JavaScript seems to be disabled in your browser. For the best experience on our site, be sure to turn on Javascript in your browser. Notes: After completing the online portion of this course, you must complete a hands-on session sold separately with an AHA Training Center to obtain a course completion card. Please note: This product is currently on back order and is expected to ship in 2 to 3 weeks. HeartCode blended learning delivers quality resuscitation education regardless of where providers are located and gives them more control to complete the course at their own pace.
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View more. Total 23 active shop. Exchanges from an online course to a physical in-class course is only allowed if the keycode has not been sent to the student. The AHA is an advocate of good health, promoting positive behaviors, nutritious eating habits and healthy lifestyles. Once the patient is more stable, an x-ray may be obtained to optimize ET tube position and assess lung pathology.
An x-ray takes too long to be used as a means of confirming tracheal placement of an ET tube. Recognizing misplacement of an ET tube is a clinical responsibility. Because there is significant potential for ET tube movement with head f lexion and extension and when the patient is moved from one location to another, secure the ET tube with tape or a commercial device. Devices and tape should be applied in a manner that avoids compression of the front and sides of the neck to protect against impairment of venous return from the brain.
Confirmation of ET Tube Placement: Physical Exam Confirm tube placement immediately, assessing the first breath delivered by the bag-mask device. This assessment should not require interruption of chest compressions. You should use both clinical assessment and confirmation devices to verify tube placement immediately after insertion and again when the patient is moved.
However, because no single confirmation technique is completely reliable, particularly when cardiac arrest is present, the AHA recommends the use of continuous waveform capnography, in addition to clinical assessment, as the most reliable method of confirming and monitoring of correct placement of an ET tube. Assessment by physical examination consists of visualizing chest expansion bilaterally and listening over the epigastrium breath sounds should not be heard and the lung fields bilaterally breath sounds should be equal and adequate.
As the bag is squeezed, listen over the epigastrium and observe the chest wall for movement. If you hear stomach gurgling and see no chest-wall expansion, you have intubated the esophagus.
Stop ventilations. Remove the ET tube at once. Resume bag-mask ventilation or consider an alternate advanced airway. If, after intubation, the chest wall rises appropriately and stomach gurgling is not heard, listen to the lung fields with 5point auscultation: over the stomach, left and right anterior lung fields, and left and right midaxillary lung fields.
If you have any doubt, stop ventilations through the tube and use the laryngoscope to see if the tube is passing through the vocal cords. If still in doubt, remove the tube and provide bag-mask ventilation until the tube can be replaced. Secure the tube with a commercial device designed for this purpose or with tape, avoiding compression of the front and sides of the neck.
Once the tube is secured, insert a bite-block if the commercial device used to secure the tube does not prevent the patient from biting down and occluding the airway. If the device is attached to the bag before it is joined to the tube, it will increase efficiency and decrease the time in which chest compressions must be interrupted.
Waveform Capnography Continuous waveform capnography, in addition to physical assessment, is recommended as the most reliable method of confirming and monitoring correct placement of an ET tube. Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor ET tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the r isk of unrecognized tube misplacement or displacement.
Studies of colorimetric P ETCO2 detectors indicate that the accuracy of these devices does not exceed that of auscultation and direct visualization for confirming the tracheal position of an ET tube in patients in cardiac arrest. Detailed assessment of out-of-hospital intubation attempts has concluded that ET tubes are 1 much more difficult to place properly in that setting and 2 highly susceptible to misplacement and displacement.
Proper training, supervision, frequent clinical experience, and a process of quality improvement are the keys to achieving successful intubation. The use of capnography to confirm and monitor correct placement of supraglottic airways has not been studied. Figur e Waveform capnography with ET tube. Waveform capnography. A, Normal range approximately 35 to 45 mm Hg. B, Expected waveform with adequate chest compressions in cardiac arrest approximately 20 mm Hg.
C, ET tube incorrectly placed or dislodged 0 mm Hg. Figur e 13A. Figur e 13B. Figure 13C. This capnometer provides a single quantitative readout of the concentration of CO2 at a single point in time. The device provides a continuous display of the level of CO2 as it varies throughout the ventilation cycle.
These monitors can help confirm successful ET tube placement within seconds of an intubation attempt. ET tube displacement is an adverse event that is alarmingly common during out-of-hospital transport of a patient. Exhaled Qualitative CO2 Detectors A number of commercial devices can react, usually with a color change different colors for different CO 2 detectors , to CO 2 exhaled from the lungs.
This simple method can be used as a secondary method of detecting correct tube placement if waveform capnography is not available, even in the patient in cardiac arrest Figur e The qualitative detection device indicates proper ET tube placement. The absence of a CO2 response from the detector ie, results are negative for CO2 generally means that the tube is in the esophagus, particularly in patients with spontaneous circulation. Studies of colorimetric exhaled CO 2 detectors indicate that the accuracy of these devices does not exceed that of auscultation and direct visualization for confirming the tracheal position of an ET tube in patients of cardiac arrest.
Confirmation of tracheal tube placement with colorimetric exhaled CO2 detectors. A, Purple color indicates the presence of carbon dioxide and tube in the airway. B, Yellow indicates lack of carbon dioxide and tube probably in the esophagus. Figure 14B. Note that the carbon dioxide detection cannot ensure proper depth of tube insertion. The tube should be held in place and then secured once correct position is verified.
Different manufacturers may use different color indicators. EDD is a secondary method of detecting correct tube placement if waveform capnography is not available. The EDD should be used before any breaths are given. This results in slow or no re-expansion of the bulb. With the syringe-style EDDs, the vacuum occurs when the rescuer pulls back on the syringe plunger. Esophageal placement results in the inability of the rescuer to pull back on the plunger. If the tube rests in the trachea, the vacuum will allow smooth reexpansion of the bulb or aspiration of the syringe.
Esophageal detector device: aspiration bulb technique. Hold the tube in place until you confirm that it is in the correct position and then secure it. However, although the device is g enerally sensitive for detection of ET tube placement in the esophagus, it is not specific for ET tube placement in the trachea. Although the EDD indicates that the tube is in the trachea by rapid re-expansion of the suction bulb or withdrawal of the plunger, prior CPR or ventilations using a bag can fill the stomach or esophagus with air, permitting bulb reexpansion or plunger withdrawal.
The unwary provider, thinking the tube is in the trachea, may leave the tube in the esophagus, a potentially fatal error. In addition, the EDD may yield misleading results in patients with morbid obesity, late pregnancy, or status asthmaticus. For these reasons, the EDD should be considered a less reliable device for confirmation of ET tube placement compared to continuous waveform capnography and physical examination.
Table 2. The columns vertical indicate the reading and actual location of the ET tube. The rows across indicate the expected results from using either a colorimetric end-tidal CO2 detector A or bulb-type esophageal detector device B. W ith both devices assume that the rescuer made a conscientious intubation effort and thinks the ET tube is in the trachea. Reintubation attempts increase chances of other adverse consequences. Consequences: Rescuer recognizes ET tube is not in trachea; properly and rapidly identified; tube is removed at once; patient is reintubated.
A potentially life-threatening adverse event has been detected. Consequences: Rescuer correctly recognizes ET tube is in esophagus; ET tube is removed at once; patient is reintubated. Consistent With Tube in Esophagus Device sugg ests tub e in esophagus when it is in esophagus. Device suggests t ube in esophagus when it is in trachea. Causes: Secretions in trachea mucus, gastric contents, acute pulmonary edema ; insertion in right main bronchus; pliable trachea morbid obesity, late-term pregnancy Consequences: Rescuer correctly recognizes ET tube is in esophagus; ET tube is removed at once; patient is reintubated.
Consequences: Leads to unnecessary removal of properly placed ET tube. Results su ggest that tube is NOT in the esophagus ie, that it i s in th e trachea when it IS in th e trachea. Esophageal detector device indicates ET tube is in trachea. Proceed with ventilations. The ITD limits air entry into the lungs during the decompression phase of CPR, creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR.
It does so without impeding positive pressure ventilation or passive exhalation. A Figur e 16A. Figure 16B. Anatomy of the cardiac conduction system: relationship to the ECG cardiac cycle. A, Heart: anatomy of conduction system. B, Relation of cardiac cycle to conduction system anatomy.
W ithout organized ventricular depolarization the ventricles cannot contract as a unit and they produce no cardiac output. Baseline undulations occur between and per minute. Collapse, unresponsiveness. Agonal gasps or apnea. Sudden death. Figure 17B. A, Coarse ventricular fibrillation. Note high-amplitude waveforms, which vary in size, shape, and rhythm, representing chaotic ventricular electrical activity.
B, Fine ventricular fibrillation. In comparison with Figure 17A, the amplitude of electrical activity is much reduced. Note the complete absence of QRS complexes. In terms of electrophysiology, prognosis, and the likely clinical response to attempted defibrillation, adrenergic agents, or antiarrhythmics, this rhythm pattern may be difficult to distinguish from that of asystole. Wide QRS and slow heart rate are mostly caused by cardiac etiology.
Very low systolic blood Manifestations pressure could still be present in such cases. This patient is pulseless and unresponsive. Note the 2 Q RS-like complexes at the start of this rhythm display.
These complexes represent a minimum of electrical activity, probably ventricular escape beats. Note the long section in which electrical a ctivity is completely absent. This patient is in asystole at this point. Sinus tachycardia. Can also be observed in multifocal atrial tachycardia MAT. Atrial fibrillation. Atrial flutter sawtooth pattern. For such otherwise healthy people, many factors can provoke the reentry SVT: caffeine, hypoxia, cigarettes, stress, anxiety, sleep deprivation, numerous medications.
Frequency of SVT increases in unhealthy patients with coronary artery disease, chronic obstructive pulmonary disease, and congestive heart failure. Sinus rhythm with a reentry supraventricular tachycardia SVT. Symptoms of decreased cardiac output are typical orthostasis, hypotension, syncope, signs of poor perfusion, etc. Torsades de pointes: a unique type of polymorphic VT. With increased activity and sinus node dysfunction, a persistent slow rate can lead to symptoms of easy fatigue, shortness of breath, dizziness or lightheadedness, syncope, hypotension, diaphoresis, pulmonary congestion, and frank pulmonary edema.
Sinus bradycardia. First-degree AV block. Type I second-degree AV block. Figur e 29B. For adult defibrillation, both handheld paddles and self-adhesive pads 8 to 12 cm in diameter perform well, although defibrillation success may be higher with electrodes 12 cm in diameter rather than with those 8 cm in diameter, whereas small electrodes 4.
When using handheld paddles and gel or pads, you must ensure that the paddle is in full contact with the skin. Even smaller pads have been found to be effective in VF of brief duration. Use of the smallest pediatric pads, however, can result in unacceptably high transthoracic impedance in larger children.
Early defibrillation is critical to survival from sudden cardiac arrest SCA. A common initial rhythm in out-of-hospital witnessed SCA is VF, the treatment for which is defibrillation. The probability of successful defibrillation diminishes rapidly over time, and VF tends to deteriorate to asystole within 10 to 15 minutes.
Therefore, whether the adhesive electrode pads or paddles are being used, you should be very careful not to delay the shock during CPR to minimize the time between last compression and shock delivery. Intervals between pausing chest compressions and shock delivery have been shown to last approximately 20 to 30 seconds, which is no longer acceptable. If CPR is in progress, chest compressions should continue until the defibrillator electrode adhesive pads are attached to the chest and the manual defibrillator is ready to analyze the rhythm.
When any rescuer witnesses an out-of-hospital arrest and an automated external defibrillator AED is immediately available onsite, the rescuer should start CPR and use the AED as soon as possible. If VF persists after the first shock, second and subsequent shocks of J should be given. After delivering a single shock, immediately resume CPR, pushing hard and fast at a rate of at least compressions per minute.
Minimize interruption of CPR and allow full chest recoil after each compression. You should state the warning quickly to minimize the time from last compression to shock delivery. One, two, three, shocking. You do not need to use those exact words. But it is imperative that you warn others that you are about to deliver a shock and that everyone stand clear. Make sure all personnel step away from the patient, remove their hands from the patient, and end contact with any device or object touching the patient.
Any personnel in indirect contact with the patient, such as the team member holding a ventilation bag attached to an ET tube, must also end contact with the patient. Take the time to learn to operate the defibrillator used in your workplace and its energy settings.
This principle holds true regardless of the type of defibrillator or waveform. However, new science and consensus opinion have prioritized both access routes and drug administration. Remember, no drug g iven during cardiac arrest has been shown to improve survival to hospital discharge or improve neurologic function after cardiac arrest. Drug administration is of secondary importance. Drugs can be administered while other interventions are underway and should not interrupt chest compressions.
Unless bag-mask ventilation is ineffective, insertion of an advanced airway whether for drug administration or ventilation is of secondary importance. Some advanced airway devices can be placed while chest compressions continue. If insertion of an advanced airway requires interruption of chest compression for many seconds, the provider should weigh the need for compression against the need for an advanced airway. Absorption of drugs given by the endotracheal route is unpredictable, and optimal dosing is unknown.
For this reason, the IO route is preferred when IV access is not available. A peripheral IV is preferred for drug and fluid administration, unless a central line is already in place. Central line access is not needed during most resuscitation attempts. Attempts to insert a central line may interrupt CPR. In addition, CPR can cause complications during central line insertion, such as vascular laceration, hematomas, and bleeding.
Insertion of a central line in a noncompressible area of a vein is a relative contraindication to fibrinolytic therapy eg, for the patient with an ST-segment elevation myocardial infarction [STEMI] and sudden cardiac arrest. Establishing a peripheral line should not require interruption of CPR. Drugs typically require 1 to 2 minutes to reach the central circulation when given by the peripheral IV route. Keep this in mind during CPR. The drug you give based on a rhythm check will not take effect until it is flushed into the patient and has been circulated by the blood flow generated during CPR.
Briefly elevating the extremity during and after drug administration theoretically may also recruit the benefit of g ravity to facilitate delivery to the central circulation, but has not been systematically studied.
IO access is safe and effective for fluid resuscitation, drug delivery, and blood sampling for laboratory evaluation. IO access can be established in all age groups. Any drug or fluid that can be given by the IV route can also be given by the IO route. The IO route is preferred over the ET tube route. IO cannulation provides access to a noncollapsible venous plexus in the bone marrow. This vascular network provides a rapid, safe, and reliable route for administration of drugs, crystalloids, colloids, and blood during resuscitation.
It is often possible to achieve IO access in 30 to 60 seconds. The technique uses a rigid needle, preferably a specially designed IO or bone marrow needle. Use of an IO needle with stylet may be preferred to use of a needle without stylet because the stylet prevents obstruction of the needle with cortical bone during insertion.
Butterfly needles and standard hypodermic need les can also be used. Commercially available kits can facilitate IO access in adults. Endotracheal Route The IV and IO routes of administration are preferred over the endotracheal route of administration during CPR because drug absorption and drug effect are much less predictable when drugs are administered by this route.
To give drugs via the endotracheal route, dilute the dose in 5 to 10 mL of sterile water or normal saline and inject the drug directly into the ET tube. Follow with several positivepressure breaths. You can give the following drugs by the endotracheal route during cardiac arrest: vasopressin, epinephrine, and lidocaine.
Favored sites are the dorsum of the hands, the wrists, and the antecubital fossae. Ideally, only the antecubital veins should be used for drug administration during CPR. Anatomy: Upper Extr emi ti es Figure 31 Starting at the radial side of the wrist, a thick vein, the superficial radial vein, runs laterally up to the antecubital fossa and joins the median cephalic vein to form the cephalic vein.
Superficial veins on the ulnar aspect of the forearm run to the elbow and join the median basilic vein to form the basilic vein. The cephalic vein of the forearm bifurcates into a Y in the antecubital fossa, becoming the median cephalic laterally and the median basilic medially. Technique: Antecubital Venipuncture The largest surface veins of the arm are in the antecubital fossa.
Select these veins first for access if the patient is in circulatory collapse or cardiac arrest Figur e Select a point between the junctions of 2 antecubital veins. The vein is more stable here, and venipuncture is more often successful. If peripheral access is impossible, consider central access via the femoral veins since chest compressions and other resuscitation interventions should not be interrupted, and potential vascular injuries can be better controlled at this site. If upper extremity access is impossible and a central line is not an option, consider a peripheral leg vein.
Antecubital venipuncture. A, Scene perspective from a distance. B, Close-up view of antecubital area: anatomy of veins of upper extremity. Figur e 31A. Strict aseptic technique is compromised in most emergency venipunctures, where speed is essential. This compromise is particularly likely when emergency vascular access is established outside the hospital, because personnel and equipment are limited.
IV solutions are usually packaged in nonbreakable plastic bottles or bags. Squeeze plastic bags before use to detect punctures that may lead to contamination of the contents. Avoid adding drugs that may be adsorbed by the plastic bag or tubing eg, IV nitroglycerin.
If you must administer these drugs without specialty infusion systems, allow for drug adsorption when you titrate the drug administration rate. Saline lock catheter systems are particularly useful for patients who have spontaneous circulation and require drug injections but not IV volume infusion. Most contemporary systems use needleless injection sites. These systems permit drug and flush infusions without the use of needles and the associated risk of needle sticks.
Avoid letting the arm with the IV access hang off the bed. Place the arm at the level of the heart, or slightly above the heart, to facilitate delivery of fluids and medications to the central circulation. During cardiac arrest follow all peripherally administered drugs with a bolus of at least 20 mL of IV flush solution. Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.
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