EMERGENCY

NURSING
BY:BSN 4D GROUP 3
TRIAGING
● It involves the sorting of patients in emergency care settings according to their level of
acuity.
Acuity = is the general level of patient illness, urgency for clinical intervention, and intensity of
resource use in an ED environment.

● It also aims to ensure that all patients receive access to care in an organized,equitable
and timely manner based on the urgency of their clinical needs
● Basically, we are trying to answer the question…
● Who do we see first?”

The most common triaging system before utilizes(3-tier triangle tool):

1. Emergency
2. Urgent
3. Non-urgent
What is the problem in the 3-tier triage tool?

● Some triage officers still get confused between emergent and

urgent
 01 ● Life threatening or possible loss of limb
● To be seen and treated now
EMERGENCY ● Example:
CP arrest
Severe respiratory distress

02 ● Requires prompt care but will not cause loss of life of

limb if left untreated for hours
URGENT ● Example:
Abdominal pain
Multiple fractures

03
● Is non-urgent and treatment is not time-bound
● Example:
DIAGNOSIS Sprains
Cough and colds
5- Tier triage Tool
● Better than 3-tier since there are more categories and is based on
patient acuity and resource
● Emergency severity index (ESI)
● 5 levels

● ESI 1, 2, 3, 4 & 5
● ESI 1- the most critical
● ESI 5 - the least critical/problem case

Patient acuity
● The patient measurement of the
intensity of care that is required by a
patient
Resource
● Interventions needed to be done
above and beyond physical
assessment/examination
● After a brief physical exam at the
triage area, what further action will
you do?
Resources
● Labs (Blood, Urine)
● ECG
Imaging: X-rays, CT, MRI
● IV fluids
● IV or IM or NEB
medications
Specialty consultation
● Simple procedure = 1
- [ Simple toilet &
Suturing (T&S),
- Foley catheter, STO]
● Complex procedure = 2
- (Complicated T&S,
- Procedural sedation
analgesia
Non Resources
● History taking
● Physical examination
● Point-of-care testing (reflo,
PEFR)
- Example: CBG
Prescription refills
● Saline or heparin lock
● PO medication
● IM tetanus injection
● Simple wound care
(check dressing)
● Crutches, splinting
How to know if how many resources?

Diagnostic Test Resource Assigned

CBC and electrolyte panel One resource (lab test)

CBC and chest x-ray Two resources (lab, x-ray)

CBC and UA One resource (lab)

Chest X-ray, Abdominal X-ray One resource (x-ray)

MRI of the brain plain, Chest CT-scan Two resources (MRI and CT)
Four Decision Points in ESI A. Decision Point A
A. Does this patient require immediate life-saving intervention? ● Does this patient require immediate life-saving
B. Is this a patient who shouldn't wait? intervention?
C. How many resources will this patient need? - Yes-YES
D. What are the patient's vital signs? - No-proceed with decision point B

Questions to determine whether a patient requires an immediate life-saving intervention

● Does this patient have a patent airway?
● Is the patient breathing?
● Does the patient have a pulse?
● Is the nurse concerned about the pulse rate, rhythm, and quality?
● Was this patient intubated pre-hospital because of concerns about the patient's ability to maintain a patent airway,
spontaneously breathe, or maintain oxygen saturation?
● Is the nurse concerned about this patient's ability to deliver adequate oxygen to the tissues?
● Does the patient require an immediate medication or other hemodynamic intervention such as volume replacement or blood?
● Does the patient meet any of the following criteria: already intubated (pre-hospital setting), apneic, pulseless, severe respiratory
distress, SpO2 <90%, acute mental status changes or unresponsive?

✔ Key point: immediate physician involvement in the care of the patient is key difference between ESI 1 and ESI 2 patients
● If the patient needs to be seen by a physician right now, it is ESI 1
● If the patient needs to be seen but can wait for at least or within 10 minutes, that is ESI 2.
For mental status in triaging, we use AVPU (Alert, Verbal, Pain, Unresponsive)
● When determining whether the patient require immediate life- saving intervention,
the triage nurse must also assess the patient's level of responsiveness.
- Alert
- Verbal
- Pain
- Unresponsive

**Pain and Unresponsive usually meet the ESI 1 criteria**

Examples of ESI 1
● Cardiac arrest
● Respiratory arrest
● Critically injured trauma patient who presents unresponsive
● Drug overdose with a respiratory rate of 6
● Anaphylactic shock
● Hypoglycemia with a change in mental status
B. Decision Point B

● Should the patient wait?

● Guide questions if the patient can wait?
- High risk situation?
- Confused/lethargic/disoriented?
- Severe pain/distress?
● YES - ESI 2
● NO-proceed to decision point C

Is it a high-risk situation?

● High risk patients are those whose condition could easily deteriorate or who presents with symptoms suggestive of a
condition requiring time-sensitive treatment.
● ESI 2 patients are very ill and at a high risk
● Examples of high-risk situations:
- Active chest pain, suspicious for ACS but does not require an immediate life-saving intervention
- Signs of stroke but does not meet ESI 1 criteria
- A rule-out ectopic pregnancy, hemodynamically stable
- A suicidal patient
Is the patient confused, lethargic, or disoriented?
● Concern is whether the patient is demonstrating an acute change in LOC
● Example: new onset of confusion in an elderly client stroke patient

Is the patient in severe pain or distress?

● Self-reported pain rating of 7 or higher on a scale of 0-10, combined with the nurse's clinical observation
● Clinical observation:
- Distressed facial expression, grimacing crying
- Diaphoresis
- Body posture
- Change in VS (BP, HR, RR)

NOTE: For ESI 1 and ESI 2 patients, there is no need to identify how many resources are needed. For ESI 1, immediate life-
saving interventions. For ESI 2 patients, these cases/patients need to be seen within 10 minutes upon arrival.
C. Decision Point C

● How many resources are needed?

● The disposition of the patient could either be:
- Send the patient home
- Admit to the hospital
- Transfer to another institution

NOTE: Basically, stable patients will fall under the category, decision point C
ESI 3 These are patients that need 2 or more resources

ESI 4 These are patients that need only 1 resource

ESI 5 These are patients that do not need any resource

D. Decision Point D
● Patient’s Vital signs
- Is the patient’s vital signs stable? If not, Upgrade to ESI 2.
- Before assigning the patient to ESI level 3, the nurse needs to look at the patient’s vital
signs and decided whether they are outside the accepted parameters for age and are felt by
the nurse to be meaningful
- If the vital signs are outside the accepted parameters, the triage nurse should consider
upgrading the triage level to ESI level 2, however it is the triage nurses’ decision as to
whatever or not the patient should be upgraded to be an ESI level 2 base on vital sign
abnormalities

AGE HR RR SpO2

<3 months >180 >50 <92%

3 mos. - 3 yo >160 >40

3 yo - 8 yo >140 >30

>8 yo >120 >20

Example Scenarios:

A 34-year-old male presents to triage with right lower quadrant pain, 5/10, all day. Pain is associated with
loss of appetite, nausea, and vomiting.
Past medical history: None. The patient appears in moderate discomfort, skin warm and dry, guarding
abdomen.
● Decision point A: Does the patient need lifesaving intervention? NO-proceed to decision point B
● Decision point 8: should the patient be seen within 10 minutes or can the patient wait? YES, patient
can wait.
● However, RLQ pain, loss of appetite, nausea and vomiting moderate pain, etc. we have a lot of
possible resources (labs, imaging, ultrasound/CT scan of the abdomen)
● 2 or more resources = ESI 3
How many ESI resources will this patient need?

A 22-year-old female involved in a high-speed rollover motor vehicle collision and thrown from the vehicle,
presents intubated, no response to pain and hypotensive.
● Decision point A: Does the patient need a life-saving intervention?
- The patient is intubated, with no response to pain, hypotensive. This patient is already categorized as
ESI level 1.
- Note: for ESI 1, we do not need to determine the number of resources.
- Answer: The patient does not need to make a determination of the number of resources in order to
make the triage classification.
How many ESI resources will this patient need?

A 60-year-old healthy male who everted his ankle on the golf course present with moderate swelling and
pain upon palpation of the lateral malleolus.

● Note: if you are given this type of case scenario, just focus on what is given. Do not overthink.

● Since the patient is only having moderate swelling and pain upon palpation, technically if you think
about it, patient only needs an x-ray on his ankle.

● There is only 1 resource = patient is classified as ESI 4

● Crutches (non-resource): patient will need crutches

● Patient will be given PO medications for pain relief. PO medication is not a resources.

● When can be classified as ESI 3?

- If and when patient is in severe pain (e.g continuous oa with PS = 9/10). Most likely, patient will
not be given PO medication. Pain medication will be given either IV or IM, which is a resource.
So 2 or more resources = ESI 3.
PRIMARY AND SECONDARY SURVEY Breathing
Primary Assessment Look -Listen- Feel - Approach
● Airway •Assess:
● Breathing - Respiratory rate and effort
● Circulation - Breath and added sounds
● Disability - Subcutaneous emphysema
● Exposure/Environment - Symmetry of chest movement
Airway - Tracheal deviation
• Assess: - Jugular vein distention
- Airway noises - Cyanosis
- Position of head What to do?
- Foreign body ● 02 supplementation according to Sp02
- Fluid, secretions ● Pneumothorax therapy - if with no breath
- Edema sounds
What to do? ● Inhalation therapy - if with abnormal
● Open airway Suction breath sounds (wheezing)
● Secure airway ● Ventilation
● 02 supplementation
Circulation Disability
● Assess: ● Assess:
- Heart rate - AVPU/GCS
- Blood pressure - Reactivity and symmetry of
- Capillary refill time pupils
- Bleeding - Blood glucose level
- Skin color - Basic neurological examination
- Blood samples - Posture
- Diuresis - Toxicological examination
What to do? What to do?
● IV /IO access ● Glucose
● Control of bleeding ● Antidotes
● Massive hemorrhage protocol
● Fluids
● Drugs
● Transfusion
Environment
● Assess:
- Head to toe examination
- Medical history Secondary Survey
- Temperature • Uses acronym SAMPLE
- Injuries
- Edemas Symptoms
- Scars Allergies
- Signs of drug abuse
Medication
- Skin changes
- Signs of infection / sepsis Past medical history
What to do? Last oral intake
● Identified cause therapy
● Thermomanagement
Events
● Trauma management
● Insertion of NGT, IUC
A.) Symptoms (Patient's Chief Complaints)
- What's wrong?
- What brought you to the hospital?
B.) Allergies (Seeking to know what type of allergic reaction they experience)
- Are you allergic to anything?
- What happens to you when you use something that you are allergic to?
C.) Medications (Prescribed, OTC drugs, herbal medications etc.)
- Are you taking any medications?
- What are you taking the medications for?
- When did you last take your medications?
D.) Past Medical History (Seeking to know the previous state of health, and previous illnesses)
- Do you have other medical problems?
- Do you have other medical problems?
E.) Last Oral Intake (Seeking what are the last oral intakes of the client)
- When did you last eat or drink anything?
- What was it that you last ate?
F.) Events (Events leading up to the illness or injury)
Injury: How did you get hurt?
Illness: What led to this problem?
1. Foreign Body Obstruction
● Despite improvements in medical care and public awareness, approximately 3000 deaths occur each year
from foreign body aspiration.

● Most deaths occur in pre-hospital evaluation and treatment

● Usually lodged in the larynx, trachea, and bronchus

● Aspiration of foreign bodies produces the following 3 phases:

a) Initial phase: choking and gasping, coughing or airway obstruction at the time of aspiration
b) Asymptomatic phase: subsequent lodging of the object with relaxation of reflexes that often results
in a reduction or cessation of symptoms, lasting hours to weeks (e.g. ingestion of fishbone)
c) Complications phase: foreign body producing erosion or obstructions leading to pneumonia,
atelectasis, or abscess
● The presentation depends on the location of the foreign body:

1. Laryngeal foreign bodies

✔ present with airway obstructions and hoarseness or aphonia
2. Tracheal foreign bodies
✔ present similarly to laryngeal foreign bodies but WITHOUT hoarseness or aphonia, can
demonstrate wheezing like asthma
3. Bronchial foreign bodies
✔ typically present with cough, unilateral wheezing, and decreased breath sounds, but
only 65% of patients present with this classic triad

● Workups include auscultation of breath sounds (which tends to be decreased or presents

wheezing) and chest radiograph
❑ MANAGEMENT:

1. Heimlich Maneuver
• the manual application of sudden

upward pressure on the upper

abdomen of a choking victim to force

a foreign object from the trachea.

• Use of the Heimlich maneuver has improved the mortality rate of patients
with complete airway obstruction, but its employment in patients with
partial obstruction may produce complete obstruction.
❑ Surgical Therapy

• Insufflation Catheter through the nose, with its tip into the hypopharynx to
maintain anesthesia and oxygenation
• After that, the tip of the laryngoscope is placed in the vallecula of the throat for
exposure and the foreign body is visualized in the larynx and removed with
appropriate foreign body forceps
 2. Smoke Inhalation
• Is the leading cause of death due to fires.
• It produces injury through several mechanisms including THERMAL INJURY to the upper
airways, IRRITATION or CHEMICAL INJURY to the airways from soot, ASPHYXIATION, and
TOXICITY from carbon monoxide and other gases such as cyanide.
❑ Signs and symptoms: ❑ Diagnostics:

• Facial burns • ABG

• Blistering or edema of the oropharynx • Lactate

• Hoarseness • CBC

• Stridor • Chest radiograph

• Upper airway mucosal lesions • ECG and/or cardiac enzymes (with

• Tachypnea, dyspnea, cough chest pain)

• • Direct laryngoscopy and fiberoptic

Decreased breath sounds, wheezing, rales,
rhonchi bronchoscopy

• Retractions
❑ Management
• IV access, cardiac monitoring and supplemental oxygen
✔ Especially below 94%
• Bronchospasm: use of bronchodilators
• Upper airway injury suspect: elective intubation is considered
✔ Important assessment by the doctors
✔ Possible edema of the airways
✔ Fast determination for intubation is critical
✔ It’s difficult to intubate when there is edema
• Steroid use
⮚ Control studies are disappointing
⮚ Use of steroids has some value in exposure to the following
- Nitrous oxide - Sulfur trioxide
- Zinc oxide - Titanium tetrachloride
- Red phosphorus
• Hyperbaric oxygen therapy
✔ Primary features for carbon monoxide poisoning / indications for hyperbaric therapy

o Pt experiencing neurologic abnormalities

o history of loss of consciousness

❑ Admission is advised for

• History of closed-space exposure for longer than 10min
• Metabolic acidosis
• Arterial PO2 less than 60mmHg
• Carboxyhemoglobin levels above 15%
• Bronchospasms
• Odynophagia
• Central facial burns
3. Anaphylaxis
● Is an acute, potentially fatal, multiorgan system reaction caused by the
release of chemical mediators from mast cells and basophils
● A majority of adult patient have some combination of urticaria, erythema,
pruritus or angioedema
Signs and symptoms
● Initially, patients often experience pruritus and flushing. Other symptoms
can evolve rapidly such as the following
Dermatologic ● Flushing, urticaria
● Angioedema
● Conjunctival pruritus
● Warmth and swelling
Respiratory ● Nasal congestion
● Coryza, rhinorrhea
● Sneezing, throat tightness
● Wheezing,
● Shortness of breath
● Cough, hoarseness
● Dyspnea
Cardiovascular ▪ Dizziness
▪ Palpitation
▪ Weakness
▪ Syncope
▪ Chest pain
Gastrointestinal ● Dysphagia
● Nausea, vomiting
● Diarrhea
● Bloating
Neurologic ● Headache
● Dizziness
● Blurred vision
● Seizure (rare and often associated with
hypotension)
Other ● Metallic taste
● Feeling of impending doom
Diagnosis
• The priority in the physical examination should be to assess the
patient’s airway, breathing, circulation and adequacy of mentation
(alertness, orientation, coherence)
• Laboratory studies are not usually required and are rarely helpful. If
the diagnosis is unclear, SERUM TRYPTASE may help confirm
diagnosis of anaphylaxis
• Urinary 24H histamine may help in the diagnosis of current
anaphylaxis
Treatment
• Airway:
o Immediate intubation if evidence of impending airway
obstruction from angioedema
• Medication of choice:
o IM Epinephrine (1 mg/mL): 0.3-0.5mg IM (mid outer
thigh), can repeat every 5-15 min as needed
o No contraindications for epinephrine for anaphylaxis
• Position:
o Place in recumbent position, elevate lower extremities
• Oxygen: 8-10L/min via face mask
• Normal saline rapid bolus: treat hypotension with rapid
infusion of 1-2 liters IV
• Salbutamol: for bronchospasm resistant to IM epinephrine
4. Emergency Trauma
● Traumatic injuries can range from minor isolated wounds to complex injuries involving multiple organ systems
● All trauma patients require a systematic evaluation to maximize outcomes and reduce the risk of undiscovered injuries

Assessment
● The primary survey consists of the following steps:
● Airway assessment and protection
o maintain cervical spine stabilization when appropriate
● Breathing and ventilation assessment
o Maintain adequate oxygenation
● Circulation assessment
o Control hemorrhage and maintain adequate end-organ perfusion
● Disability assessment
o Perform basic neurologic evaluation
● Exposure, with environmental control
o Undress patient and search everywhere for possible injury while preventing hypothermia
o Maintain privacy
Diagnostic studies
● Portable radiographs
● Emergency CT scan
● For critically unstable patients, the physician must first evaluate the risk
for performing this vs stabilizing the patient first.
● Helps in planning what to do next
● ECG: make sure there is no cardiac involvement
● Lab test: CBC, Bleeding parameters / bleeding times

Treatment
● intubation: usually done for an unconscious patient
● 2 important steps to gain control of hemodynamics
● Hemorrhage must be controlled with direct pressure
● IV access must be established to begin fluid replacement
 ENVIRONMENTAL EMERGENCY

1. Stings and Bites

● Most common are Hymenoptera stings from: ● Generalized reaction
- Bees - Urticaria
- Wasps - Confluent red rash
- Yellow jackets - Shortness of breath, wheezing
- Hornets o Ants Edema in airway, tongue, uvula
- Weakness, syncope
● Local reactions - Anxiety, confusion
- Pain (immediately occurs after sting) - Chest pain
- Edema (marked and extended up to 10cm
from site of envenomation)
- Bleeding (occurs at site of sting)
- Pruritus
- Vasodilation (produces warmth sensation)
- Nausea and vomiting (occur without
generalization)
 ● Pre-hospital
- Care must assess severity immediately and provide immediate appropriate
treatment because the most endangered patients die within 30-minutes of a
sting
- Local reactions can be life-threatening, and it usually affects the airway;
initiate invasive procedures to secure the airway
- Provide supplemental oxygen
- Diphenhydramine limits the size of the local reaction
- Clean wound and remove stinger if present
- Apply ice or cool pack
- Elevate the extremity to limit edema

● Emergency department care

- Epinephrine is the mainstay of treatment for anaphylaxis (dosage: 0.3-0.5
mg IM at the mid outer thigh)
- H2-blockers + diphenhydramine
2. Poisoning
● Food poisoning is defined as an illness caused by
the consumption of food or water contaminated
with bacteria and or their toxins, or with parasites,
viruses, or chemicals

● Most common pathogens

- Norovirus
- E.Coli
- Salmonella
- Campylobacter
- S. Aureus
 Symptoms Include
● Abdominal pain
● Stool changes
- Most severe inflammatory
- Bloody or mucousy if invasion of
processes
intestinal colonic mucosa
- Painful abdominal muscle cramps
- Perfused and watery if cholera
such as underling electrolyte loss
● Reactive arthritis
● Vomiting - Salmonella
- Major presenting symptom
- Shigella
- Norovirus, S. aureus - Campylobacter
● Diarrhea o Lasts less than 2 weeks - Yersinia
● Headache
● Bloating
● Fever - giardiasis
- Invasive disease
- Indicative of infection outside of
GI tract
 General
Findings:
● Mild dehydrations:
➔ a dry mouth,
➔ decreased axially sweat,
➔ decreased urine
● More severe volume depletion:
➔ orthostasis,
➔ tachycardia
➔ hypotension
● ●
S. Typhi infection:
➔ upper abdominal rose spot
➔ Macules
➔ hepatosplenomegaly
● Y.infection
➔ Exudative pharyngitis
● Vibrio vulnificus
➔ Celluitis
➔ Otitis media
Treatment:
● Supportive care:
➔ Rehydration & electrolyte supplementation
➔ ORS, IV sol, (ex. isotonic sodium chloride
solution, PLR)
Pharmacotherapy:
Antidiarrheals
➔ Absorbents
➔ Antisecretory agents
➔ Antiperistaltics (Loperamide)
● Antibiotics
➔ Depends on clinical setting and guided by microbiology
and blood culture sensitivity results
➔ Ciprofloxacin
➔ Doxycycline
➔ Norfloxacin
➔ Rifaximin
3. Drowning
● 3rd leading cause of unintentional injury death
● Accounts to 7% of all injury-related death
● Is a process that results in primary respiratory
impairment from submersion in a liquid medium
● A liquid-air interface is present at the entrance to
the patient’s Airway which prevents the individual
from breathing oxygen
Pre-hospital Care Emergency Department Care
● Victims of drowning should be ● Early use of intubation and PEEP
removed from the water at the (mechanical ventilation)
Earliest opportunity ● BiPap or CPAP
● Rescue breathings ○ Alert and cooperative
○ While still in the water patients to provide
○ No chest compressions adequate oxygenation
since there are buoyancy before intubation
issues
● Once out of water, begin CPR.
○ With emphasis on rescue
breaths compared to
Compressions only
○ CPR + CHEST
COMPRESSIONS +
RESCUE BREATHS
 Cardiac Arrest
Explanation of Diagram:
First, upon witnessing an unconscious patient:
1) Verify scene safety
- Check if the environment is safe for you and the patient
(eg. Falling debris, wet floors, presence of sharp objects)
2) Check for responsiveness
• Chant: Hey, hey, are you okay? Hey, hey, are you
alright?
• Shout for nearby help: Help, help! I need help
• Activate emergency response system via mobile devices
• Get an AED (Automated External Defibrillator) and
emergency Equipment (or send someone to do so).
• Check simultaneously breathing and pulse (carotid
pulse)
• Done in 6-10 seconds. No more than 10 seconds.
• Upon opening the airway by the head tilt chin lift or
jaw Thrust maneuver, check the breathing utilizing your
cheek.
• Check for chest rise and carotid pulse.
• Counting: 1 1002 1003 1004…
There is breathing: Monitor until emergency responder arrives

No normal breathing, but there is a pulse: - Provide rescue breathing (1 breath every 6
- seconds or 10 breaths per minute)
- Check pulse every 2 minutes. If no pulse, start CPR.
- If possible opioid overdose, administer naloxone if available per protocol.

If no pulse and no breathing: START CPR

• Perform cycles of 30 compressions and 2 breaths
. • Use AED as soon as it is available.
• AED arrives
Attach AED as soon as possible so we can determine the rhythm
Is the rhythm shockable?
• Shockable if pulseless Ventriculartachycardia (pulseless V-Tach) & Ventricular
Fibrillation (V-Fib)
If shockable:
• Give 1 shock, resume CPR immediately for 2 minutes (until prompted by AED to
allow rhythm check)
•Continue until ALS providers take over or victim starts to move
If non-shockable:
•Resume CPR immediately for 2 minutes (until prompted by AED to allow rhythm
check)
•Continue until ALS providers take over or victim starts to move.
 ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS)
1. The initial evaluation is as follows:
· Activate emergency response system.
· Initiate adult basic life support.
2. The initial intervention is as follows:
· Start high-quality CPR (emphasis)
· Administer oxygen if hypoxemic.
· Attach monitor/ defibrillator.
· Monitor BP and oximetry; do not delay
defibrillation.
3. Check rhythm, as follows:
· Shockable rhythm (pulseless V-tach &
V-fib)
· Non- shockable rhythm (asystole &
pulseless electrical activity (PEA)
Shockable rhythm
● Initial treatment of VT / VF
○ Defibrillate immediately (200 joules if
pulseless)
■ Monophasic 360 joules
■ Biphasic- 200 joules (for uniformity, use
200 joules)
○ Continue CPR for 2 min.
■ Minimal disruption (less than 10
seconds)
○ Obtain IV/IO access.
○ Consider advanced airway (Intubation)
● Administer vasopressor.
○ Epinephrine every 3-5 min (1st)
■ 1mg/mL 1:10,00 dilution
■ Preparation: 9mL saline + 1mL
epinephrine
● If IV access
○ Give epinephrine IV, flush with 10-20mL of
PNSS and raise extremity (promotes faster
blood flow to the heart)
● Check pulse and rhythm every 2min, as follows:
○ If non-shockable, see non-shockable
rhythm algorithm.
○ If shockable see shockable rhythm
algorithm and administer amiodarone after
second defibrillation attempt.
○ Rotate chest compressors.
○ Identify and treat reversible causes.
● If with return of spontaneous circulation (ROSC),
do post-cardiac arrest care.
○ Stop CPR, check V/S and manage the
patient.
Non-shockable rhythm
● Initial treatment of asystole/PEA
○ Continue CPR for 2min.
○ Obtain IV/IO access.
○ Consider advanced airway.
● Administer vasopressor (epinephrine every 3-
5min)
● Check pulse and rhythm every 2min as
follows:
○ If non-shockable, see non-
shockable rhythm algorithm.
○ If shockable, see shockable
rhythm algorithm and administer
amiodarone (300 mg IV and
flush with 10-20 ml PNSS) after
second defibrillation attempt.
○ Rotate chest compressors.
○ Identify and treat reversible
causes.
ACLS CPR quality
● Push hard and fast, at least 2 inches
(5cm) and 100-120 compressions per
minute.
● Allow complete chest recoil.
● Minimize interruptions in compressions.
● Avoid excessive ventilation.
● Rotate compressor every 2min or if
fatigued.
● The compression to ventilation ratio is
30:2 (if absence of advanced airway)
● Continuous compressions if advanced
airway present.
Shock Energy ACLS
● Biphasic: 200j or (120-200j)
● Monophasic: 360j
ACLS Drug Therapy
● Epinephrine 1mg IV/IO every 3-5min.
○ 9mL PNSS w/1mL of epinephrine then
give IV bolus.
● After 2nd defibrillation: Amiodarone 300mg
IV/IO initial dose (150mg second dose)
○ For amiodarone drip: PNSS or D5W
250 mL then add 600 mg of
amiodarone to run for 25cc/hour for
6hours then 13cc/hour thereafter.
 ACLS reversible causes
ACLS (Advanced H’s T’s
airway)
● ETT-endotracheal tube ● Hypovolemia- ● Tension
● SGA-Supraglottic airway fast drip NSS pneumothora
● WAVEFORM CAPNOGRAPHY- ● Hypoxia x
● Hydrogen ion ● Tamponade
to confirm and monitor ET tube (acidosis) - (cardiac)
placement ABG ● Toxins
● Ventilation every 6 seconds ● Hypo/ ● Thrombosis
asynchronous with compressions hyperkalemia (pulmonary)
- ABG ● Thrombosis
● Hypothermia (coronary)
 ADDITIONAL NOTES FROM THE SENIORS:
CARDIAC ARREST
BLS survey
➔ In hospital
➔ Before hospital
➔ First, for unconscious patient
➔ Check for the environment.
➔ Adult Arrest/Algorithm
● Verify Scene Safety
○ to check potential hazards in the environment both in the rescuer and the patient (e.g., incoming traffic in the
streets)
● Check for responsiveness
○ Chant: Hey, hey are you okay? Hey. Hey are you alright? Tapping the shoulders and ask for help and ask to
activate the emergency response system and to get an AED
○ What to do if alone? Personally call for help, leave the px, activate emergency response system (via mobile phone)
and then bring an AED
● Assess for breathing and check for pulse
○ Simultaneously checked: breathing and carotid pulse for less than 10 seconds
○ for uniformity, we will utilize 6 seconds
○ Chant: 1: 1002, 1003, 10004, 10005, 1006
 ○ Check for chest rise and place your cheek near the nostrils of the patient
○ Checking for the carotid pulse: make sure in the same side where you are situated,
avoid crossing your arm over the patient's neck; patient position is flat (Rationale: No
crossing of hands as this may block the simultaneous checking of chest rise)
● If no normal breathing but pulse is present
○ provide rescue breaths
○ At 1 breath for every 5-6 seconds (6seconds)
○ Then, still continue checking for pulse every 2 minutes
● If no breathing and no pulse
○ Start high quality CPR at a compression-to-breaths
○ 30 compressions: 2 rescue breaths (1 cycle=5times of 30.2) then check for pulse and breathing,
if still no progress resume high-quality CPR
○ If only alone you will do the compressions and rescue breaths. If there is another rescuer,
switch roles as the compressor and the one providing the rescue breaths (vice versa)
○ Pulse/rhythm check every 2 minutes
● If with AED attached.
○ While doing chest compression, AED pads are already attached
○ Where to put first pad: Upper right of the chest above the nipples avoid hairy areas, patches
(fentanyl patch) and avoid implantable devices
○ Second pad: lower left chest area, in between the nipple line and left axillary line
○ Not to interrupt chest compressions while attaching AED pads; stop chest compressions
once AED is attached and let it analyze the rhythm shockable or not? If shockable, press
defibrillate or shock button then resume CPR
○ If not shockable: high quality CPR for 2 mins
○ After 2 mins, always assess for presence of pulse and breathing
○ What to do?
○ Rescue breaths: 1 every 6 seconds
 COMPRESSION
• Check pulse at Carotid area
• COMPRESSION LANDMARK: lower half of the sternum between the nipples,
place the heel of the one hand and the other hand on top.

✓ COMPRESSION METHOD
• Kneel both knees on the side of the patient, apart.
• Hands are clasped directly above the sternum of the patient.
• Always make sure to lock elbow when doing compressions.
• Allow complete chest recoil every after each compression.
• Compression rate : 100-120 compressions per min.
• Compression to ventilation ratio: 30:2
• Rotate compressor every 2 min or if fatigue
• Minimize interruptions in compression to less than 10 secs
 AIRWAY
✓ HEAD TILT CHIN MANEUVER
• Place one heel of the right and placed in the forehead of the patient.
Then the other hands index finger lift the chin away from the chest.
• Tilt the patient's head back by pushing down on the forehead
• Place the tips of your index and middle fingers under the chin and
pull up on the mandible
• Be sure to pull up only on the bony parts of the mandible

✓ JAW THRUST MANEUVER

• Place both heels in the occipital area of the head of the patient,
using the index and middle finger placed at the tip of the mandible
of patient and simultaneously leave the jaw or mandible of the
patient.
• Stand at the head of the stretcher and place your palms on the
patient's temples and your fingers under the mandibular rami.
• In patients with possible cervical spine injury avoid extending the
neck.
• Lift The mandible upward with your fingers, at least until the lower
incisors are higher than the upper incisors.
• Be sure to pull or push up only on the body parts of the mandible.
 DEFIBRILLATION
• Attach and use AED as soon as available without interrupting chest
compressions
• Minimize interruptions in chest compressions before and after shock.
• Resume CPR beginning with compressions immediately after shock
 THANKS!
DO YOU HAVE ANY
QUESTIONS?
jamesedisonjintalan@gmail.com
+63 956 766 3148

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