Defibrillation Power Point Presentation

8/3/2019 Defibrillation Power Point Presentation

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Special Considerations in Pediatric Advanced LifeSupport (PALS)

1.Simultanous Actions Chest compressions should be immediately started by one rescuer,

while a second rescuer prepares to start ventilations with a bag and

mask.

The effectiveness of PALS is dependent on high-quality CPR, which

requires an adequate compression rate (at least 100

compressions/min), an adequate compression depth (at least one thirdof the AP diameter of the chest or approximately 1 inches [4 cm] in

infants and approximately 2 inches [5 cm] in children), allowing

complete recoil of the chest after each compression, minimizing

interruptions in compressions, and avoiding excessive ventilation.

While one rescuer performs chest compressions and another performsventilations, other rescuers should obtain a monitor/defibrillator,

establish vascular access, and calculate and prepare the anticipated

medications.


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2.Monitored Patients

3. Respiratory Failure

-Respiratory failure is characterized by inadequate ventilation,

insufficient oxygenation, or both. Anticipate respiratoryfailure if any of the following signs is present:

An increased respiratory rate, particularly with signs of

distress (eg, increased respiratory effort including nasal

flaring, retractions, seesaw breathing, or grunting)

An inadequate respiratory rate, effort, or chest excursion

(eg, diminished breath sounds or gasping), especially if

mental status is depressedCyanosis with abnormal breathing despite

supplementary oxygen


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4.Shock-Shock results from inadequate blood flow and oxygen

delivery to meet tissue metabolic demands. The mostcommon type of shock in children is hypovolemic,

including shock due to hemorrhage.

Typical signs of compensated shock include:

Tachycardia

Cool and pale distal extremities

Prolonged (>2 seconds) capillary refill (despite warm

ambient temperature)Weak peripheral pulses compared with central pulses

Normal systolic blood pressure


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Depressed mental status

Decreased urine output

Metabolic acidosis

Tachypnea

Weak central pulsesDeterioration in color


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5. Airways

Oropharyngeal and Nasopharyngeal Airways

Laryngeal Mask Airway (LMA)

Oxygen Pulse Oximetry

Bag-Mask Ventilation

Gastric Inflation

Ventilation With an Endotracheal TubeAfter intubation, secure the tube. After securing

the tube, maintain the patient's head in a neutral

position; neck flexion may push the tube farther

into the airway, and extension may pull the tubeout of the airway.


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If an intubated patient's condition deteriorates, consider

the following possibilities :

Displacement of the tube

Obstruction of the tube

Pneumothorax

Equipment failure


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POSTRESUSCITATION STABILIZATION (POST CARDIACARREST CARE)

The goals of post resuscitation care are to preserve

neurologic function, prevent secondary organ injury,

diagnose and treat the cause of illness, and enable the

patient to arrive at a pediatric tertiary-care facility in anoptimal physiologic state.


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Respiratory System

Nursing Management:

1.Assist ventilation if there is significant respiratory

compromise (tachypnea, respiratory distress with

agitation or decreased responsiveness, poor air exchange,

cyanosis, hypoxemia). If the patient is already intubated,

verify tube position, patency, and security.


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2.Control pain and discomfort with analgesics (eg, fentanyl or

morphine) and sedatives (eg, lorazepam or midazolam).Neuromuscular blocking agents (eg, vecuronium or

pancuronium) with analgesia or sedation, or both, may

improve oxygenation and ventilation in case of patient-

ventilator dyssynchrony or severely compromised

pulmonary function. Neuromuscular blockers, however, can

mask seizures and impede neurologic examinations.

3.Monitor exhaled CO2 (PETCO2), especially during transportand diagnostic procedures

4.Insert a gastric tube to relieve and help prevent gastric

inflation.


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Cardiovascular System

1.Monitor heart rate and blood pressure.

2.Repeat clinical evaluations at frequent intervals until thepatient is stable. Consider monitoring urine output with

an indwelling catheter.

3.Performing ECG may be helpful in establishing the causeof the cardiac arrest.

4. Monitor venous or arterial blood gas analysis and serum

electrolytes, glucose, and calcium concentrations.

5.A chest x-ray should be performed to evaluateendotracheal tube position, heart size, and pulmonary

status.

6.Assess adequacy of tissue oxygen delivery


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Neurologic System

A primary goal of resuscitation is to preserve brain function.

Limit the risk of secondary neuronal injury by adhering to

the following precautions:Nursing Management:

1.Do not routinely provide excessive ventilation or

hyperventilation.

2.Prevent shivering by providing sedation and, if needed,neuromuscular blockade, recognizing that this can mask

seizure activity.

3.Closely watch for signs of infection and other potential

complications of hypothermia include diminished cardiac

output, arrhythmia, pancreatitis, coagulopathy,

thrombocytopenia, hypophosphatemia, hypovolemia from

cold diuresis, hypokalemia, and hypomagnesemia.


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4.Monitor temperature continuously and treat fever (>38C)

aggressively with antipyretics and cooling devices because

fever adversely influences recovery from ischemic braininjury.

5.Treat postischemic seizures aggressively

6.Identify for a correctable metabolic cause such as

hypoglycemia or electrolyte imbalance.7.Avoid rewarming from 32 to 34C faster than 0.5C per 2

hours unless the patient requires rapid rewarming for

clinical reasons.


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Renal System

Decreased urine output (


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Medications to Maintain Cardiac Output and forPostresuscitation Stabilization

Epinephrine Low-dose infusions (03 mcg/kg per minute) cause -adrenergic vasoconstriction.

Epinephrine or norepinephrine may be preferable in

patients (especially infants) with marked circulatory

instability and decompensated shock.


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Dopamine

Dopamine can produce direct dopaminergic effects and

indirect - and -adrenergic effects through stimulation of

norepinephrine release.Titrate dopamine to treat shock that is unresponsive to

fluids and when systemic vascular resistance is low .

Typically a dose of 2 to 20 mcg/kg per minute is used.

Although low-dose dopamine infusion has been frequently

recommended to maintain renal blood flow or improve

renal function

At higher doses (>5 mcg/kg per minute), dopaminestimulates cardiac -adrenergic receptors, but this effect

may be reduced in infants and in patients with chronic

congestive heart failure. Infusion rates >20 mcg/kg per

minute may result in excessive vasoconstriction.


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Dobutamine Hydrochloride

Dobutamine has a relatively selective effect on 1- and

2-adrenergic receptors due to effects of the twoisomers; one is an -adrenergic agonist, and the other is

an -adrenergic antagonist.

Dobutamine increases myocardial contractility and can

decrease peripheral vascular resistance, improve cardiacoutput and blood pressure due to poor myocardial

function.


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Norepinephrine

Norepinephrine is a potent vasopressor promoting

peripheral vasoconstriction,treat shock with low systemicvascular resistance (septic, anaphylactic, spinal, or

vasodilatory) unresponsive to fluid.


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Sodium Nitroprusside

Sodium nitroprusside increases cardiac output by

decreasing vascular resistance (afterload). If hypotension is related to poor myocardial function,

consider using a combination of sodium nitroprusside to

reduce afterload and an inotrope to improve contractility.

Fluid administration may be required secondary tovasodilatory effects.


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Inodilators

Inodilators (inamrinone and milrinone) augment cardiac

output with little effect on myocardial oxygen demand. Itis reasonable to use an inodilator in a highly monitored

setting for treatment of myocardial dysfunction with

increased systemic or pulmonary vascular resistance.

Administration of fluids may be required secondary tovasodilatory effects.

N i R ibiliti i D fib ill ti


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Nursing Responsibilities in Defibrillation

Before

1. Identify ventricular fibrillation (VF) on the monitor.Check leads, confirm pulselessness.

2. Call an arrest. Notify physician STAT.

3. If arrest is witnessed, give precordial pump.

4. Initiate CPR until defibrillator available.

P ti t f d fib ill ti


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Prepare patient for defibrillation:

side rail down bed and patient flat

apply gel pads in correct position

one pad on upper chest, below the right clavicle and thesecond pad below the left nipple at the midaxillary line

as shown below

place pads at least 2 cm. away from electrodes and 10

cm away from a pacemaker generator

Pad Placement:

place one pad over the precordium, to the left of the

lower sternal border position the second pad on the back, opposite the front

pad

press pads firmly onto the skin, moving any air pockets

to the outer edges. Connect R2 pads to the R2 cable

D i


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During

1. Prepare the machine for defibrillation:

Plug cart in

Turn defibrillator on and ensure setting is "defib" Set charge at 200 joules.

Hold paddles firmly to chest until charge is complete.

Ensure that paddles to not come in contact with ECG leads.

2. Ensure there is no contact with metal on bed, and allpersonnel are away from bed contact.

3. Call "ALL CLEAR".

P ddl fi l t l d l i 25 30 lb


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Press paddles firmly onto gel pads applying 25-30 lbs

pressure.

Discharge by simultaneously depressing buttons on

paddle. Be sure to depress buttons firmly and hold for 2

seconds.

Deliver shock following exhalation.

Immediately press charge button on paddles withoutremoving the paddles from the chest. Have a second

person reset charge to 300 Joules.

Quickly reassess rhythm while paddles are recharging to

ensure that rhythm conversion has not occurred;

proceed to deliver the second shock as soon as the

paddles are charged. Immediately press charge button

on paddles without removing the paddles from the

chest. Have a second person reset charge to 360 Joules.


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Between initial 3 shocks: do not lift paddles from the chest

do not pause for pulse check

recharge as soon as first shock is delivered

do not resume CPR between shocks

do not stop for medications

4 Defibrillate as per step 4 if VF or p lseless VT persists


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4.Defibrillate as per step 4 if VF or pulseless VT persists.

5.Administer 1 mg epinephrine IV push as per procedure

and q 5 minutes following initial 3 shocks.

(alternatively, the physician may order 40 unitsvasopressin X 1 dose).

6.Continue to manage ABCs between shocks.

7.possible causes of non-responsive VT/VF (e.g. electrolyte

or acid-base disturbance, pulmonary artery catheter inright ventricular position, hypoxemia, hypothermia).

8.Ensure adequate paddle pressure, machine off

synchronization.


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After

If successful:

1. Administer 1 mg/kg lidocaine bolus, and start aninfusion at 2 mg/min

2. Evaluate and maintain ABC's

3. Evaluate serum electrolytes, blood gases and pulmonary

artery position.4. Obtain order for electrolyte replacement if required.

5. Correct problems with pulmonary artery placement.

6. Correct acid-base disturbances.

7. Assess and treat for side effects: burns, arrhythmias,anxiety.

8. Post rhythm strips in chart and document on the cardiacarrest record.


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