, prepares meds, monitors patient response to treatment, overview of all activity. Code 2 Nurse / T1 - Performs procedures and administers meds. Code 3 Nurse / T2 - Usually nurse in charge, helps with procedures or clinical staff nurse. Emergency Staff MD - Should run code unless delegated to Consultant. Establish MD in Charge and take orders from one person only. Patient Attendant - Performs CPR (RVH) , assists as delegated by Code 1 nurse for tray and equipment Unit Co-ordinator - Should be aware and available of cases in Resus. Communication Imperative that all participants communicate in clear and calm matter. Will directly affect outcome of medical crisis. Resuscitation room nurse must take initiative in setting tone of interactions. Problem situations should be addressed after event. 2. FAMILY PRESENCE 3. AIRWAY MANAGEMENT Objectives  List the different artificial airway device and their indications  Assist for endotracheal intubation and confirm right tube positioning  List the steps for a rapid sequence intubation (RSI)  Name the different categories of medications use for RSI and their actions  Describe difficult airway alternatives  Describe the care for an intubated patient Introduction Airway management is widely believed to be the first priority in the management of any critically ill or injured patient. However, in spite of this, it can often be overlooked and, consequently, can be a source of error in the care of the critical patient. Recognition of the need for airway management is only the first part of the problem in emergency resuscitation. MANAGING the airway may be one of the most difficult aspects of the entire resuscitation. Time pressures imposed by the need to avoid cerebral anoxia force difficult decision-making, therefore tools must be at hand and decision-making must be sharp if optimal emergency airway management is to occur. Life-threatening airway conditions  Obstruction by the tongue in an unconscious patient (most common).  Partial or complete obstruction of the airway from foreign bodies or debris, e.g., blood, mucus, vomitus, broken teeth, tissue, environmental debris (e.g., glass, pebbles, etc).  Penetrating wounds may cause disruption of the integrity of the airway, and blunt trauma may lead to injury of the larynx and/or upper airway structures, e.g., tongue injury during seizure.  Angioedema in the case of allergy and/or anaphylactic shock.  Pathophysiology of pharyngeal or laryngeal structures, e.g., tumor, epiglottitis.  Poisoning, head trauma, CVA, facial trauma, seizures, cardiac arrest.  Post-anaesthetic patients  Iatrogenic causes, e.g., problematic central line insertion or any other invasive procedure causing carotid bleeding and tracheal shift The first priority in nursing care of a critically ill patient is the establishment of a patent airway; therefore, assessment of airway patency is paramount in both the semiconscious and unconscious patient. Airway is the first step of the ABC Signs of partial or total airway obstruction  Noisy airflow, coughing  Vocalization (can the patient phonate)  Bleeding  Snoring sounds  Vomitus or other secretions (mucus plug/phlegm)  Stridor  Oedema  Use of accessory muscles  Apnea  Tongue obstruction  Drooling  Loose teeth or foreign objects Therapeutic interventions Partial airway obstruction in the patient with a decreased level of consciousness is commonly due to posterior displacement of the tongue. Basic airway management maneuvers should be performed on every unconscious patient to ensure airway patency. When uncertain about cervical spine status, the neck must be maintained in a neutral position. Figure 3.1. Airway obstruction by tongue on an unconscious patient Source: First Aid – The Vital Link, Mosby, 1997 Jaw thrust maneuver “The jaw thrust maneuver results in less motion at an unstable C1–C2 injury as compared with the head tilt–chin lift maneuver. Therefore, the use of the jaw thrust is recommended to improve airway patency in the trauma patient with suspected cervical spine injury.”(Prasarn et al., 2014) To perform the jaw-thrust maneuver, stand at the head of the stretcher and place your palms on the patient’s temples and your fingers under the mandibular rami. Lift the mandible upward with your fingers, at least until the lower incisors are higher than the upper incisors. This lifts the tongue along with the mandible, which results in relieving upper airway obstruction. Be careful to only pull or push up the bony parts of the mandible, as pressure to the soft tissues of the neck may obstruct the airway. (Habrat, 2019) Figure 3.2. Head-tilt/Chin Lift. Source: UpToDate – Basic Airway Management in Figure 3.3. Jaw-thrust without head-tilt maneuver. Adults. Graphic 70710 Version 7.0 Source: Uptodate.com. Graphic 53277 Version 2.0 In the unresponsive patient with potential spinal injury, the patient should be kept in the supine position (see section on spinal immobilization). Turning the patient on the side with the log roll technique can allow for drainage of upper airway secretions if needed, to avoid aspiration. The occasional patient who presents with complete airway obstruction secondary to food aspiration may be treated with the Heimlich maneuver if conscious, or abdominal thrusts as described in basic cardiac life support. Other therapeutic interventions Ongoing hemorrhage, vomitus, and particulate debris often require suction to clear and maintain the respiratory passage. An effort should be made to minimize stimulation of the gag reflex to prevent further airway compromise from vomitus. It is essential that Code 1 Trauma Leader Nurse, Nurses and PAB’s know the location of suction equipment and know how to operate it during an emergency. The equipment should be connected and ready to use at all times. Complications of airway suctioning (Sinha et al., 2021) Complications from airway suctioning are relatively uncommon if performed with care and adequate pre-oxygenation.  Hypoxia can be profound from occlusion, interruption of oxygen supply, and prolonged suctioning. Therefore; pre- oxygenation should be initiated prior to suctioning. Brief, 10-second suction duration is usually recommended to avoid mucosal damage and prolonged hypoxia.  Suctioning can stimulate the vagal nerve, predisposing the patient to bradycardia and hypoxia.  Mucosal trauma and infections are also possible complications of suctioning.  Basilar skull fractures can allow the inadvertent placement of nasal suction tubes in the brain Generally, it is best to perform suctioning under direct visual inspection Once the airway has been established by various maneuvers and suctioning, the patient may require further temporary support to maintain airway patency. Oxygen supplementation and an artificial airway may be all the support that is necessary. Artificial Airways (Wittels, 2021) The simplest artificial airways are the oropharyngeal and nasopharyngeal airways. They are intended to prevent the tongue from obstructing the airway by falling back against the posterior pharyngeal wall. The oropharyngeal airway may also prevent teeth clenching. Finally, they are useful in facilitating manual ventilation with BMV. Oropharyngeal Airway Oropharyngeal airway can be used in unresponsive patients with no gag reflex. Its primary use is to prevent the tongue from slipping back into the posterior pharyngeal area. Select the correctly sized airway (sizes: 8-10 for adults) by holding the proximal end of the airway at the corner of the mouth and the distal end should reach the tip of the earlobe. Insert the airway with the distal tip of the oropharyngeal airway turned toward the roof of the mouth. As the airway device passes across the back of the tongue, gently rotate the airway 180 degrees OR use a tongue depressor to hold the tongue against the floor of the mouth and insert the airway following the curvature of the mouth. The flange should rest against the patient’s lips. If the oropharyngeal airway is not positioned properly, it may actually cause airway obstruction, therefore, it is very important to REASSESS FREQUENTLY THE AIRWAY. Definitive airway management should be planned and put in place. Figure 3.4. Oropharyngeal airway sizing. Figure 3.5. Oropharyngeal airway insertion Source: Uptodate.com. Graphic 77645. Version 3.0 Source: Uptodate.com. Graphic 62820. Version 3.0. Figure 3.6. Oropharyngeal airways. Figure 3.7. Improperly positioned oropharyngeal airway. Source: Uptodate.com. Graphic 50230. Version 2.0 Source: ACLS, Mosby, 1994 Nasopharyngeal Airway A nasopharyngeal airway (NPA) can be used in responsive or unresponsive patients, but not in patients with facial trauma or a basilar skull fracture. NPA’s can occasionally be used in patients requiring frequent nasotracheal suctioning, to reduce trauma to the nasal passage. The device may be left in place by RT for patient’s comfort during suctioning rather than as an airway. Use the largest size that will fit in the patient’s nostril. Select the correct length of nasopharyngeal airway (sizes: 6-7 for adult females, 7-8 for adult males) by holding the proximal end of the airway at the nares and the distal end should reach the tip of the earlobe. Lubricate the airway with a water-soluble lubricant prior to insertion. Insert the nasopharyngeal airway with the bevel facing the nasal septum. Direct the airway posteriorly and slightly rotate it toward the ear until the flange rests against the nostril. Avoid inserting the airway into a nostril obstructed by septal deviation, polyps, etc. The majority of available nasal airways are made to insert in the right nostril. If the left nare must be used, the airway must be turned upside down to be sure the bevel faces the septum. Figure 3.8. Nasopharyngeal airway insertion Source: Uptodate.com. Graphic 79849. Version 4.0 Reassessment of the airway All patients with oral or nasal pharyngeal airways should be observed constantly, because these devices are temporary measures and cannot substitute for tracheal intubations. Look for:  Spontaneous breathing  Chest rises and fall  Skin color (pallor, mottling, cyanosis)  General rate and depth of respirations (bradypnea, tachypnea)  Soft tissue and bony chest wall integrity (open chest wound, bruising)  Use of accessory muscles and/or abdominal muscles  Bilateral breath sounds upon auscultation (clear, absent, wheezing)  Jugular veins and position of trachea (distension of jugular veins, trachea midline) Oxygen delivery devices Table 3.1. Summary of Oxygen Delivery Devices Device FiO2 L/min Comments Nasal cannula 24%-44% 1 to 6 Difficult to tolerate flow > 6 L Venturi mask 24%-50% 2 to 12 6 different adapters Nonrebreather mask 60%- 90% 12 to 15 Prevents accumulation of CO2 Bag-valve with O2 reservoir 60%-100% 15 Delivers highest concentration of O2 Bi-PAP 21%-100% Pressures Difficult to tolerate for (IPAP/EPAP) extended period of time. Not appropriate for agitated patients. Pt needs to remain NPO. Efficient for resolving respiratory acidosis if can be tolerated Hi-Flow Nasal Cannula 21%* to100% 30 to 60 May be better tolerated than Bipap *Normally if the patient is on 30% FiO2 on HFNP, they are weaned off HF and placed on NP/VM as is appropriate. However, the HFNP system can deliver 21% FiO2 to deliver humidity only. (Association, 2000) Oxygen delivery devices are connected to an O2 flowmeter and not a medical air flowmeter. There can be Medical Air flowmeters present in Resus rooms for patients at risk of hypercapnia, i.e., consecutive nebulizing treatment. Bag-valve mask (BVM) device If the patient is not breathing spontaneously or at a rate and depth that is inadequate for proper ventilation, use of a bag- valve mask (BVM) device is indicated. A BVM must have an oxygen reservoir system and be connected to an oxygen source. Maintain an oxygen flow rate sufficient to keep the reservoir bag inflated; usually requires 15L/min. Effective BVM ventilation requires a tight seal of the face mask, in conjunction with adequate compression of the bag. Having a pre- prepared bag-mask with filter attached in every room with a COVID-19 patient is prudent. Using a two-person technique for an adequate face mask seal is also suggested. (Anesi, 2021) BVM ventilation by one person Stand at the patient’s head and place the narrow end of the mask over the bridge of the patient’s nose. Hold the mask firmly with the thumb over the patient’s nose; grasp and lift the mandible with the fingers. Compress the bag with the other hand. The hand position is referred to as the “C and E position”. It is also important to tilt/chin lift to open the airway while bagging. Individuals with small hands may be able to generate larger tidal volume by compressing the bag against their bodies. Figure 3.9. Use of BVM by a single rescuer. Source: EMT – Basic Textbook, Mosby, 1996 Figure 3.10. One-hand BVM technique. Source: Uptodate.com. Graphic 80091 Version 2.0 BVM ventilation by two persons The two-hand mask hold requires two providers, but it is the most effective method of opening the patient's airway while maintaining an adequate mask seal and minimizing provider fatigue. One person stands at the patient’s head and places the thumbs on each side of the mask; he or she then grasps and lifts the mandible with the fingers of both hands. The second person stands to the patient’s side and compresses the bag. Figure 3.11. Two-handed bag mask ventilation techniques Source: Uptodate.com. Graphic 82048. Version 4.0. Assess for effective ventilation by inspecting for chest rise and fall and skin color. Hypoventilation often occurs because of the difficulty of carrying out the technique properly. Four things can result in complications 1. Poor mask seal 2. Failure to achieve airway patency 3. Low tidal volume 4. Gastric distension Gastric distension is a result of air insufflated down the esophagus, which inflates the stomach. Consequently, the risk of regurgitation and aspiration increases. Sellick Maneuver – Cricoid pressure Sellick Maneuver (Cricoids pressure) is not recommend (ACLS, 2010) The maneuver consisted of occlusion of the upper esophagus by backward pressure on the cricoid ring against the bodies of cervical vertebrae to prevent gastric contents from reaching the pharynx (Ovassapian & Salem, 2009). “Backward-upward-rightward pressure (BURP) maneuver is a technique used to improve glottis visualization during laryngoscopy. The patient is placed in the sniffing position and the assistant’s thumb and middle finger are placed on the cricoid cartilage slowly pushing it backward, upward, and rightward. One of the advantages of this maneuver is the low incidence of airway traumatization, aspiration, and hypoxia. However, its efficacy in all difficult airway scenarios is controversial and its application is limited in anterior airway trauma” (Mohseni et al., 2017).Note that the MD manipulating the laryngoscope is the one who is initially manipulating the cricoid/larynx based on his view. Once he is satisfied with the view, the assistant takes over holding the cricoid cartilage. If cricoid pressure is applied during ventilation with a BVM and landmark visualization is limited during intubation, consider releasing it and try the BURP maneuver. Extraglottic airway devices (EAD) “Airway management devices that allow gas to enter and exit the airway via an airway tube, which sit above the glottis, are commonly referred to as supraglottic airways. However, because a number of device designs incorporate components that are inferior to, but remain outside the glottis, the term extraglottic airway device (EAD) is more appropriate.”(Ramaiah et al., 2014) Two such airway devices are the Combitube, and the LMA. Esophageal-tracheal combitube airway The insertion of the combitube is a blind technique for providers who have not been trained in the use of a laryngoscope (Urgences Sante). Patients in cardiac arrest, arriving without an Urgences-Sante M.D. on scene, will often have an EAD in place when they arrive in the ED. Not to be inserted on a patient > 7 feet or < 5 feet and in presence of a tracheostomy. Figure 3.12. Combitube inserted into the oesophagus or the trachea. Source: Programme Combitube, Urgences Santé, 2000 Laryngeal mask airway (LMA) (Doyle, 2021) The LMA consists of a hollow tube connected to a cuff designed to sit in the hypopharynx facing the glottis, with the tip at the esophageal inlet. The LMA is used clinically as an alternative to both mask ventilation and endotracheal intubation. The LMA is used if BMV/intubation are difficult to do or have failed. It is usually easily placed and is less stimulating than endotracheal intubation, but it does not provide complete protection against aspiration and does not prevent laryngospasm. The i-gel uses a non-inflatable cuff and wider tubing for stability (Figure 8). The device seals the glottic opening through its shape. A bite block and gastric suction channel are integrated into the device. At the MUHC the available LMA is the i-gel You can view a video on how to place the i-gel on UpToDate. Complications  Laryngeal spasm  Aspiration of stomach contents  Incorrect placement causing obstruction. Figure 3.13. i-gel LMA. Source: https://www.intersurgical.com/info/igel-emergency-medicine Figure 3.14. LMA position. Source: Uptodate.com. Graphic 79779. Version 3.0 Tracheal Intubation Patients present to the emergency department (ED) with a wide range of conditions that may require tracheal intubation or positive pressure ventilation, including: Covid-19, pneumonia, asthma, chronic obstructive pulmonary disease (COPD), cardiogenic pulmonary edema, acute respiratory distress syndrome, stroke, trauma, drug overdose, severe sepsis, shock, and neuromuscular disorders such as myasthenia gravis or Guillain-Barré syndrome. The critically ill patient must be well oxygenated with a protected airway. If the airway is not obstructed and respirations are spontaneous and adequate, oxygen supplementation and artificial airway placement may be enough. Breathing is a dynamic function that must be monitored constantly. Other indications for airway control:  Unconscious from head trauma  Failure of spontaneous respiratory effort  Presence of hypovolemic shock that does not respond rapidly to oxygen supplementation and volume replacement with decreasing level of consciousness, acidosis, hypoxia, or hypoventilation  Unable to maintain airway patency/ Unable to manage secretions  Unable to protect airway (Unconscious, GCS 1 mm) and broad (>0.03 to 0.04 seconds). The Q waves are more likely to be diagnostic of a prior MI if there is also an inverted T wave in the same lead. An abnormal Q wave is defined by:  Any Q wave in leads V2 to V3 ≥20 msec or QS complex in lead V2 to V3  In two contiguous leads, Q wave ≥30 msec and ≥ 0.1 mV deep, or QS complex in leads I, II, aVL, aVF, or V4 to V6  R wave ≥ 40 msec in V1 to V2 and R/S ≥ 1, with a concordant positive T wave Figure 6.5. Q wave Source: Carlson KK, American Association of Critical-Care Nurses. AACN Advanced Critical Care Nursing. St. Louis, Mo.: Saunders/Elsevier; 2009. Figure 6.6. Timely care goals for STEMI screening, diagnosis and treatment: ED arrival to treatment Source: Yiadom, et al. (2017). Performance of Emergency Department Screening Criteria for an Early ECG to Identify ST-Segment Elevation Myocardial Infarction. Journal of the American Heart Association, 6(3). Cardiac Biomarkers (Jaffe & Morrow, 2021) Cardiac troponin I and T are specific and sensitive biomarkers of myocardial injury. They are the preferred blood test used to evaluate patients suspected of having and AMI. In addition to clinical evidence of ischemia, e.g., chest pain or an abnormal ECG, diagnosis of AMI requires also evidence of acute myocardial injury (myocyte death) and Troponin is the standard blood-based test. Troponin level must be above the 99th percentile of the upper reference limit. A rise and/or fall of the troponin value should be observed. Cardiac troponin concentrations usually begin to rise two to three hours after the onset of acute MI. Patients who present late after the onset of AMI, may be on the downslope of the time-concentration curve. In 2019, the Beckman Coulter High Sensitivity Troponin I assay (HS Trop) was introduced at the MUHC:  Initial sample should be taken at time T=0  Subsequent sample should be taken at T+3hrs  Reference range: 0 - 17.5 ng/L As per MUHC protocol consider myocardial damage/infarction if: HS Trop is greater than or equal to 87.5 ng/L in the initial sample OR there is a change of greater than or equal to 22 ng/L, 3 hours later, with clinical evidence of ischemia. As per MUHC protocol myocardial damage/infarction is ruled out in patients if: The patient presents with chest pain for more than 3 hours, without clinical evidence of ischemia and HS Trop is less than or equal to 6 ng/L in the initial sample. OR HS Trop is less than or equal to 17.5 ng/L in the initial sample and a change of less than or equal to 5 ng/L between 2 samples 3 hours apart. Management of patients with AMI Reeder and Kennedy (2021) Patients with suspected ACS or high-risk features should receive a 12 lead electrocardiogram and have it interpreted within 10 min of their arrival in the ED. The diagnosis of STEMI in the ED is made solely by ECG. DOOR TO ECG = 10 MINUTES Once the diagnosis of an AMI is made the patient should have:  Continuous cardiac monitoring,  Oxygen  Intravenous access While the patient is being assessed as a candidate for fibrinolysis or primary percutaneous coronary intervention (PCI), therapy should be started to:  Relieve ischemic pain  Stabilize hemodynamic  Reduce ischemia status Oxygen Supplemental oxygen should be given to patients with an SPO2 < 90%, patients in respiratory distress, or those with other high-risk features for hypoxia. Supplemental oxygen in patients without hypoxia has not been shown to lead to benefit or harm and has the disadvantages of discomfort of use and cost. Morphine In the setting of acute myocardial infarction, intravenous morphine should be avoided if possible and reserved for patients with an unacceptable level of pain since a large but retrospective study suggests its use is associated with an adverse effect on outcome. Nitrates Sublingual nitroglycerin is the therapy of choice for acute anginal episodes and for patients with acute MI to improve symptoms, lower blood pressure, and improve pulmonary congestion. Intravenous nitroglycerin is typically initiated in patients with persistent ischemic chest pain despite sublingual nitroglycerin treatment. However, nitrates must be used with caution or avoided in settings such as:  Right ventricular infarction  Severe aortic stenosis  Use of phosphodiesterase inhibitor within the previous 24 hours Antiplatelets All STEMI patients should receive aspirin as soon as possible after presentation of symptoms All STEMI patients who will be treated with fibrinolytic therapy, should receive clopidogrel as soon as possible For patients with planned primary PCI, ticagrelor (loading dose 180 mg) or prasugrel (loading dose 60 mg) is preference to clopidogrel. If clopidogrel is chosen, the recommend a loading dose is 600 mg Anticoagulants All STEMI patients should be treated with anticoagulant therapy as soon as possible after diagnosis. The choice of anticoagulant agent depends upon the treatment strategy for each patient. Reperfusion Prompt restoration of myocardial blood flow is essential to optimize myocardial salvage and to reduce mortality. A decision must be made as soon as possible as to whether reperfusion will be achieved with fibrinolytic agents or primary (direct) PCI.  If high-quality PCI is available, it is the preferred therapy as it enhances survival and has a lower rate of intracranial hemorrhage and recurrent MI compared to fibrinolysis.  If primary PCI is not available on site, rapid transfer to a PCI center can produce better outcomes than fibrinolysis, as long as the door-to-balloon time is less than 90 minutes. For patients with STEMI in whom fibrinolysis is chosen as the reperfusion strategy, e.g., when primary PCI is not available, treatment should be given as soon as possible after the diagnosis. The time from first medical contact, i.e., arrival in the hospital emergency department, to drug administration is 30 min; door-to-needle time should be less than 30 minutes. Refer to Structured prescriptions in MedUrge for the guidelines on administration and monitoring parameters for tenecteplase (TnK) (Gibson et al., 2021) Tenecteplase has comparable efficacy to alteplase but has a lower rate of non-cerebral bleeding events and is easier to use. It is given as a single bolus. Fibrinolysis immediately before primary PCI, previously called facilitated PCI, is not recommended. EKG pre thrombolytic EKG 30 minutes AND 1h post thrombolytic Right side EKG (v#R, V4R) if inferior MI 7. ACLS Introduction Advanced cardiac life support (ACLS) guidelines have evolved over the past several decades based on a combination of scientific evidence of variable strength and expert consensus. Excellent cardiopulmonary resuscitation (CPR) and early defibrillation for appropriately shockable arrhythmias remain the cornerstones of basic life support (BLS) and ACLS. The following goals are essential for performing excellent chest compressions: Figure 7.1 Provided by Marie-Josee Jobin Use the LUCAS whenever available LUCAS chest compressions do not need to be interrupted during shock delivery. LUCAS chest compressions do not need to be interrupted during shock delivery. Manual chest compressions (ACLS Provider Manual, 2020):  Press hard and press fast  Maintain the rate of chest compression at 100 to 120 compressions per minute  Compress the chest at least 5 cm (2 inches) with each down-stroke  Allow the chest to recoil completely after each down-stroke to allow irrigation of cardiac tissues.  Minimize the frequency and duration of any interruptions: continue chest compression while the defibrillator is charging. Restart chest compressions immediately after shock delivery.  Change the provider q 2 minutes maximum Adult cardiac arrest algorithm Figure 7.2. Adult cardiac arrest algorithm. Source: ACLS 2020. Adult bradycardia algorithm Figure 7.3. Adult Bradycardia Algorithm. Source: ACLS 2020. Adult tachycardia with pulse algorithm Figure 7.4. Adult Tachycardia with pulse algorithm. Source: ACLS 2020. Adult post-cardiac arrest care algorithm Figure 7.5 Cardiac arrest in pregnancy algorithm Figure 7.6 Figure 7.7 Manual left uterine displacement, performed with the 2-handed technique and 1-handed technique during resuscitation (ACLS Provider Manual, 2020) In cardiac arrest, the reduced venous return and cardiac output caused by the gravid uterus puts the mother at a hemodynamic disadvantage, thereby potentially reducing the effective coronary and cerebral perfusion produced by standard chest compression. Therefore, when there is aortocaval compression, the effectiveness of the chest compressin may be limited. Patient positioning has emerge as an important strategy to improve the quality of CPR and the resultant compression force and cardiac output. The gravid uteris can compress the inferior vena cava, impending venous return, thereby reducing stroke volume and cardiac output. In general, aortocaval compression can occur for singleton pregnancies at proximately 20 weeks of gestational age, at about the time when the fundus is at or above the umbilicus. Although chest compressions in the left lateral tilt position are feasible in a mannequin study, the result in decreased CPR quality (less forceful chest compressions) that is possible in the supine position. Manual left lateral uterine displacement effectively relieves aortocaval pressure in patients with hypotension. Chest compressions performed while the patient is tilted are no ideal. Although it is feasible to perform chest compressions in the tilted patient. Chest compression performed in the tilted position are less forceful when compared with the supine position. However, there are no physiologic data available for chest compressions in the tilted position. High-quality chest compressions are essential to maximize the chance of a successful resuscitation. An alternative method of relieving aortocaval compression, such as manual displacement, may be nore practical and ideal during resuscitation because it allows for continuous and easier delivery of all other aspects of resuscitation, including high-quality chest compressions, defibrillation, IV access, and intubation. ACLS medications Adenosine: antiarrhythmic class V Tachyarrhythmia algorithm: First dose 6mg fast IV push Second dose 12mg fast IV push Amiodarone: antiarrhythmic class III Cardiac arrest algorithm: First dose: 300mg IV push IV/IO Second dose: 150mg IV push IV/IO Tachyarrhythmia algorithm: Bolus 150mg over 10 minutes IV/IO Maintenance infusion (see protocol) IV/IO Atropine: Parasympatholytic Bradyarrhythmia algorithm: 0.5-1mg IV/IO q 3-5 minutes (max 3mg) Epinephrine: sympathomimetic (alpha + beta agonist) Cardiac arrest algorithm: 1mg IV/IO push q 3-5 minutes, no limits Lidocaine: antiarrhythmic Cardiac arrest algorithm: First dose 1-1.5mg/Kg IV/IO Second dose: 0.5-0.75mg/Kg IV/IO Magnesium: electrolyte Torsade de pointes: 1-2g IV push Procainamide: antiarrhythmic class IA Tachyarrhythmia algorithm: Loading dose 20-50mg/min for a max fo 17mg/Kg IV/IO Maintenance infusion: 1-4mg/min x 6 hours 8. PACEMAKER THERAPY Introduction “Cardiac pacemakers deliver an electrical stimulus to the heart through electrodes, causing depolarization and subsequent cardiac contraction” (Tintinalli et al., 2016). Asynchronous pacing mode refers to delivery of electrical stimuli at a selected rate regardless of patient’s intrinsic cardiac activity. Synchronous pacing mode refers to the delivery of electrical stimulus only when needed. Pacemaker detects or “senses” the patients intrinsic electrical activity and inhibits the pacemaker from firing an electrical stimulus (Ganz, 2021). Indications for Emergency Pacing (Tintinalli et al., 2016)  Symptomatic or hemodynamically unstable bradycardia  AV block characterized by hypotension  Change in mental status  Angina  Pulmonary edema Transcutaneous Pacing Adhesive pads are placed directly on the patient's chest, typically in the anterior and left lateral positions or in the anterior and posterior positions (Ganz, 2021). The pads applied to the chest wall deliver an electric impulse to stimulate the myocardium. Muscle contraction is notable, especially at high outputs, and may be painful (Tintinalli et al., 2016). In the RVH ED currently “Multifunctional stat-padz” from Zoll Medical Corporation are being used. Placement as per the manufacturer: Figure 8.1. Stat-padz placement. Source: Zoll.com Transvenous Pacing The preferred access sites are the left subclavian vein and the right internal jugular vein. The subclavian access permits more freedom of patient motion. A brachial vein approach is not recommended because of the risk of cardiac puncture and instability. Femoral vein approach is fairly common, particularly in the cardiac catheterization lab while undergoing PCI. However, it is not recommended longer-term because of the risks of DVT’s and the need for the patient to remain continuously supine. Once central venous access has been secured and the introducer sheath is in place, the transvenous lead is inserted and advanced into the heart. When the lead is placed in the right ventricular apex, there should be slight excess lead or "slack" to ensure that the lead does not become dislodged. The lead should be tied down. The connector cable connects the pacing lead to the generator. The settings should be whatever rate optimizes the patient's hemodynamics. For most other patients, a rate of 60 to 70 beats per minute will likely be adequate. To ensure proper pacemaker sensing and capture, the pacemaker output should be set at least two to three times the pacing threshold, which should ideally be less than or equal to 1 milliamp.2 Figure 8.2. Transvenous pacing Source: EM:RAP.org Permanent pacing is not performed in the ED. Permanent pacemaker pulse generator placement is usually on the side of the patient’s nondominant hand. The leads insert into the right ventricle at the apex, septum, right ventricular outflow tract, or His Bundle region and, in the case of a dual- chamber device, also in the right atrium. Pacemaker Nomenclature (Tintinalli et al., 2016) A five-letter code describes the features of the pacemaker. 1. The first letter refers to the chamber or chambers in which the pacing occurs:  A = atrium  V = ventricle  D = dual chamber or both A and V 2. The second letter refers to the chamber or chambers in which sensing occurs.  A = atrium  V = ventricle  D = dual chamber or both A and V 3. The third letter responds to how the pacemaker responds to a sensed event  I = sense event inhibits the output pulse and causes the pacemaker to recycle the timing cycles  T = output pulse is triggered in response to a sensed event  D = both “T” and “I” responses can occur 4. The fourth letter is used to indicate the presence or absence of rate modulation 5. The fifth letter indicates whether multisite pacing is present and is rarely used The pacemaker senses the heart’s intrinsic electrical activity, and responds by pacing or inhibiting pacing. The pacemaker can inhibit itself but cannot inhibit the heart. It may incidentally suppress intrinsic activity because paced depolarizations will make the myocardium refractory to native impulses. A function of newer pacemakers is rate responsiveness. This allows for increased physical activity by increasing the paced rate in response to increased metabolic demands (Reichman, 2018). Table 8.1. The North American Society of Pacing and Electrophysiology/British and Electrophysiology Group Generic Pacemaker Code (Bernstein et al., 2002) -1- -2- -3- -4- -5- Chamber(s) Chamber(s) Response to sensing Rate modulation Multisite Pacing paced sensed O – None O – None O – None O – None O – None A – Atrium A – Atrium T – Triggered R – Rate modulation A – Atrium V – Ventricle V – Ventricle I – Inhibited V – Ventricle D – Dual (A + V) D – Dual (A + V) D – Dual (T + I) D – Dual (A + V *Some manufacturer use the designation S – Single (A or V) * Position 4 assumed that all contemporary pulse generators are capable of comprehensive noninvasive adjustment and of providing information by telemetry, so that the “programmability” hierarchy incorporated in the previous version of the code is no longer needed. Figure 8.3. Pacemaker under the skin. Source: Uptodate.com. Graphic 128077. Version 2.0. Procedure for transcutaneous pacing (Zoll, 2018) 1. Gather necessary equipment: Defibrillator w/ pacer pads and EKG electrodes, Cardiac Monitor, Supplemental O2 PRN, PIV access. 2. Remove all clothing. Dry chest if necessary. If patient has excessive hair, clip it to ensure proper adhesion of electrodes. 3. If time and conditions allow, explain the procedure to the patient and administer IV sedation and analgesia before pacing. Tell the patient in advance that he will feel a ``thumping`` sensation in his chest. 4. Place Pacer pads in the anterior and posterior position on chest. Do not place over nipple, cuts, ECG electrodes, NTG patch. Preferably put the pacing electrode under the female patient breast. 5. Connect pacing cable to outlet on monitor. 6. Push or select pacer on. Put on synch (synch by default) 7. Set Pacer output to 0 mA, if not already. 8. Increase output until capture; titrate down till capture lost to find minimal output necessary for have electric capture. 9. Confirm electrical capture w/ palpation of femoral pulse and HR reading w/ the SpO2 sensor. 10. Increase output from minimal mA necessary to have electric capture by 10% 11. Set rate as per Rx 12. Confirm capture by palpating pulse manually 13. Activate pacer by pushing start/stop button. 14. For unconsciousness, initiate pacing with the mA up to maximum. Confirm electrical capture and decrease the mA until only that which is necessary for capture is used. For a conscious patient, activate the pacemaker at the lowest current setting and increase (increase current by 5 mA) until capture. 15. Check pulse and BP continuously 16. After defibrillation, pacer becomes disarmed. Repeat activating sequence. 17. As per manufacturer, replaced pads after 24hrs or after 8hrs or continuous pacing Figure 8.4. Pacing stimulus on rhythm strip Source: Zoll (2018) Figure 8.5. Effective pacing. Source: Zoll (2018) Magnet Application for Implantable Cardioverter Defibrillators (ICDS) (CorHealth Ontario, 2017)  Locate the ICD: It is usually located in the upper left chest area, under the collarbone but sometimes the ICD is located on the right side of the chest. In rare instances it may be located in the abdomen. Subcutaneous ICDs are usually located along the left mid axilla area.  Palpate the ICD: To ensure that you have the correct magnet placement location, ensure that you can feel the ICD under the skin. Place the magnet directly over the ICD and secure it with any type of tape (see Figure below).  Secure the magnet: If the magnet were to lose connection with the ICD, the therapies you are suspending will no longer be suspended.  Suspend the ICD: Once the magnet is placed, tachyarrhythmia detection and therapy will be suspended so the ICD will not deliver any anti-tachycardia pacing (ATP) or shocks for ventricular arrhythmias. After magnet placement you may or may not hear a tone coming from the device. Not all devices will have this tone or ringing feature. If you hear a tone, it lasts for approximately 10-20 seconds which indicates the magnet has been properly placed.  Pacemaker functions for a slow heart rate are NOT affected by the magnet. Even when the magnet is in place the patient will continue to receive the programmed pacing for a slow heart rate at the programmed rate.  Removal of the magnet will restore all anti-tachycardia detection and shock therapy.  Skin integrity: assessment of skin integrity is required for magnet application longer than 24 hours. Figure 8.6. Magnet taped directly over ICD Source: CorHealth Ontario, 2017. CorHealth Ontario. (December 2017). Implantable Cardioverter Defibrillator (ICD) Deactivation: A Guide for Health Care Professionals. https://www.corhealthontario.ca/Implantable-Cardioverter-Defibrillator-Deactivation-A-Guide-for-Health- Care-Professionals.pdf. 9. CARDIOVERSION Introduction Figure 9.1. ZOLL R-Series Rectilinear Biphasic waveform. Source: Zoll.com Certain arrhythmias, such as atrial fibrillation, atrial flutter, and ventricular tachycardia require synchronizing the defibrillator discharge with the ECG R-wave to avoid the induction of ventricular fibrillation. A synchronizing (Sync) circuit within the defibrillator detects the patient’s R-waves; the unit displays markers (↓) above the ECG trace to indicate the points in the cardiac cycle (R waves) where discharge can occur. When the SHOCK button is pressed (or buttons are held down, if using paddles), the unit discharges with the next detected R-wave, thus avoiding the vulnerable T-wave segment of the cardiac cycle. Figure 9.2. R Waves Detected during synchronization Source: Zoll.com Verify that markers are clearly visible on the monitor and their location is appropriate and consistent from beat to beat. If necessary, use the LEAD and SIZE buttons to establish settings that yield the most consistent Sync marker pattern. The synchronized cardioversion procedure for ZOLL hands-free therapy electrodes is identical to that for paddles with the exception of the SHOCK button location. Synchronized Cardioversion Procedure To prepare the patient, remove all clothing covering the patient’s chest. Dry chest if necessary. If the patient has excessive chest hair, clip or shave it to ensure proper adhesion of the electrodes. Attach ECG electrodes as described in figure below. Attach hands-free therapy electrodes according to Figure 9.3. 3-lead ECG configuration Figure 9.4. Stat-padz placement. instructions on the Source: liftl.com Source: Zoll.com electrode packaging. If patient is unstable or cannot easily be repositioned apply the pads on the anterior chest. Ensure that the therapy electrodes are making good contact with the patient’s skin and are not covering any part of any other electrodes. Connect the hands-free therapy electrodes to the OneStep cable if not preconnected.  If therapy electrodes are not making good contact with the patient’s skin, the unit issues the messages CHECK PADS and POOR PAD CONTACT and does not allow delivery of energy.  If a short circuit exists between the electrodes, the unit issues the message DEFIB PAD SHORT.  An ECG LEAD OFF condition prevents synchronized discharge if leads are selected as the ECG source. This condition does not prevent the use of the defibrillator; it simply prevents use in a synchronized manner. Turn the Mode Selector to DEFIB. Select the desired energy using the up and down arrow keys on the front panel. Press the Sync On/Off softkey to turn on sync mode. The Sync On/Off softkey is off by default. After every shock, by default the SYNC mode is automatically disabled. If you need to give subsequent shocks PRESS SYNC SOFT KEY AGAIN. Figure 9.5. Sync On/Off Key Placement Source: Zoll.com Figure 9.6. Syn On and Off Source: Zoll.com The selected energy level is displayed on the monitor. A Sync marker (↓) appears on the monitor above each detected R- wave to indicate where discharge will occur. Verify that the markers are clearly visible on the monitor and their location is appropriate and consistent. Figure 9.7. Sync Marker above detected R waves Source: Zoll.com The unit automatically exits Sync mode after each shock and when the Mode Selector is moved to MONITOR, PACER or OFF. To reactivate Sync mode, press the Sync On/Off softkey again. Changing the selected energy levels does not cause the unit to leave Sync mode. To abort charging and increase or decrease the selected energy after the CHARGE button has been pressed, use the ENERGY SELECT buttons on either the defibrillator front panel or the sternum paddle. Press the CHARGE button again to charge the unit to the newly selected energy level. After charging the unit to the selected energy, either the front panel SHOCK button or the APEX paddle charge indicator illuminates. A distinctive audible tone sounds and the SYNC XXXJ READY message is displayed. The defibrillator is now ready to deliver therapy (Zoll, 2018). Adult tachycardia with a Pulse Algorithm Figure 9.8. 2020 Adult Tachycardia with a Pulse Algorithm. Source: American Heart Association Complications (Knight, 2021) While electrical cardioversion is generally well tolerated, complications may occur. 1. Electrocardiographic (ECG) changes can occur immediately after cardioversion, usually consisting of ST segment and T wave changes. The pathogenesis of ST elevation is uncertain. However, both the incidence and the extent of ST segment changes appear to be lower with the use of biphasic waveforms. 2. Arrhythmias are frequently observed after cardioversion. In many cases the following arrhythmias are benign (eg, sinus tachycardia, non-sustained ventricular tachycardia), but in other cases they can be clinically and/or hemodynamically significant.  Ventricular arrhythmias  Atrial arrhythmias  Bradyarrhythmias and conduction abnormalities  A transient left bundle branch block is occasionally seen after cardioversion, but high-degree atrioventricular block is more common 3. Cardioversion may be associated with pulmonary or systemic thromboembolism. Thromboembolism after the return of synchronous atrial contraction can occur because of dislodgement of left atrial thrombi present at the time of cardioversion or a thrombus that forms after cardioversion due to transient post conversion left atrial mechanical dysfunction. This complication is more likely to occur in patients with atrial fibrillation (AF) who have not been anticoagulated prior to cardioversion. For patients with AF of at least 48 hours duration, the current recommendation is to anticoagulate patients for several weeks prior to and following cardioversion. 4. Minimal myocardial necrosis, particularly of the epicardium, may occur as a result of high-energy shocks. This is typically asymptomatic and is manifested by small rises in serum CK-MB and troponin levels. In contrast, substantial elevations of either CK-MB or troponin following electrical cardioversion, or the development of chest pain suggestive of angina, suggests the presence of myocardial injury from causes unrelated to the procedure. 5. Global left ventricular dysfunction due to myocardial stunning may be seen in patients with cardiac arrest who have undergone successful cardiopulmonary resuscitation. This is related in part to defibrillation, but is also a result of the arrhythmia itself and due to the absence of cardiac output and coronary blood flow during the period of arrest with resultant ischemia. Myocardial dysfunction due to stunning may reverse within the first 24 to 48 hours after cardiac arrest. 6. Pulmonary edema is a rare complication of cardioversion, which is probably due to transient left atrial standstill or left ventricular dysfunction. It is unrelated to the amount of energy used. Pulmonary edema may be more common in patients with AF associated with valvular heart disease or left ventricular dysfunction. 7. Transient hypotension can occur for several hours after cardioversion. Most patients require no therapy; if necessary, the fall in blood pressure usually responds to fluid replacement. 8. Cutaneous burns occur in 20-25 percent of patients following cardioversion or defibrillation. They are likely due to improper technique and placement of electrodes. The risk of burns is lower with the use of biphasic waveforms and the use of gel-based pads. In the RVH ED, cardioversion is preferably done in one of the resuscitation rooms. However, it can be done in any of the Horizontal Monitored room as long as a dedicated RESUS trained nurse is available to remain at bedside for the length of the procedure. If the patient is in stable condition prior to cardioversion, consider procedural sedation. Refer to the “procedural sedation” section of the manual. If the patient is hemodynamically unstable do not delay cardioversion for sedation unless specifically instructed by MD. 10. EXTRACORPORAL MEMBRANE OXYGENATION (ECMO) ECMO is an advanced mechanical therapy that provides cardiovascular support for patients with refractory, life- threatening cardiopulmonary failure (Yam & McMullan, 2017). The primary indication for ECMO is acute severe heart or lung failure with high mortality risk despite optimal conventional therapy (Extracorporeal Life Support Organization, 2017) Inclusion Criteria (McGill University Health Center, 2019a)  Cardiac arrest due to MI / cardiac dysfunction / circulatory collapse  Massive / submassive pulmonary / amniotic fluid embolism  Post-cardiotomy inability to separate from CPB  High risk cath lab procedures where more than temporary LVAD “back-up” is needed  Sepsis with myocardial depression and LVEF 65  Expressed wishes against  Weight > 140 kg MCS/resuscitationUnwitnessed arrest or known  Stage II or higher malignancy poor neurologic status  Septic patients without cardiac dysfunction  Witnessed arrest where ACLS has been performed  Advanced liver cirrhosis (Childs B or higher) by longer than 75 min without ROSC (time to  Aortic dissection and/or severe aortic insufficiency cannulation)  Severe pulmonary hypertension  Presence of mechanical cardiac valve Veno-Venous (VV) ECMO During VV ECMO, blood is extracted from the vena cava or right atrium and returned to the right atrium. VV ECMO provides respiratory support, but the patient is dependent upon his or her own hemodynamics (Manaker, 2021). For severe respiratory failure; accesses and returns blood from venous system and provides non-pulmonary oxygenation as well as CO2 elimination (McGill University Health Center, 2019a). Figure 10.2. VV ECMO Source: Uptodate.com. Graphic 56622. Version 5.0 Exclusion Criteria (McGill University Health Center, 2019a)  Age >75 years  Weight >140 kg  Non-recoverable status: o pulmonary (including severe pulmonary hypertension) o cardiac (severe RV failure and/or severe LV failure) o or neurologic  Active malignancy (stage II or higher cancer, other than non-melanoma skin), or graft-versus-host disease of the lung  Childs B or higher cirrhosis  Wishes against resuscitation  Technical inability to cannulate Figure 10.3. ECMO Timeline Source: (McGill University Health Center, 2019a) The ECMO team will bring their own material. The ED ECMO BOX is in H1 in front of R55. Room Layout Figure 10.4. Room layout for CODE ECMO Source: (McGill University Health Center, 2019a) Due to the Covid-19 pandemic, infection prevention and control guidelines:  Med Cart is outside of the room.  Pharmacist or RN will be outside of the room to prepare medication. Be aware that the space will be crowded. Nursing Role Communicate well and continue with your tasks. The ED MD will continue to be responsible for the patient. The ECMO team will be responsible for the ECMO procedure. As the Resus nurse, you will continue the ACLS algorithm and the resuscitation maneuvers. The Resus nurse’s role (Extracorporeal Life Support Organization, 2017): 1. Responsible for the care of patient:  Monitor/expect changes in vital signs and hemodynamic instability  Monitor ECMO complications  Draw labs, type & screen 2. Administration of:  Blood products, fluids,  Antibiotics  Anticoagulation  ACLS drugs  Vasoactive drips 3. Accompanies patient during transport 4. Ensures electrical plug available to connect ECMO machine 5. Ensures free dedicated area for ECMO machine Documentation Documentation of:  ACLS maneuvers, patient status  Communication: decision, time of activation and time of arrival of team  Process of insertion of ECMO therapy  Decision of transfer Do not document on the ECMO machine data Transfer Patient Transfer to Cath lab or ICU with:  2 x ED RNs  ECMO leader  Perfusion  RT  PAB  ICU MD Give report to the cath lab or ICU nurse and return to the ED. Debriefing ANM/NIC to gather ED personnel and lead a 5-10 minutes debriefing There is a debriefing form in MedUrge under PAPER FORM — ECMO DEBRIEFING FORM

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