3.07.2006
ACLS Algorithms - [ACLS.net]
I always like to find some interesting articles and since i am on the ACLS mood...i tried to scour the net for some eay to remember algorithms...
ACLS.net has some good algorithms with mnemonics and simulation practices (love those!)
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Universal Algorithm for Adult Emergency Cardiac Care
and Primary Survey ABCDs (Excerpt)
Assess responsiveness by speaking loudly, or gently shaking the patient if there are no signs of trauma.
Call for help/crash cart if the patient is unresponsive.
A Airway: Open airway, look, listen, and feel for breathing.
B Breathing: If not breathing, slowly give 2 rescue breaths.
C Circulation: Check pulse. If pulseless, begin chest compressions at 100/min (15:2 ratio with unprotected airway). Consider precordial thump in witnessed arrest with no defibrillator immediately available.
D Defibrillation: Attach monitor/AED. Assess rhythm. Search for and Shock VF/PVT up to 3 times if needed.
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Secondary Survey ABCDs (Excerpt)
A Airway: Establish and secure an airway device.
B Breathing: Ventilate with 100% O2. Confirm airway device placement by exam, end-tidal CO2 monitor, and O2 saturation monitor.
C Circulation: Evaluate rhythm, check pulse, if pulseless continue chest compressions (5:1 ratio with protected airway), obtain IV access, give rhythm-appropriate medications.
D Differential Diagnosis: Attempt to identify and treat reversible causes.
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Asystole Algorithm
Asystole may be discovered during the primary ABCD survey after attaching a monitor, or it may develop in a previously monitored patient. In either case, it is essential that asystole be confirmed in another lead with properly functioning equipment. If the patient is in true asystole and is a candidate for resuscitation, then proceed with the secondary ABCD survey.
Interventions for asystole are guided by the instructive phrase and acronym,
"Asystole ..... Check me in another lead,
then let's have a cup of TEA."Acronym - Intervention - Comments/Dose
T Transcutaneous Pacing (TCP) Only effective with early implementation
along with appropriate interventions and medications.
NOTE: Not effective with prolonged down time.
E Epinephrine 1 mg IV q3-5 min.
A Atropine 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)
Consider termination of efforts if asystole persists despite appropriate interventions.
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Bradycardia Algorithm
Treatments for absolute bradycardia (<60 bpm) or relative bradycardia (slower than expected) with serious signs or symptoms due to the bradycardia are guided by the mnemonic:
"All Trained Dogs Eat Iams"NOTE:(The sequence reflects interventions for increasingly severe bradycardia)
Mnemonic - Intervention - Comments/Dose
All - Atropine - 0.5-1.0 mg IV push q 3-5 min. (max. dose 0.03-0.04 mg/kg)
Trained - TCP - Use Transcutaneous Pacing (TCP) immediately with severely symptomatic patients.
Dogs - Dopamine 5-20 µg/kg/min.
Eat - Epinephrine 2-10 µg/min.
Iams - Isoproterenol 2-10 µg/min.
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PEA Algorithm
Pulseless Electrical Activity may be discovered during the primary ABCD survey when a monitor is attached to a pulseless patient and a rhythm is shown. As part of the secondary ABCD survey, a doppler should be used to confirm pulselessness.
Interventions for pulseless electrical activity are guided by the letters
"P-E-A"Intervention - Comments/Dose
Problem - Search for the probable cause and intervene accordingly. (see PEA Problem Table )
[Pulmonary Embolism] - No pulse w/ CPR, JVD - Thrombolytics, surgery
[Acidosis] - (preexisting) Diabetic/renal patient, ABGs -Sodium bicarbonate,
hyperventilation
[Tension pneumothorax] - No pulse w/ CPR, JVD, tracheal deviation - Needle thoracostomy
[Cardaic Tamponade] - No pulse w/ CPR, JVD, narrow pulse pressure prior to arrest - Pericardiocentesis
[Hyperkalemia] - (preexisting) Renal patient, EKG, serum K level - Sodium bicarbonate, calcium chloride, albuterol nebulizer, insulin/glucose, dialysis, diuresis, kayexalate
[Hypothermia] - Core temperature - Hypothermia Algorithm
[Hypovolemia] - Collapsed vasculature - Fluids
[Hypoxia] - Airway, cyanosis, ABGs - Oxygen, ventilation
[Massive MI] - History, EKG - Acute Coronary Syndrome algorithm
[Drug Overdose] - Medications, illicit drug use - Treat accordingly
Epinephrine - 1 mg IV q3-5 min.
Atropine - With slow heart rate, 1 mg IV q3-5 min. (max. dose 0.04 mg/kg)
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Posted by nixinne ::
08:55 ::
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3.03.2006
Emergency Cardiovascular Care
this is one of the few things that i always carry on my work bag (see side nav bar: my work bag). you could never go wrong with this one since it has almost everything that you needed in adult and pediatric emergencies (except for broselow pediatric tape). it is the bible of acls and pals providers. this one is the 2004 updated edition but soon it will be replaced by the 2005 guidelines.
Note: Please refer to American Heart Association - PDF of the 2005-2006 Winter issue of the ECC free quarterly newsletter, Currents for further information. This information is copyrighted by AHA. Also, please note the Purpose & Intent of the blog author on the right side nav bar.
The 5 major changes in the 2005 guidelines are these:
• Emphasis on, and recommendations to improve, delivery of effective chest compressions
• A single compression-to-ventilation ratio for all single rescuers for all victims
(except newborns)
• Recommendation that each rescue breath be given over 1 second and should
produce visible chest rise
• A new recommendation that single shocks, followed by immediate CPR, be used to
attempt defibrillation for VF cardiac arrest. Rhythm checks should be performed every
2 minutes.
• Endorsement of the 2003 ILCOR recommendation for use of AEDs in children 1 to 8 years old (and older); use a child dose-reduction system if available.
when i took my pals late last week, they tol us about the updated guidelines but as i have read on AHA website, they are going to release everyhting on december 2006. by updating their guidelines, they are giving easier to remember algorithms that is beneficial to both the rescuer and the patient. time is a valuable part of an emergency situation and assessments needed to be done by professionals and lay rescuers are now more definitive. chance of survival on emergency situations are increased with the new guidelines and recommendations. aed is still one of the most important things that a lay rescuer can learn. it remarkably increases the survival rate of adult cardiovascular emergency patients. especially now that a lot of establishments are investing on aed and training employees on how to use them. recommendations on aed for children ages 1 yr old and above is also promising although most of pediatric emergencies usually are respiratory in origin than cardiovascular.
there are still a lot to learn and i wish i can delve into it more. but i guess thats why AHA is there. i try to check for news and updates every week. i salute them for including lay rescuers in their endeavors to save lives.
Posted by nixinne ::
14:47 ::
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No Lifting >5 lbs.: Working with Injury
i really didn't know how to but i managed...like a good soldier, i went to the battle. especially now that i actually found my keys on time.
1806 - on my way to work
1826 - parking garage
1829 - clocked in
1840 - report taken [chatted with co-workers. went to copier to copy my own nursing form.]
1845 - started vital signs and assessments. flushed all iv ports. [patient 1 = arf/acute encephalopathy/afib; patient 2 = pneumonia/chest pain/nsr; patient 3 = aortic dissection/ng tube feed/afib]
1925 - started charting.
2005 - pain meds given to patient 1 along with 2100 meds. fsg = 446. md paged. Waiting for calabash
2020 - orders received. faxed to pharmacy. Waiting for meds
2025 - meds given to patient 1.
2030 - iv & po meds given to patient 2 & 3. [five r's!]
2045 - checking charts for orders, labs, transcriptions, scheduled meds
2115 - nursing rounds [toileting issues, snacks, answering questions of relatives and patients]
2216 - [patient 4] er admit arrives. assessment done. allergies, weight & height documented. fsg taken. Immediate needs given (water, food, socks etc) charge nurse in room to take history & list of medications
2225 - fsg of patient 1 taken = 333. md made aware. insulin iv ordered. faxed to pharmacy. given to patient 1
2240 - pain pill given to patient 2. checked patient 3 iv fluids. snack given to patient 1
2330 - picked up one more patient from leaving nurse [patient 5]. take report. started vital signs and focused assessments.
0010 - fsg of patient 3 & 1 taken. insulin given
0030 - forganized chart and entered orders for patient 4. called md for latest fsg of patient 1. catch up with charting then start 24 hour chart check
0200 - lunch
0230 - patient 3 to bedside commode with help of male monitor tech. my splint is still in place and at this time, everything is hurting on me]
0315 - family of patient 1 at nurses station. pt getting more agitated and confused. Trying to get out of bed.
0330 - charge rn and monitor tech settle pt in bed. anti anxiety meds given po. vital signs taken. litened and re-assured family.
0350 - started vital signs & focused assessments.
0430 - pain pill for patient 4 given. iv fluids changed on patient 3.
0445 - on patient 1 room. re-assuring family. checking patient 1 needs. Snack given.
0515 - fsg taken for patients 1, 3, 4 and 5. documented
0543 - meds given to patient 4. insulin coverage given to others as needed
0620 - start emptying foleys of patients 1, 3, 4 and 5. documented intake and output.
0645 - report given to voice mail system
0650 - patient 1 iv out. changed. pain meds given to patient 1 and 3. md inquires about patient 1
0710 - on my way to home [yipee! 5 nights off!]
it wast such a bad night. although i was really hurting. with all the signing and other stuff. i didn't need to lift anythig but constant movement was not also helping my wrist. maybe i should call employee health today.
Posted by nixinne ::
13:30 ::
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3.02.2006
Employee Injury: My Trip to ER
Last night was a perfect exapmle how employee injuries are handled by management.
1900 - lost car keys.
1815 - car keys are still missing. called work as there might be a possibility that i will be late
1840 - found car keys. off to work
1900 - arrived at parking garage
1902 - slipped awkwardly on the hallway with a puddle of water besdie a cleaning equipment. NO SIGN OF WET FLOOR! i got up immedietely and took one of the floor signs that was sitting at the wall, unfolded it and stood it at the middle of the puddle. one witness.
1904 - at the unit desk. my right wrist ad right hip was hurting. blurted out to charde nurse that i was sorry i was late that my car keys were lost and i slipped on a puddle downstairs.
1905 - charge nurse on the phone with housekeeping and house supervisor. i was trying to get report and get started.
1910 - incident report was filled. my rigt wrist pain is now shooting to my elbow. charge notices my grimacing while typing. also got insultd by a housekeeper asking me why i was not wet if i really did fell on the floor.
1920 - on my way to ER.
1930 - reception desk at ER. my info were being taken by the clerk. id band in place
1945 - called by triage nurse. interrupted by another patient. i gave way to the other patient.
1950 - called by triage nurse again. triage completed. my vs stable. pain level = 2. right wrist slightly swollen
1955 - waiting for a nurse doctor at the reception area. [and im getting bored]
2015 - my unit manager came in and talked to me about the incident. was very sorry about what happened. [i thought she was really sincere]
2040 - called in to the fast track room. [id rather call it "long wait room']
2042 - changed gown [i dont like being on a hospital. its not guess or dkny]
2110 - er doc came in and evaluated me. [nope it wasnt george clooney].
2130 - toradol im given to me. ouch! called mike 7 told him what happened. [i htought the nurse was pretty rude]
2140 - waiting for radiology to do my xrays. marti came down and sked how i was doing. gave her the scenario and then she vehemently denied me coming back to work. oops! rad techs calling me in. [darn, i didnt shave my legs today!]
2155 - talked to marti again in my fast rack room. nope, i definitely am not coming back to the floor to work. charge and supervisor agreed i should go home eventhough they are short of nurses. [i felt really bad at this point]
2230 - er tch checked on me. said doc will be here any minute.
2245 - er doc came. said everything was ok, no broke bones just a few minor sprain and muscle pulled. [i told him that when he firt checked me out]
2300 - splint applied to right wrist. prescription given. ace wrap to right knee. im off ot my floor to get my stuff
2315 - on my way home.
it wasnt fun but at the very least it was handled pretty well by management although i cannot blame er for the time it consumed to check my minor injuries. the housekeeper who earlier insulted me was apologetic when he saw me on the hallway and gave me a hug. i drove home despite a pain shot was dangerous but i was hurt when mike was laguhing at me ont he phone. but he actually came to the hospital to pick me up anyway eventhough i did not call me back to confirm that he was to pick me up.
Posted by nixinne ::
12:50 ::
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3.01.2006
Night Shift:: My Work Routine
i've got four patients last night. there wasnt much of any challenges or interesting facts over the entire night. in fact, it was pretty quiet.
my daily routine starts out by getting report from the day nurse. i hate kardex's since they always prove useless to me since i still have to go to the chart anyway to do a 24 hour check. i also read transcripts from doctors since it is easier to read than their chicken scratch handwriting on the chart. sometimes i think they should be liable to how they write but then again thats a different topic.
after i get the pertinent info about my patients (name, age, doctor, diagnosis, diet, iv fluids, activity, current status, etc), i start by taking their vital signs and doing my general assessment. It takes me 5-8 minutes each patient for the complete assessment of ambulatory patients, 8-12 minutes for bedrest/very weak patients and sometimes 15-20 minutes for patiets who are either grossly obese or is a complicated case (several tubes, IV's, isolaton, vasoactive drips, restraints, etc.). My assessment includes full body assessments, noting the general systems, iv status, pain status, any tubes, iv drips, skin & fall risk asseement. After assessing the patients, if the patients have no pertinent or immediete needs, i chart my assessments. then i start out looking at their charts to check recent orders and carrying them out if needed.
luckily last night everything wsa done except for a couple of consent forms to be signed, plavix to be given as a pre-op med for cardiac catheterization and hanging of iv fluids that are almost finished.
medication pass starts at 9pm but i started out at 8:50 last night. checking the 5 R's (right patient, time, dose, route, medication) is very important to me. i carry the mars with me and check their armbands too. these mostly cover up my time till the next vital signs are to be taken. I had to call pharmacy a couple of times to correct some medication issues such as missing medications and incorrect medication dosage entered in the pyxis. it was a near miss incident since i could have given a double dose of cardizem bt as i have saig, it was caught and was a near miss situation instead f an incident report.
In between giving medications, patients needed to be taught about their expectations on the upcoming procedures, assist them in their toileting needs, inseritng IV's (which i did twice last night), and if someone is in distress (thank goodness nobody was in that position last night), i will have to take care of that too. As i have said earlier, it was pretty quiet for me so i finished my med pass as half past nine. then i dcisded to check teir labs, radiology reports, history, plan of care and doctors transcriptions of procedures and consults. this things are very helpful to me during my shift so i can understand better what their symptoms are telling me.
11:30 is the mark for my next vital signs. i also give out their midnight medications at this hour and check if any patients needs their sleep aid medications if indeicated in their charts. i briefly assess them during this time focusing on the symptoms for their diagnosis. I make it a habit to chart after all of this has occured so i wouldnt get behind on my charting.
then, it is time for 24 hour checks making sure their admission status is up to date, orders have been taken care of, medications have been signed and given. then we take or lunch break. this is the time when it gets really slow unless our patient are having distress.
afer this had all been done, we do our hourly nursing rounds until it is time for the 3rd vital signs. at appoximately 3:30 am, i start doing their vital signs and their wieghts. after this chart again (did you notice that we cart a lot?...yea...we are too liable to a lot of things and as they say in nusing school, at work and probably in court, you didnt you do it if you didnt chart it.
5:30 is the mark for gathering 6 am medications but since our monitor tech went home early cause she was sick, i rotated with the chrage nurse to be at the monitor room. my patients are pretty mucjust sleeping away and their IV fluids are all set for the next bag. nobody had 6 am medications.
0620 cath lab called toask if patient 4 is ready. i informed the patient of the intent and was okay about it. she told me to notiy a friend about it and proceeded to brush her teeth while waiting for the courier.
0630 they came to get patietn 4 and patient 2 is now asking for pain medication.
after all of this has been done. we gave report and proceeded to go home!
Posted by nixinne ::
08:19 ::
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2.24.2006
PALS: Pediatric Emergencies
I finished my PALS (pediatric advance life support) course today. I was given my Pin reward for completing the 2 day course in addition to the standard wallet size card certification.
Everybody in that room was an emergency nurse. I was the only one who were not from that department. Rounding the table for names and work background, I always joke around and told them I was a lost sheep among wolves. I have worked as a cardiac / stepdown nurse my entire career and I am ready to take on a more challenging position. Taking ACLS was the first step, then PALS to seal my certification toward the career choice that I have wanted. The only missing piece now is the actual full time position on an emergency department.
Ok, back to PALS...
I hate working with children. Not because i hated children but i just don't have the emotional restriction in caring for children. It just breaks my heart to see a child suffer. I have a child myself which makes it more difficult for me to take care of other children who are sick. I did not want to take this course but as i have said above, i had to if i want an advancement in my career and it also looks good in my resume.
Anyway, PALS is much simpler than ACLS as i remember. There are slight differences in BLS procedure, less drugs to memorize and the chain of survival involves prevention of injuries and accidents that may lead to the emergency.
This are the summary of the things that i have learned during that course.
1. BLS Procedures
- Check for responsiveness
- Check airway (do not do blind sweep on mouth!)
- Check breathing
- Give 2 full breaths
- Check for circulation
- Give 5 compressions if no pulse
- Alternate 1 breathe and 5 compressions for one whole minute
(with at least 100 bpm)
- Call 911 for assistance
- Use defibrillator if indicated / as needed
2. Chain of Survival
- prevention of injuries or emergencies requiring resuscitation
(VERY IMPORTANT!)
- early CPR
- early defibrillation
- early advanced life support
3. Medications
- coming soon
4. PALS Megacode
- if you need to practice megacodes, i have found a great site for you to practice
http://www.mdchoice.com/cyberpt/pals/pals.asp
5. Important points to consider
- Respiratory cases are more prevalent in pediatrics on acute amercgency situation than cardiovascular cases.
- If you witness a pediatric patient fall down without warning, there's a big chance the case is cardiovascular. But if you dont witness the fall, assume it to be a respiratory case.
- Remember: AIRWAY MANAGEMENT is the very first thing to consider in pediatric emergencies. Open, maintain and support airway!
- Intraosseous site is much better than intravenous site since there is very little or no chance of infiltration.
- Rapid cardiopulmonary assessment is very very important on the first 30 seconds! Learn it by heart!
- Do not forget to treat the cause of emergency first! (Remember your 4H & 4T!)
Posted by nixinne ::
23:52 ::
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