Paramedic Spring Final

Normal Sinus Rhythm

Rate: 60-100

Rhythm: regular

Sinus Arrhythmia

Rate: 60-100

Regularity: depends on respiration

Sinus Bradycardia

Rate: <60

Regularity: regular

Sinus Tachycardia

Rate: >100

Regularity: regular

Sinus Pause/ Arrest

Rate: varies

Regularity: irregular

Sinoatrial (SA) Block

Rate: varies

Regularity: irregular

PAC

Rate: depends on underlying rate

Regularity: irregular

Ectopic Atrial Rhythm (EAR)

Rate: <100

Regularity: irregular

P wave morphology is different

Focal Atral Tachycardia (FAT)

Rate: >100

Regularity: irregular

P wave morphology is different

Wandering Atrial Pacemaker (WAP)

Rate: <100

Regularity: irregularly irregular

At least 3 different P wave morphologies

Multifocal Atrial Tachycardia (MAT)

Rate: >100

Regularity: irregularly irregular

At least 3 different P wave morphologies

Atrial Flutter (A-Flutter)

Rate: atrial rate ~250-350, ventricular rate ~125-175

Regularity: usually regular, but may be variable

Saw toothed appearance

Atrial Fibrillation (A-Fib)

Rate: variable, ventricular response can be fast or slow

Regularity: irregularly irregular

No P waves

PJC

Rate: depends on underlying rhythm

Regularity: irregular

P waves are either absent, in QRS, after QRS, or inverted before QRS

Junctional Escape Beat (JEC)

Rate: depends on underlying rhythm

Regularity: irregular

P waves are either absent, in QRS, after QRS, or inverted before QRS

Junctional Rhythm

Rate: 40-60 bpm

Regularity: regular

P waves are either absent, in QRS, after QRS, or inverted before QRS

Accelerated Junctional Rhythm

Rate: 60-100

Regularity: regular

P waves are either absent, in QRS, after QRS, or inverted before QRS

Junctional Tachycardia

Rate: >100-200

Regularity: regular

P waves are either absent, in QRS, after QRS, or inverted before QRS

Supraventricular Tachycardia (SVT)

Rate: 180-250

Regularity: regular

Can’t determine P waves

First Degree Heart Block

Rate: depends on underlying rhythm

Regularity: regular

PRI is >0.20 seconds

Second Degree Type 1/ Mobitz 1/ Wenckebach

Rate: depends on underlying rhythm

Regularity: irregularly irregular

Longer, longer, longer, drop

Second Degree Type 2/ Mobitz 2

Rate: depends on underlying rhythm

Regularity: irregularly irregular

If some P’s don’t get through

2:1 AV Block

Rate: depends on the underlying rhythm

Regularity: regular

Third Degree Heart Block

Rate: separate rate for underlying and escape rhythm

Regularity: regular, but P and QRS rates are different

If P’s and Q’s don’t agree

PVC

Rate: depends on underlying rhythm

Regularity: irregular

Ventricular Escape Beat

Rate: depends on underlying rhythm

Regularity: irregular

Idioventricular Rhythm (IVR)

Rate: 20-40

Regularity: regular

QRS > 0.12

Accelerated Idioventricular Rhythm (AIVR)

Rate: 60-100

Regularity: regular

QRS > 0.12

Ventricular Tachycardia (V-Tach)

Rate: 110-250

Regular: regular

QRS > 0.12

Torsade De Pointes

Rate: 200-250

Regularity: irregular

QRS width is variable

Ventricular Fibrillation (V-Fib)

Rate: indeterminate

Regularity: chaotic rhythm

AV Paced Rhythm

Rate and regularity are dependent

Asystole

not consistent with life

Agonal

Rate: <20

Regularity: irregular

QRS < 0.12

Cardiac Tamponade

Becks Triad: hypotension, JVD, muffled/faint heart sounds

• will also see pulsus paradoxus with a manual cuff

ex; hit chest on steering wheel

Non-Compliant HTN uncontrolled

Rapid transport to the hospital

Symptoms of cardiogenic shock

Decreased level of consciousness, tachycardia, hypoxia, cyanosis, pulmonary edema, Hx of MI

Unstable Angina

angina that meets any of the 3:

1. lasts longer than 20 minutes at rest

2. new onset

3. crescendo (more frequent or longer duration)

4. not readily responding to treatment

Stable Angina

episodic chest discomfort resulting from myocardial ischemia, usually resolve with rest and/or treatment

Prinzmetals Angina

angina resulting from abnormal spasm of coronary arteries

Why is nitro given for CHF/difficulty breathing?

dilates peripheral arteries and veins, reducing preload, afterload, and myocardial oxygen demand; can cause some coronary artery dilation increasing blood flow through the collaterals

Risks for CVD

• smoking

• advanced age

• family Hx of CVD

• HTN

• hypercholesterolemia

• carbohydrate intolerance (DM)

• substance abuse

• lack of exercise

Synchronized cardioversion

the defibrillator interrupts the QRS cycle and delivers electrical discharge during the R wave

To maintain BP in cardiac arrest:

push hard/fast

Chest contustion Tx

support ventilations, large bore bilateral IV, monitor EKG, rapid transport

Runaway pacemaker

Pacemaker malfunction where it causes rapid ventricular pacing

• turn off with a donut magnet

NTG given in CHF patients

Decrease venous return

Synchronized cardioversion

Electrical current through the heart during a specific cardiac cycle (absolute refractory period)

Dropping pulse

Reduced cardiac output

Treatment for MI

Administer NTG

Stroke Volume

Depends on 3 factors: preload, contractility, afterload

• venous return most influential to SV

Pediatric Bradycardia Algorithm

1. Epinephrine 0.01 mg/kg every 3-5 min

2. Atropine 0.02 mg/kg x1

3. Consider TCP

heart sounds

S1: “lub” caused by AV valves closing

S2: “dub” caused by closing of semilunar valves

S3: linked the flow of blood into the ventricles “slosh-ing-in” or “ken-tuck-y”

S4: linked with atrial contraction “a-stiff-wall” or “tenn-ess-ee”

After drowning, alveoli collapse is caused from:

Lack of alveolar surfactant

What medication with benefit asthma attacks without negatively affecting a heart attack

Atrovent

Tx for a patient with cyanosis and absent breath sounds

Nebulizer, steroid, BVM, IM Epinephrine, IV access with fluids

Inspiration and Expiration

Depend on changes in the volume of the thoracic cavity

• stretch receptors limit inspiration

diffusion

• affected by change in concentration of O2 in the alveoli (extending high altitudes)

• affected by any disease that alters the structure of patency of the alveoli will limit diffusion

• pulmonary edema, drowning, inhalation injury, prolonged hypoxia

lung perfusion depends on 3 conditions

adequate blood volume, intact pulmonary capillaries, efficient pumping of blood by the heart

• pH falls, O2 becomes easily dissociated from hemoglobin causing O2 to be transported with hemoglobin instead of globin leaving little CO2 bound to hemoglobin

Emphysema

destruction of alveolar walls distal to terminal bronchioles, decrease in alveolar membrane surface area lessening the area available for gas exchange causing an increased ratio of air to lung tissue

• commonly prescribed: steroids, Atrovent, betamethasone, metoprolol

S/S for pulmonary edema

SOB, recent Hx of surgery, Hx of asthma

Indications of treatment failure

• increased cyanosis

• decreased level of consciousness

• decreased lung sounds

• increased RR (tachypneic)

ARDS (acute respiratory distress syndrome)

commonly called “stiff lungs”

• increased fluid in the interstitial space

• rapidly progressing, life-threatening

• adversely effects gas exchange in lungs causing hypoxia

• form of pulmonary edema

Capnography

• when perfusion decreases, ETCO2 levels reflect pulmonary blood flow and cardiac output not diffusion

• decreased CO2 levels found in shock, cardiac arrest, pulmonary embolism, bronchospasm, and incomplete airway obstruction (mucus plugging)

• increased CO2 levels are seen in hypoventilation, respiratory depression, hyperthermia

Bohr Effect

changes in body temperature, blood pH, and PCO2 alter the O2 dissociation curve—> within the tissues (as hemoglobin becomes bound with CO2) it loses its affinity for O2 resulting in more O2 being released and available to cells for metabolism

upper airway anatomy

lower airway anatomy

upper and lower airway anatomy

alveoli and pulmonary capillary anatomy

right heart failure

body

• heart loses some of its ability to move O2 depleted blood to the lungs to pick up new O2

• most often caused by L sided HF- can occur if L side is normal

• pitting edema common sign

S/S

• peripheral edema

• ascites

• JVD

• cor pulmonale

• high diastolic

• uncontrolled HTN

left heart failure

lungs

• most common type of HF

• heart loses some of its ability to pump blood out to your body after it’s been re-oxygenated

• usually caused by coronary artery disease

• SOB common sign

S/S

• O2 sat low

• crackles bilaterally

• pink, frothy sputum

• dyspnea (paroxysmal, nocturnal)

• accessory muscle use

Tx of HF

1. monitor rhythm accordingly

2. 12-lead and IV access

3. mild- low dose nitro x3-5 mins max

4. moderate/severe- CPAP, high dose nitro (0.4 SL and 1” paste)

5. HTN/CHF: 250 mL, Epi infusion (1 mg in 100 mL at 1mL per minute- 60 gtts/min) titrate to SBP of 90 mmHg

Sodium-potassium pump

ships NA+ out of cell and K+ inside the cell against their concentration gradient

• 3 NA+ out of the cell and 2 K+ inside the cell

• ATP drives the energy

• from low to high

• sodium is the main positive ion in the body

• more positive on the outside than the inside at rest to create the squeeze and send more positive in

• potassium= depolarization

• once it’s all in (+), heart squeezes, it all goes out because it recognizes that it’s not supposed to be in there

Aspirin (ASA)

class: NSAID/ platelet inhibitor

indications: suspect ACD and/or STEMI

contraindications: allergy, patients who took a full dose prior to EMS arrival

dose: 324 mg (4×81mg chewable)

Nitroglycerin (NTG)

class: vasodilator

indications: angina, CHF, acute pulmonary edema

contraindications: allergy, peds <13y, pulmonary HTN or ED meds in the past 24 hrs., asymptomatic HTN, SBP <90, HR <60 or >150, inferior STEMIS

dose:

• chest pain= 0.4 mg SL repeat x2 every 3-5 minutes, max dose 1.2 mg

• pulmonary edema or CHF= low dose 0.4 mg SL, repeat 3-5 mins, max dose 1.2 mg; high dose x1 0.4 mg SL and 1” paste, x1 0.8 mg SL, continue 0.8 to achieve 20% reduction in SBP

NTG paste: 1” for adults

Adenosine

class: antiarrhythmic

indications: slow rate of narrow complex tachycardia, only effective in SVT, stable/wide complex tachycardia (possible VT) for pediatrics with caution

contraindications: allergy, Hx of moderate to severe asthma or active bronchospasm, polymorphic or irregular wide complex tachycardia

dose: adult 0.6 mg rapid IVP bolus followed by flus, give 12 mg if no response within 2 mins, give 12 mg if no response after another 2 mins; pediatrics 0.1 mg/kg rapid IVP/IO, max initial dose of 6 mg, 2nd and 3rd doses 0.2 mg/kg, max additional dose of 12 mg

Atropine

class: anticholinergic

indications: symptomatic bradycardia if pacing is ineffective

contraindications: known allergy, dysrhythmias in which enhancement of conduction may accelerate ventricular rate and cause < cardiac output (A-Fib, A-flutter, PAT with block)

• risk/benefit contraindications: AV block at His- Purkinje level (Mobitz II or 3rd degree), suspected AMI/ ischemia, glaucoma

Epinephrine

class: sympathomimetic

indications: medical cardiac arrest/ peds trauma arrest

contraindications: HTN, preexisting tachydysrhythmias with a pulse (ventricular and supraventricular), IVP Epi should not be administered to any patient with a pulse

dose: PEA/asystole (0.1 mg/mL) 1 mg IVP every 4 mins, max dose 4 for initial arrest, 2 more for rearrest; VF/VT (pulseless) single dose (0.1 mg/mL) 1mg IVP/IO following initial dose of amiodarone, 1 more dose for rearrest, peds get max 4 initial and 2 for rearrest

Amiodarone

class: class III antiarrhythmic

indications: prevent recurrence of VF/VT after defibbing and conversion to SVT rhythm, VF, VT, A-fib, A-flutter with aberrancy (wide QRS), HR >130 and SBP >100

contraindications: seconds or third-degree AV block, allergy, idioventricular escape rhythm, accelerated idioventricular rhythm, sinus brady, block, or arrest, hypotension, cardiogenic shock, ventricular conduction defects, iodine hypersensitivity

dose: adult with pulse (A-fib or A-flutter with aberrancy) 150 mg IV/IO over 10 min mixed with 50-100 mL dilute, repeat x1; adult without pulse VF/VT (torsade after mag) 300 mg repeat x1 with 150 mg IV/IO; peds with a pulse 5 mg/kg IV/IO over 20 mins in 50-100 mL dilute; peds without pulse 5 mg/kg max single dose 300 mg repeat twice to max dose of 15 mg/kg

Esomolol

class: class II antiarrhythmic

indications: persistent VF or pulseless VT after the second dose of amiodarone

contraindications: allergy

dose: adult (>13y) 0.5 mg/kg IV/IO over 1-2 min no repeat; peds not indicated

Diltiazem (Cardizem)

class: calcium channel blocker

dose: 0.25 mg/kg (max 20 mg) IV bolus slow over 2 mins, if response not adequate repeat 15 mins of 0.35 mg/kg (max 25) over 2 mins; 50y or older, borderline BP (SBP 100-12