1-Epinephrine 2-Atropine 3-Amiodarone 4-Lidocaine 5-Magnesium

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2 1-Epinephrine 2-Atropine 3-Amiodarone 4-Lidocaine 5-Magnesium ٢

3 When VF/pulseless VT cardiac arrest is associated with torsades de pointes, providers may administer magnesium sulfate at a dose of 1-2 g diluted in 10 ml D5W IV/IO push, typically over 5-20 minutes ٣

4 When torsades is present in the patient with pulses, the same 1-2 g is mixed in 50 to 100 ml of D5W and given as a loading dose. It can be given more slowly (eg, over 5 to 60 minutes IV) ۴

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6 Resuscitation of the Pregnant Patient

7 Key Points During resuscitation there are two patients, mother & fetus The best hope of fetal survival is maternal survival Consider the physiologic changes due to pregnancy

8 Successful resuscitation of a pregnant woman & survival of the fetus require prompt & excellent CPR with some modifications in techniques By the 20th week of gestation, the gravid uterus can compress the IVC & aorta, obstructing venous return & arterial blood flow Rescuers can relieve this compression by positioning the woman on her side or by pulling the gravid uterus to the side

9 Defibrillation Defibrillate using standard ACLS defibrillation doses There is no evidence that shocks from a direct current defibrillator have adverse effects on the heart of the fetus If fetal or uterine monitors are in place, remove them before delivering shocks

10 Summary Defibrillation & medication doses used for resuscitation of the pregnant woman are the same as those used for other adults Rescuers should consider the need for ER Caesarian Delivery as soon as the pregnant woman develops cardiac arrest Rescuers should be prepared to proceed if the resuscitation is not successful within 4 minutes

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12 DEFIBRILLATION

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14 Some AEDs will automatically switch themselves on when the lid is opened ١۴

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17 Stand clear Deliver shock ١٧

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19 30 2 ١٩

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21 defibrillation

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23 DEFIBRILLATION The most effective treatment of VF is timely defibrillation early defibrillation :defined as defibrillation under 4 minutes of onset successful defibrillation implies delivering the appropriate amount of current or energy to the fibrillating myocardium, such that the chaotic electrical activity is terminated and a supraventricular perfusing rhythm is established

24 CPR prior to defibrillation Lack of success for in-hospital resuscitation appears to result from delays in time to first shock from collapse.

25 Defibrillation Equipment

26 List of Materials for Defibrillation Defibrillator/ECG monitor Handheld defibrillation electrodes quick-look paddles Patient interface cables; multifunctional for ECG monitoring and defibrillation Electrodes and pads for ECG signal acquisition and defibrillation Conductive gel (not ultrasound gel)

27 Additional Equipment (Pertinent to VF/VT) ACLS Medications Epinephrine Vasopressin Amiodarone Lidocaine Magnesium sulfate Procainamide Atropine Miscellaneous IV access equipment, central line kits, and the like

28 Code cart with defibrillation equipment.

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30 always kept in a constant state of readiness Wherever possible, the defibrillator,patient cables, quick-look electrode paddles and ECG and defibrillation electrodes and pads should be preconnected and labeled to facilitate application to the patient members of the designated resuscitation team should check the equipment at the beginning of their clinical shifts

31 Remember the longer VF persists, the harder it is to defibrillate

32 Multifunction defibrillator/monitor

33 Defibrillator monitor capable of 12-lead ECG/cardioversion/pacing/limited ECG interpretation.

34 Basics of Defibrillator Function and Operation

35 Defibrillator Types

36 Defibrillators (operational characteristics) Manual Semiautomated fully automatic

37 Monophasic damped sinusoidal (MDS) and monophasic truncated exponential(mte) waveforms

38 Biphasic waveforms.

39 no specific waveform has been proved to be superior to another regarding survival from SCA or for the return of spontaneous circulation biphasic waveforms have been shown to be more efficient in achieving first-shock termination of VF than monophasic waveforms.

40 Monophasic Defibrillators/Energy Selection first type introduced still available in various patient care settings MDS waveform for defibrillation an energy level of 360 J be used for the first shock

41 Biphasic Defibrillators Defibrillator today are primarily biphasic an output waveform that flows back and forth between the electrodes BTE waveform or a biphasic rectilinear waveform more successful defibrillation shock /less energy / better first-shock defibrillation success an optimal energy level for first-shock for VF has not been established, several studies have demonstrated that using relatively low energy of 200 J or less

42 unaware of waveform dose range, a consensus default of 200 J should be used for the initial shock Energy Selection device-specific effective waveform dose range biphasic rectilinear waveform BTE waveform 120 J 150 to 200 J

43 Absolute refractory period of the cardiac cycle

44 Vulnerable period of the cardiac cycle

45 Manual Defibrillation Attach Electrodes to patient Select DEFIB Unit automatically defaults to first shock setting determined in Configuration (typically 120J, 150J, 200J) To change energy setting, use UP/DOWN ARROWS. Selected energy is displayed as DEFIB xxxj SEL Press CHARGE Make sure everyone is clear When SHOCK button lights, press SHOCK If so configured, the M Series automatically increments the energy setting after the first shock according to configuration. Manually changing the energy setting disables this function. Note: Changing the energy level or switching to MONITOR after CHARGE is pressed results in

46 Manual Defibrillation with Paddles Select DEFIB Unit automatically defaults to first shock setting To change energy setting, use UP/DOWN ARROWS Press CHARGE on the panel or on the apex handle Apply electrolyte gel to the paddles and apply paddles to chest Make sure everyone is clear When SHOCK button lights, place paddles on chest with 25 lb pressure and simultaneously press SHOCK on both paddles Note: Changing the energy level or switching to MONITOR after CHARGE is

47 Advisory Defibrillation Attach MFE Electrodes to patient Select DEFIB Press ANALYZE. ANALYZING ECG will be displayed for about 9 seconds. If unit displays SHOCK ADVISED, defibrillator automatically charges to first shock setting determined in Configuration (typically 120J, 150J, 200J) If automatic charge is disabled, SHOCK ADVISED and PRESS CHARGE will be alternately displayed. To change energy setting, use UP/DOWN ARROWS. Selected energy is displayed as DEFIB XXXJ SEL Make sure everyone is clear When SHOCK button lights, press SHOCK

48 Automatic Defibrillation (AED) Attach MFE Electrodes to patient Turn unit ON Unit automatically defaults to first shock setting determined in Configuration (typically 120J, 150J, 200J) To change energy setting, use UP/DOWN ARROWS. Selected energy is displayed as DEFIB XXXJ SEL Press CHARGE Make sure everyone is clear When SHOCK button lights, press SHOCK If so configured, the M Series automatically increments the energy setting after the first shock according to configuration. Manually changing the energy setting disables this function. Note: Changing the energy level or switching to MONITOR after CHARGE is pressed results in defibrillator being disarmed

49 Correct position for electrode/paddle placement

50 Use of quick-look paddle electrodes for rhythm (ECG) determination and defibrillation

51 Front/back position of electrodes on patient (alternate position).

52 Complications soft tissue injury myocardial injury Cardiac dysrhythmias multifunctional electrode pads better applicators for electrode gels have decreased the potential for soft tissue injuries such as burns to the chest biphasic defibrillation

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