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familiarization of er's or any dept crash cart
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CRASH CART FAMILIARIZATON& ARRYTHMIAS
E.R. STAFF
Define the term crash cart Understand the purpose of crash cart Identify the content of crash cart, their
use and the nursing consideration for all the:
medicationsSupplies
Objectives
A crash cart or code cart is a special mobile unit with drawers used in health care facilities and emergency rooms that contain the necessary medications and equipment to respond to a cardiopulmonary arrest.
Definition of Crash Cart
The purpose of the crash cart is to have a portable life saving unit that contains all the medications, supplies and equipment necessary to initiate a treatment in emergency and life threatening situations on all health care facilities.
Purpose of Crash Cart
1. Crash cart must be checked by head nurse/staff nurse every shift and document in checklist
2. Standarization must be maintained.3. Defibrillator will be checked by biomed
department regularly or as necessary.4. Crash cart items must be checked monthly
for expiry dates.5. Each unit will have crash cart placed in and
easily place accessible location.
Policy
Top shelf Defibrillator and manual spO2 probe ECG strips Ultrasound jelly for DC Shock Checklist Right sideAdjustable iv pole Ambu bag adult with mask Ambu bag pedia with mask Oxygen cylinder
Arrangement of Crash Cart
Top SlidePenlightStyletScissorsMagills forcepExtra batteryLidocaine GelCurve/straight forcepLaryngoscopeDisposable razorsAirway different sizes
Chest leads Chest electrodes Conductive gel ECG recording paper Defibrillator paddlesTo know the rhythm and or delivering
shock
defibrillator
First Drawer
EMERGENCY DRUGS Adenosine Adrenaline Amiodarone Aminophylline Atropine Calcium Chloride Dexamethasone Diazoxide Digoxin Dopamine Sodium bicarbonate Procainamide Dextrose 50%
Dobutamine Isoproterenol Magnesium Sulfate Methylprednisolone Noradrenaline Hydrocortisone Furosemide Calcium chloride Potassium chloride Propranolol Verapamil Vasopressin Lidocaine 1% and 2% Hydralazine
AIRWAY/BREATHINGOxygen mask (Adult/Pedia)Nasal cannula/cathAdul/pedia neb. KitETT all sizesLAMAStyletNasopharyngeal tubes
Second Drawer
CIRCULATION IV Set IV cannula all sizes 3way stopcock Foley catether NGT all sizes Blood transfusion set Syringes all sizes BP APP TORNIQUET
Third Drawer
IV Fluids RL NS D5W D5NS ½ D5NS ¼ D5NS D10 HUMAN PLASMA ALBUMIN MANNITOL EXTRA AMBUBAGS
FRONT SIDE CARDIAC BOARD
Lower Portion
Adenosine Antiarrhythmic Conversion to sinus rhythym of paroxysmal
supraventricular tachycardia Dose: 6mg by rapid bolus: for repeat dose, use
12mg by IV bolus within 1-2 mins.
Epinephrine Adrenergic agent choice for cardiac arrest,
vasopressor used in Pulseless VT/VF, Asystole and PEA
Dose : 1mg IV every 3-5mins or more frequently. May be given endotracheal route.
Stocked 1mg/ 10ml 1:10,000. If used for hypersensitivity reaction 0.1- 0.25mg
SC
EMERGENCY DRUGS
AMIODARONE (antidysrhythmics, 3rd)-malignant Ventricular Arrythmia, V-Fib/Pulseless V-
Tach-markedly prolongs action potential and
repolarization-300 mg IV x1 after dose of epinephrine if no initial
response to defibrillation. May repeat 150 mg IV q5-10min. Rapid IV push if pulseless/no BP.
Not to exceed 2.2 g/day, may be diluted in N.S. or D5W
AMINOPHYLLINE (Xanthine Derivatives)-Acute Bronchospasm-Methylxanthines directly relaxes the smooth
muscle of the Respi Tract.-6 to 7 mg/kg IV/PO; infuse iv over 20 mins
Atropine Sulfate Parasympatholytic Anticholinegic Antidote for organophosphate poisoning Agent used for symptomatic bradycardia, PEA Dose : 0.5-1mg IV push, repeat at 3-5 mins Intervals to max. total dose of 0.4mg/kg May b given via endotracheal route. Stocked 1mg/
10ml
Digoxin
-(antidysrhythmics, 5th, inotropic agents)-heart failure, A-FIB,-0.4-0.6 mg once then may cautiously give add’tl doses
of 0.1-0.3 mg q6-8hrs until adequate.-slow IV push over 5 mins
DOBUTAMINE-inotropic agents-low cardiac output and CHF-0.5-1 mcg/kg/min IV initially, then 2-20
mcg/kg/min; not to exceed 40mcg/kg/min-infuse to large vein via infusion pump
DOPAMINE-inotropic agents-hypotension, cardiac output and poor perfusion of
vital organs. Mean arterial pressure in Septic shock patients
-in large vein, via infusion pump.
D50W (glucose-elevating agents)-hypoglycemia-10-25g (20-50ml 50% solution)-high concentrations should be administered via Central Veins
and only after appropriate dilution
SODIUM BICARBONATE-alkalinizing agent-cardiac arrest, hyperkalemia-1 mEq/kg/dose IV x 1
POTASSIUM CHLORIDE (Electrolytes)-conduction of nerve impulses in the heart, contraction of
cardiac, smooth muscle-hypokalemia-40 to 100 mEq KCL diluted in an appropriate amount and type
of solution to be intravenously infused once at a rate not to exceed 10 to 40 mEq/hour.
CALCIUM GLUCONATE-antidote, calcium salts-hypocalcemia (hypocalcemic tetany,
hypoparathyroidism) cardiac arrest (+ hyperkalemia, hypocalcemia, hypermagnesemia)
-1.5-3g IV over 2-5 minutes, diluted in N.S or D5W-rapid IV admin.: arrythmias, hypotension, M.I. or
vasodilation
CALCIUM CHLORIDE-antidote, calcium salts-hypocalcemia, arrythmias, hypermagnesemia-500-1000mg IV over 5-10 mins/-C/I in Vfib during CPR,PVT
DEXAMETHASONE (corticosteroid)-hormones and synthetic substitutes-inflammation, cerebral edema and shock-1-6 mg/kg IV or 40 mg IV q2-6hrs PRN, diluted in D5W, N.S.
DIAZOXIDE (Glucose Elevating Agents)-hyperinsulinemic hypoglycemia-now in oral form. -the injectable form used for HTN emergency is no longer
available
FUROSEMIDE (loop diuretic)-edema asso. With CHF, liver cirr. & Renal dse. HTN-A.Pulmonary Edema, HTN crisis, ICP- 0.5-1mg/kg (40mg) IV over 1-2 mins. Or up to 80 mg but should
not exceed 200mg -hyperkalemia, hypermagnesemia (hpk: 40-80 mg IV; hpm: 20-
40mg iv/q3-4hrs PRN)
HYDRALAZINE (vasodilators)-HTN crisis, CHF-^ 10-50 mg IM, or 10-20 mg IV, repeat PRN-may induce SLE-type syndrome-D5W
HYDROCORTISONE (corticosteroids)-status asmaticus, anti-inflammatory &
immunosuppressive-Initial dose: 100mg -500mg PRN, may repeat q2, 4,
6hrs PRN
ISOPROTERENOL-beta 1/beta2 adrenergic agonist-V.A’s due to (AV) heart block, Adams-Stokes attacks,
cardiac arrests and shock-IV Bolus: 0.2-0.06mg initially THEN doses of 0.01-
0.2mg.-IV Infusion: .5mcg/min, THEN doses of 2-20mcg/min.
by infusion pump in D5W* Direct IV, IM, SC or Intracardiac inj.(EXTREME cases)
MAGNESIUM SULFATE (antidysrhythmics, V, Electrolytes)
-hypomagnesemia, toxemia of Pregnancy and Torsades de Pointes V-TACH
-with Pulse: 1-2g slow iv (10ml/D5W) over 5-60 mins, then 0.5-1g/hr IV
-Cardiac arrest: same as above but over 5-20 mins.
METHYLPREDNISOLONE (corticosteroids)-allergic conditions, acute exacerbations of multiple sclerosis, -dose: 10-250 mg IM/IV up to q4hr PRN
NITROGLYCERINE (nitrates) ANGINA, Renal Failure-5mcg/min. if unresponsive to SL NTG-increase by 5 mcg/min q3-5mins up to 20mcg/min.-3ml/hr (50mg in 250ml D5W/NS)
NORADRENALINE (alpha/beta adrenergic agonist)-acute hypotension, cardiac arrest, sepsis/septic shock-initial: 8-12mcg/min IV Infusion. Titrate.*extravasation: infiltrate with 10-15ml NS+5-10mg of
phentolamine mesylate.*monitor BP
PROCAINAMIDE (antidysrythmics, 1a) arrythmia, IM: 0.5-1g IM q4-8hr IV: loading dose 15-18 mg/kg; slowly over 25-30
mins; may repeat q5mins PRN; not to exceed 1g. Sol’n: 2g/250ml D5W/NS , in infusion pump
PROPRANOLOL(antidysrhythmics, II) beta-blockers(nonselective), antianginal-HTN, ANGINA, Hypertropic SubAortic Stenosis,
SupraVentricular arrythmia & Portal HTN.-SVA: 1-3mg at 1 mg/min 1st, repeat q2-5 min until
5mg. Once achieved, no add’l dose for at least 4 hours.
LIDOCAINE (anesthetics pre-med agents) Cardiac arrythmias: 1.1-5mg/kg, slow IV over 2-
3mins (3mg/kg total) IV, IO/ET..Can be given IM! If, no IV and no ECG, for
V.Ar
VASOPRESSIN (antidiuretics)-Abdominal distention, Diabetes Insipidus,
Gastrointestinal Hemorrhage and vasodilatory shock.
-AD: initial: 5 units/IM, repeat q3-4hrs PRN up to 10 units.
-DI: 5-10 units IM/SC/intranasal q6-12 hrs.-dilute to NS/D5W and via controlled infusion device.
Verapamil Antianginal Antiarrhythmic Antihypertensive Calcium channel blocker Therapeutic actions: -inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells Indications: treatment of SVT, essential hypertension Dose: Adult- IV initial dose- 5-10mg over 2mins; may repeat dose of 10mg 30 mins after first dose Pedia- 1year and younger: initial dose 0.1-0.2mg/kg over 2 mins.1-15 years: initial dose 0.1-0.3mg/kg over 2mins. Do not exceed 5mg. Repeat above dose 30mins after initial dose if response is not adequate. Repeat dose should not exceed 10mg.
Monitor patient carefully (BP, cardiac rythym, and output)
Protect IV solution from light Monitor patients with renal or hepatic
impairment carefully for possible drug accumulation and adverse reactions
Nursing Considerations
Dose: IV Adult: 150mg loading dose over 10mins, followed by 360mg over 6hr at rate of 1mg/min
For maintenance infusion 540mg at 0.5mg/min over 18hr
Remember Amiodarone should be diluted with D5W
An arrhythmia is an irregular heartbeat - the heart may beat too fast (tachycardia), too slowly (bradycardia), too early (premature contraction) or too irregularly (fibrillation). Arrhythmias are heart-rhythm problems - they occur when the electrical impulses to the heart that coordinate heartbeats are not working properly, making the heart beat too fast/slow or inconsistently. Many heart arrhythmias are harmless. We all occasionally experience irregular heartbeats, which may feel like a racing heart or fluttering. Some arrhythmias, however, especially if they veer too far from a normal heartbeat or result from a weak or damaged heart, may cause troublesome and even potentially fatal symptomsRapid arrhythmias are called tachycardias, while slow ones are called bradycardias. Irregular arrhythmias - when the heartbeat is irregular - are called fibrillations, as in atrial or ventricular fibrillation. When a single heartbeat occurs earlier than it should it is called premature contraction.
ARRHYTHMIAS
The English word "arrhythmia" comes from the Greek word rhymos, meaning "rhythm", the Greek suffix a (letter "a" added to the beginning of a word) means "loss" - put together they mean "loss of rhythm". 4 MAIN TYPES1. Premature (extra) beats2. Supraventricular arrhythmias3. Ventricular arrhythmias4. Bradyarrhythmias
PREMATURE (EXTRA) BEATS- Most common type. They are harmless most of the time and often don’t cause any symptoms. Premature beats that occur in the atria (the heart’s upper chambers) are called premature atrial contractions, or PACs. Premature beats that occur in the ventricles (the heart’s lower chambers) are called premature ventricular contractions or PVCs.
SUPRAVENTRICULAR ARRHYTHMIAS
-are tachycardias (fast heart rates) that starts in the atria or atrioventricular (AV) node. The AV node is a group of cells located between the atria and the ventricles.
Types of SV ArrhythmiasAtrial Fibrillation (AF)Atrial FlutterPSVTWolff-Parkinson-White
VENTRICULAR ARRHYTHMIA-Starts at the heart’s lower chambers, the ventricles. They can be very dangerous and usually require medical care right away.Includes: Ventricular Tachycardia is a fast, regular beating of the ventricles that may last for only a few seconds or much longer.Ventricular Fibrillation is disorganized electrical signals make the ventricles quiver instead of pump normally. Without the ventricles pumping blood to the body, sudden cardiac arrest and death can occur within a few minutes.
BRADYARRHYTHMIAS-Occur if the heart rate is slower than normal. If the heart rate is too slow, not enough blood reaches the brain. This can cause you to pass out.-in adults, a heart rate is slower than 60 beats per minute is considered bradyarrhythmia. Some people normally have slower heart rates, especially people who are very physically fit. For them, a heart beat slower than 60 beats per minute isn’t dangerous and doesn’t cause symptoms. But in other people, serious diseases or other conditions may cause bradyarrhythmias.-can cause Heart attacks Conditions that harm or change the heart’s electrical
activity, such as an underactive thyroid gland or aging An imbalance chemicals or other substances in the blood,
such as potassium Medicines such as beta blockers, calcium channel blockers,
some antiarrhythmia medicines, and digoxin
Arrhythmia in children Children’s heart rates normally decreases as they get older. A
newborn’s heart beats between 95-160 times a minute. A 1 year old heart beats between 90- 150 times a minute, and a 6 to 8 year old heart beats between 60 to 110 times a minute.
A baby or child's heart can beat fast or slow for many reasons. Like adults, when children are active, their hearts will beat faster. When they're sleeping, their hearts will beat slower. Their heart rates can speed up and slow down as they breathe in and out. All of these changes are normal.
Some children are born with heart defects that cause arrhythmias. In other children, arrhythmias can develop later in childhood. Doctors use the same tests to diagnose arrhythmias in children and adults.
Treatments for children who have arrhythmias include medicines, defibrillation (electric shock), surgically implanted devices that control the heartbeat, and other procedures that fix abnormal electrical signals in the heart.
ARRHYTHMIAS
PULSELESS RHYTHYM
NON SHOCKABLEPEA (Pulseless Electrical Activity)Asystole (Silent Heart)
SHOCKABLEVF (Ventricular Fibrillation)VT(Ventricular Tach Pulseless)TORSADES de Pointes
Perfusing Rhythms(non-arrest rhythms)
BRADYCARDIASinus BradycardiaJunctional rhythymIdioventricular Rhythym
Artioventricular Block:1st degree2nd degree: Mobitz Type I Mobitz Type II3rd degree (Complete Heart Block)
TACHYCARDIAS: NARROW QRSRegular Rhythym:Sinus tacycardiaAtrial flutterSupraventricular TachycardiaJunctional TachycardiaIrreguar Rhythyms:Atrial flutterAtrial FibrillationMultifocal Atrial Tachycardia
TACHYCARDIAS : WIDE QRSRegular Rhythym:Ventricular tachycardia: monomorphicIrregular Rhythym:Ventricular Tachycardia: polymorphicTorsades de Pointes
Thank you!!!