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Acute Coronary Syndrome Algorithm

Support Notes

Signs and symptoms of acute coronary syndromes (ACS)

include chest discomfort possibly radiating to the upper

body/arms/neck/jaw, shortness of breath, sweating, indigestion, nausea, vomiting and dizziness. Atypical presenters – ACS in the

absence of chest discomfort - are more common with women, the elderly and diabetic patients.

2 -

Nitroglycerin:

nitroglycerin (NTG) produces arterial and venous vasodilation. NTG is often effective in the treatment of angina.

In contrast, evidence is inconclusive for the routine use of NTG during an acute myocardial infarction (AMI). NTG should be given

cautiously for AMI patients if an expected blood pressure drop would prevent the use of proven beneficial medications (i.e. ACE

inhibitors and beta-blockers). NTG is contraindicated with:

patients with systolic BP (SBP) < 90 mm Hg or more than 30 mm Hg below baseline

bradycardia < 50/minute or tachycardia > 100/minute in the absence of heart failure

patients with right ventricular infarction (RVI) - caution with inferior MI - approximately 50% of inferior MI are RVI

recent use of medications for erectile dysfunction - within 24 hours of Sildenafil (Viagra) - 48 hours of Tadalafil (Cialis)

NTG can relieve chest discomfort produced by gastrointestinal causes. The relief of chest discomfort by NTG does not rule out ACS.

ECG Interpretation:

the first 12 lead ECG may or may not present with immediate findings of a STEMI or NSTEMI. At least two

repeat 12 lead ECGs are advised every 15-20 minutes with persistent symptoms typical for cardiac ischemia. Threshold values of ST

deviation are provided in the table below for STEMI, UA/NSTEMI, and low to medium risk ACS.

12 Lead ECG Threshold Values (2 contiguous leads

–

standardized to 1 mV=10 mm)

GENDER & AGE

STEMI (elevated at J Point)

UA/NSTEMI

NON-DIAGNOSTIC ECG

Women

1.5 mm in leads V2/V3 &

1 mm in all other leads

ST depression >0.5 mm in leads

V2/V3 & 1 mm in all other leads

ST deviation <0.5 mm

Men 40 or older

2 mm in V2/V3 &

1 mm in all other leads

ST depression >0.5 mm in leads

V2/V3 & 1 mm in all other leads

ST deviation <0.5 mm

Men under 40

2.5 mm in leads V2/V3 &

1 mm in all other leads

ST depression >0.5 mm in leads

V2/V3 & 1 mm in all other leads

ST deviation <0.5 mm

American Heart Association Guidelines for CPR and ECC. Circulation: 2010;122: Supplement p S791.

Supplemental Therapies:

these include Enoxaparin or heparin, Clopidogrel 75-600 mg according to patient history and strategy

chosen (fibrinolytic or PCI), oral beta blockers (IV for select cases), ACE inhibitors or ARBs and statin therapy

Inappropriate Delay to PCI:

goal for percutaneous coronary intervention balloon inflation is ideally 90 minutes from first medical

contact (advanced life support paramedic or emergency department). Additional direction is now available for emergency physicians

that potentially shortens or lengthens this timeline based on onset of symptoms, age of patient and whether the MI is anterior or not.

Acceptable Delay Time for PCI (balloon inflated)

–

If greater time needed, Fibrinolysis May be Preferable

Onset of

Symptoms

Anterior STEMI

& <65 years

Anterior STEMI and

>65 years

Non-Anterior STEMI and

age<65 years

Non-Anterior STEMI and

age>65 years

Within 2 hours

40 minutes

107 minutes

58 minutes

168 minutes

Beyond 2 hours

43 minutes

148 minutes

103 minutes

179 minutes

Table built from data originally reported by Pinto, D. et al. Hospital Delays in Reperfusion for ST-elevation myocardial infarction: implications when selecting a

reperfusion strategy. Circulation. 2006; 114: 2019-2025. Subsequently cited in American Heart Association Guidelines for CPR and ECC. Circulation: 2010;122:

Supplement p S799.

The figures included are to be interpreted not as an exact science but as general indicators. For example, younger patients presenting

with anterior STEMI may well benefit from fibrinolysis if transfer to a PCI is needed – delay is inappropriate. The older patient

presenting to the hospital after 2-3 hours of symptoms may well benefit from a transfer to a centre capable of PCI.

Rescue PCI:

a 12/15 lead ECG is advised 75 minutes after fibrinolytics to evaluate fibrinolytic success. If the ST-elevation

deviation has not resolved by 50%, the patient should be transferred for rescue PCI as soon as possible; there is support (possible

benefit) for post-fibrinolytic

delayed

PCI (6 hours or more after fibrinolysis).

For educational purposes only

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ECC 2011 - Stroke

Activate Emergency Response

Immediate Neurological Assessment

by Stroke Team or Designee

· Patient History

· Establish time of symptom onset

· Perform Canadian Neurological Scale

· CT Scan completed

CT Scan shows

Hemorrhage?

Candidate for fibrinolytic therapy?

Give Aspirin

Assess and Stabilize - Begin MOVIE

· Monitor - airway, blood pressure, ECG if available

· Oxygen - maintain SpO

94-98%, provide breaths prn

· Vital signs - full set & glucose (treat low glucose stat)

· IV - ensure vascular access

· ECG – 12 lead ECG if available – do not delay therapy

Perform Neurological Screening Assessment

Activate Stroke Team or Emergent Transfer

Order Emergent CT Scan & Baseline Blood Work

Probable Acute Ischemic

Stroke: Consider Fibrinolytics

· Check for fibrinolytic exclusions

· Repeat neurological exam

(if deficits recovering rapidly, avoid

fibrinolytics)

Probable Acute Hemorrhagic Stroke:

Neuro Consult

(consider transfer if neurologist or

neurosurgeon unavailable)

· Begin Hemorrhagic Stroke Pathway

· Admit to stroke unit or ICU

No Hemorrhage

Hemorrhage

Not a candidate

Review risks/benefits with patient and Family. If acceptable:

Give rt-PA – No antiplatelets/anticoagulants for 24 hours

Begin Post rt-PA Stroke Pathway

Monitor BP, glucose, temperature, neuro status (treat if indicated)

Admit to Stroke Unit if available or ICU

Support notes included on reverse page.

BC Stroke Strategy Goal: 60 minutes to rt-PA

10 min

25 min

45 min

60 min

Begin Stroke

Pathway

Admit to Stroke

Unit or ICU

Candidate

Adult Suspected Stroke

For educational purposes only

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Adult Suspected Stroke Algorithm: Support Notes

ECC 2011 - Stroke

1 -

Adult Suspected Stroke:

SIGNS AND SYMPTOMS OF STROKE INCLUDE “SUDDEN WEAKNESS OR NUMBNESS OF THE FACE, ARM OR LEG, ESPECIALLY ON ONE

side of the body; sudden confusion; trouble speaking or understanding; sudden trouble walking, dizziness, loss of balance or coordination;

OR SEVERE SUDDEN HEADACHE WITH NO KNOWN CAUSE.”

2010 American Heart Association Guidelines for CPR and ECC. Circulation: 2010;122:

Supplement p S820.

2 -

Activate Emergency Response:

Time is brain. Alteplase (tPA) must be given within 4.5 hours of symptom onset to eligible patients with

ISCHEMIC STROKE. THE EARLIER THE STROKE IS TREATED, THE GREATER THE BENEFIT. “PRE-hospital stroke assessment and rapid transport to the most

APPROPRIATE HOSPITAL IS CRITICAL TO IMPROVING OUTCOMES”

BC Stroke Strategy Provincial Stroke Action Plan: November 2010

3 -

Check for fibrinolytics exclusions: Symptomatic intracranial hemorrhage occurs in about 5% of patients who receive tPA for stroke.

Before administering fibrinolytics, the ordering physician must verify that there are no exclusion criteria (additional criteria for 3-4.5 hours

from symptom onset) and be prepared to treat any potential complications.

4 -

Stroke Pathway:

When compared to admissions to general medical units, patients who are admitted to dedicated interdisciplinary

stroke units with established stroke care pathways are discharged from hospital 20% sooner and are 20% less likely to be discharged into

institutional care and are 20% less likely to die while in hospital.

Aspirin: Note that aspirin use for the patient having an acute stroke is recommended only for those who are not experiencing a

hemorrhagic stroke and who are not candidates for fibrinolytics.

Core Principles

· Survivability to discharge with good neurological function is optimized with time-sensitive stroke care

· Minimize delays to definitive stroke diagnosis and treatment. Major steps in stroke care are also the key delay

points (D’S OF STROKE CARE):

Pre-Hospital (less than 3.5 hours from symptom onset – defined as last time patient seen as normal)

ü Detection: rapid recognition of stroke symptoms

ü Dispatch: activate emergency response

ü Delivery: rapid stroke screening assessment, management, and transport to stroke centre

ü Door: triage to appropriate stroke center

Hospital (60 minutes)

ü Data: rapid triage, evaluation (CT scan), stroke management in the emergency department (ED -first 25

min)

ü Decision: stroke expertise and therapy selection (45 minutes from arrival in ED)

ü Drug: fibrinolytic therapy (rt-PA or Alteplase) or intra-arterial strategies (60 minutes from ED arrival and

max 4.5 hours from symptom onset)

ü Disposition: rapid admission to stroke unit or ICU (within 3 hours of arrival to ED)

· Monitor and treat co-morbidities; minimize risks associated with stroke and stroke treatments (i.e. head of bed

at 30

; fluctuations in BP, temperature, glucose; airway compromise; oxygenation and ventilation; neurological

deterioration; ; bleeding; NPO until dysphagia assessment);

· For transient ischemic attack (TIA)-a brief reduction of blood flow to the brain typically lasting less than

10minutes without permanent damage- or minor stroke; as many as 10% will progress to major stroke within

the next week in left untreated. With prompt treatment (ideally within 48 hours), long term risk of stroke is

reduced by 80%. Management includes brain imaging to rule out hemorrhage, antiplatelet agents,

anticoagulation for atrial fibrillation, blood pressure and glycemic control, and possible carotid endarterectomy.

Additional Online Resources

· Canadian Neurological Scale (www.neurosurvival.ca/ClinicalAssistant/scales/CNS.html)

· Canadian Best Practice Recommendations for Stroke Care (www.strokebestpractices.ca/)

· 2010 AHA Guidelines for CPR and ECC: Adult Stroke (circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S818)

For educational purposes only

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ECC 2011 – Rapid Reference

Rapid Reference: Electrical Therapies

Defibrillation and Synchronized Cardioversion

Defibrillation is the delivery of a large electrical current through the heart over a few milliseconds with the goal of depolarizing a

critical mass of myocardial cells into a brief moment of asystole. This asystolic pause hopefully allows pacemaker cells (i.e. SA node) to

regain control of the heart in a normal organized pattern. Synchronized cardioversion is similar to defibrillation except that the

electrical energy is synchronized to deliver during ventricular depolarization (QRS complex) to avoid shocking during the relative

refractory period of the cardiac cycle (T wave). Shocks placed during the refractory period can produce VF.

Waveforms:

Monophasic waveforms deliver the energy of the shock in one direction (one polarity). Very few manufactures

worldwide make this type of defibrillator anymore but many are still in use. Biphasic waveforms deliver a current that reverses

direction during the few milliseconds of the shock as the polarity of the pads/paddles changes. Biphasic waveforms have been

shown to be superior to monophasic waveforms in implanted defibrillators and less myocardial current density is required with

biphasic waveforms.

Defibrillation Energy Selection:

· Adult Monophasic: 360 Joules all defibrillations

· Adult biphasic: Follow manufacturers recommendations (between 120-200 Joules); subsequent shocks can be at the same

energy level or escalating energies can be considered. If the recommended starting energy is unknown then using the

maximum energy setting can considered.

· Pediatric: (monophasic or biphasic) First defibrillation 2-4 Joules/kg, subsequent shocks should be at least 4 Joules/kg. Higher

energies can be considered but do not exceed 10 Joules/kg or the recommended maximum adult energy for the brand of

defibrillator.

Synchronized Cardioversion Energy Selection: Same for all energy waveform types unless otherwise indicated

· Adult Atrial Fibrillation: start at 120-200 Joules escalating with subsequent attempts. Monophasic use 200J initially.

· Adult Atrial Flutter: start at 50-100 Joules escalating with subsequent attempts.

· Adult SVT: start at 50-100 Joules escalating with subsequent attempts.

· VT with pulse: start at 100 Joules escalating with subsequent attempts.

· Pediatric Cardioversion: start at 0.5-1 Joules/kg escalating with subsequent attempts to 2 Joules/kg

Steps to Defibrillation and Synchronized Cardioversion

1. Turn on monitor/defibrillator

2. Set lead switch to pads/paddles or lead I, II, or III if leads have been connected

3. Choose energy (most brands of defibrillators come on set to charge at the first defibrillation energy for an adult) for

defibrillation or synchronized cardioversion.

4. Place defib pads/paddles on patient

· For patients in cardiac arrest most often a anterior-anterior approach is used as it is quickest for pad application. Follow

pictures on pads. Generally one pad is placed on the right upper anterior chest. Try to keep pad off larger bones such as

THE CLAVICLE AND THE STERNUM AND OFF THE PATIENT’S AREOLA. Place the second pad in the left axillary position.

· If the pads are being used in an anterior-posterior position the anterior pad is placed in an apical position and the posterior

pad placed beside the spine and below the scapula on the left side. This placement is most common for transcutaneous

pacing and is also often used in elective synchronized cardioversion.

· If paddles are used apply an appropriate conductive medium (gel pads, conductive paste). Apply hard pressure (15-25 lbs.)

and ensure that you are not in any electrical contact with the patient.

· For pediatric patients if pads are too large consider anterior-posterior placement.

· Attempt to keep paddles/pads 1-3 INCHES AWAY FROM IMPLANTED DEVICES SUCH AS AICD’S AND PACEMAKERS .

5. If performing synchronized cardioversion, ensure standard leads are connected; set synch button to on and ensure that the rhythm

is being appropriately flagged on the R wave. Give sedation as appropriate for the situation

6. Announce that you are charging. Press the charge button on the machine or if using manual paddles the button on the apex paddle.

7. Warn three times that you are about to shock and visually check that no one is in electrical contact with the patient (direct contact,

through liquids, or through metal)

8. Press shock button on machine or two buttons on paddles simultaneously. Note: for Synchronized cardioversion press shock

button(s) down until shock occurs. The defibrillator is calculating when to shock and this can be very quick or may take several

seconds. Also be sure to re-synch for any subsequent cardioversion attempts as most machines have the synch button turn off after

each attempt.

(continued on reverse page)

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Rapid Reference: Electrical Therapies

(Continued from previous page)

8. For cardiac arrest situations continue CPR if possible as machine is charged and resume with compressions immediately after

the shock to minimize CPR time off chest.

Transcutaneous Pacing (TCP)

Transcutaneous pacing (TCP) is a highly effective emergency method of pacing for severe symptomatic bradycardias. Other

methods for increasing heart rate like the use of atropine, dopamine, or epinephrine may also be attempted depending on

situational factors and what rhythm the patient is in. This non-targeted method of pacing is unique in that it will also pace skeletal

muscle, gut muscle and the diaphragm at the currents needed to capture the myocardium electrically. This can mean significant

discomfort for the patient and the need for procedural sedation. The current levels needed to achieve capture are very high in

comparison to other methods of pacing. The abnormal route of conduction from the pads leads to QRS complexes that are very

wide and bizarre resembling large PVCs. These observations are all normal and are expected.

Steps to Transcutaneous Pacing

1. Position pads on patient for pacing as indicated by the manufacturer. This is usually an anterior-posterior position. Look for a

indicator on the pads to show if one pad is specific to the apical position.

2. Ensure standard leads are also connected to the patient

3. Turn pacer on

4. Most TCP will come on default in demand (synchronous) mode, verify not set in non-demand (asynchronous) mode. This

mode is rarely used unless there is a situation where artifact is mistakenly being sensed as intrinsic ECG complexes.

5. Set pacer demand rate to 60-80 per minute

6. Set current by titrating the mA dial upwards until you have consistent electrical capture as indicated by seeing pacer spikes

followed by a new QRS morphology which is very wide with a broad T wave. Buffer the capture current (threshold) by increasing

the mA by approximately 10%.

7. Check for mechanical capture (paced rhythm produces cardiac output) by assessing distal pulses (at sites where skeletal muscles

are not contracting surrounding the vessel), level of consciousness, vital signs and other signs/symptoms of improved infusion.

8. Proceed to give analgesia and sedation as needed to keep patient comfortable.

9. Arrange transvenous or permanent pacemaker placement as needed

ECC 2011 – Rapid Reference

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Rapid Reference: Adult ACLS Medications

Drug

Dosage

(all doses are IV/IO unless otherwise noted)

ECC 2011 – Rapid Reference

For educational purposes only

Adenosine

6mg rapid push over 1-3 sec followed by a 20 ml syringe flush. If not successful a 12 mg

dose can be given also with flush. Use most proximal IV/IO access and most proximal port

___________________________________________________________________________________________________________

Amiodarone

VF/Pulseless VT: 300 mg push, a second dose of 150 mg can be given

Life-Threatening Arrhythmias: Max cumulative dose: 2.2 g over 24 hrs. May be administered as a:

Rapid infusion: 150 mg over 10 min, may repeat every 10 min as needed (15 mg/min)

Slow infusion: 360 mg over 6 hrs (1 mg/min)

Maintenance infusion: 540 mg over 18 hrs (0.5 mg/min)

___________________________________________________________________________________________________________

Atropine

0.5 mg q3-5 min. Max dose: 0.04 mg/kg (total 3 mg). Consider higher doses and shorter

dosing interval with severe compromise

___________________________________________________________________________________________________________

Calcium Chloride

500-1000mg (5-10 ml of the 10% solution) for hyperkalemia or calcium channel

blocker overdose. May be repeated as needed

___________________________________________________________________________________________________________

Digoxin

Loading dose 4-6 ug/kg, followed by 2-3 ug/kg doses at 4 hr intervals. Maximum dosing total

1 mg

___________________________________________________________________________________________________________

Diltiazem

15-20 mg (0.25 mg/kg) over 2 min. May repeat in 15 min at 20-25 mg (0.35 mg/kg) over 2 min.

Maintenance infusion for rate control 5-15 mg/hr

___________________________________________________________________________________________________________

Dobutamine

2-20 ug/kg/min. Titrate so heart rate does not increase > 10% baseline

___________________________________________________________________________________________________________

Dopamine

2-10 ug/kg/min for symptomatic bradycardia (up to 20 ug/kg/min for hypotension)

___________________________________________________________________________________________________________

Epinephrine

Cardiac arrest: 1mg q3-5min

Severe bradycardia: 2-10 ug/min

Anaphylaxis: 0.5 mg IM (ideal to lateral thigh)

___________________________________________________________________________________________________________

Ibutilide

1-2 mg IV over 10-20 minutes

___________________________________________________________________________________________________________

Isoproterenol

2-10 ug/min titrated to adequate heart rate

___________________________________________________________________________________________________________

Magnesium Sulfate

Cardiac Arrest:1-2 g as a bolus

With pulse: 1-2 g mixed in 50-100 ml D5W over 5-60 min, then infusion of 0.5-1.0 g/hr as needed

___________________________________________________________________________________________________________

Metroprolol

5 mg IV q5min to a total of 15 mg

___________________________________________________________________________________________________________

Norepinephrine

Start at 0.1-0.5 ug/kg/min then titrate to response

___________________________________________________________________________________________________________

Procainamide

20 mg/min infusion to max total dose of 17 mg/kg

___________________________________________________________________________________________________________

Propafenone

300-600 mg po

___________________________________________________________________________________________________________

Sodium Bicarbonate

1-2 mEq/kg bolus (44 mEq per preloaded syringe)

___________________________________________________________________________________________________________

Sotalol

1-1.5 mg/kg over 5 min

___________________________________________________________________________________________________________

Vasopressin

Cardiac arrest: 40 units push

Vasodilatory shock: 0.02-0.04 units/min

___________________________________________________________________________________________________________

Verapamil

2.5-5 mg over 2-3 min, repeat dose 5-10 mg every 15-30 min as needed. Max total dose 30 mg

Induced Therapeutic Hypothermia Overview

Brain injury and hemodynamic instability are the main causes of death for survivors of a cardiac arrest. Induced

therapeutic hypothermia (ITH) - active cooling to 32-34

Celsius for 24 hours - is shown to improve neurological

recovery for those who experience a prolonged cardiac arrest.

ITH is recommended for: survivors of out-of-hospital VF arrests who are unable to follow verbal commands.

ITH should be considered for:

· survivors of out-of-hospital cardiac arrest from PEA or Asystole who are unable to follow verbal commands

· survivors of in-hospital cardiac arrest of any initial rhythm who are unable to follow verbal commands 10

minutes after the arrest

Active rewarming is discouraged for unresponsive cardiac arrest survivors who spontaneously become mildly

hypothermic (core temperature >32

Celsius) for the first 48 hours post-arrest.

At the time of writing no universally accepted induced therapeutic hypothermia algorithm has been published by

AHA, ERC, or ILCOR. Many regions in Canada have adopted and/or modified the 2005 ITH guidelines of the

Canadian Association of Emergency Physicians (CAEP).

Three Phases: Induction, Maintenance and Rewarming

Induction: a combination of external and internal cooling methods are implemented early post-arrest; interventions

include rapid infusion (30 ml/kg) of 4

C 0.9% saline, ice packs, cooling blankets, intravascular heat exchangers, ice

water gastric/bladder lavage and evaporative cooling techniques

Maintenance: a cooling method is used along with continuous temperature feedback monitoring to keep the core

body temperature between 32-34

Rewarming: typically after 24 hours of cooling, rewarming should begin and progress slowly (i.e. 0.25-0.5

C/hour);

manage fluctuations in electrolyte concentrations, intravascular volume and metabolic rate that occur with changes in

body temperature; prevent hyperthermia by maintaining core temperatures at 36-37.5

Considerations

· ITH is an important component of a multisystem approach to post-cardiac arrest care; advanced airway

management, hemodynamic stabilization, treatment of acute coronary syndromes and metabolic monitoring

(serial lactate, electrolyte, glucose testing) are performed simultaneously

· Cooling suppresses several physiologic pathways that cause delayed (post-arrest) cell death; cooling also

reduces cerebral metabolic rate by 6-10% for every 1

C reduction in cerebral temperature

· Shivering is an expected physiologic response to mild hypothermia; shivering increases heat production, thus

slowing or preventing cooling; shivering should be treated; ; the threshold temperature for shivering can be

decreased with IV sedation; IV boluses of neuromuscular blocking agents (NMBA) may be warranted; note

that NMBA can eliminate skeletal muscle movement - the primary indicator of seizures activity (a seizure can

triple cerebral metabolic rate); a

continuous

NBMA infusion requires ongoing EEG monitoring

· Physiologic effects and associated complications of hypothermia include:

o increased systemic vascular resistance; continuous ECG monitoring for dysrhythmias;

o diuresis; manage hemodynamic status and electrolyte levels

o reduced insulin sensitivity and production; monitor for hyperglycemia

o possible impaired coagulation; monitor for increased bleeding

o impaired immune response; monitor for an increased incidence of infection

o impaired medication elimination (one study showed a 30% reduction in medication clearance); re-evaluate

medication dosing as temperature is reduced

· Target ITH temperatures are often maintained with simple interventions such as ongoing sedation, keeping

the patient uncovered and the occasional use of evaporative cooling (a fan directed over wetted skin)

· Prognosis of post-cardiac arrest patients treated with ITH can not be reliably predicted for at least 72 hours

ECC 2011 – Rapid Reference

For educational purposes only

ECC 2011

Abbreviations Glossary

ACLS and Emergency Cardiovascular Care 2011

abx antibiotic

ACE angiotensin converting enzyme

ACLS advanced cardiac life support

ACS acute coronary syndrome

AED automated external defibrillator

AF atrial fibrillation

AFl atrial flutter

AHA American Heart Association

ALS advanced life support

AMI acute myocardial infarction

APLS advanced pediatric life support

ASAP as soon as possible

BB beta blocker

BP blood pressure

C degrees Celsius

CAB chest compressions – airway - breathing

CABG coronary artery bypass graft

CCB calcium channel blocker

CCR cardiocerebral resuscitation

CPAP continuous positive airway pressure

CPR cardiopulmonary resuscitation

CVP central venous pressure

DBP diastolic blood pressure

DIC disseminated intravascular coagulation

ECC emergency cardiovascular care

ED emergency department

Epi Epinephrine

ERC European Resuscitation Council

ETT endotracheal intubation

FAST Focused Assessment with Sonography for Trauma

FBAO foreign body airway obstruction

HR heart rate

HSFC Heart and Stroke Foundation of Canada

Hx history

IABP intra-aortic balloon pump

ILCOR International Liaison Committee on Resuscitation

IM intramuscular injection

IO intraosseous

ITH induced therapeutic hypothermia

IV intravenous

J Joules

LLUD left lateral uterine displacement

LMA laryngeal mask airway

MAP mean arterial pressure = (2 DBP + SBP)/3

LLUD left lateral uterine displacement

MgSO

magnesium sulphate

MI myocardial infarction

mm Hg millimetres of mercury

MOVIE Monitor – Oxygen if required – Vital Signs including

glucose – IV – 12 lead ECG

MVO

mixed venous oxygen saturation

NPO nothing by mouth

NS normal 0.9% saline

NSTEMI non-ST elevation myocardial infarction

NTG nitroglycerin

PALS pediatric advanced life support

PCI percutaneous coronary intervention

PE pulmonary embolus

PEA pulseless electrical activity

end-tidal carbon dioxide

PPV positive pressure ventilations

Pt patient

ROSC return of spontaneous circulation

rt-PA recombinant tissue plasminogen activator

s+s signs and symptoms

SBP systolic blood pressure

SIRS systemic inflammatory response syndrome

SOB shortness of breath

SpO

oxygen saturation as measured by a pulse-oximeter

STEMI ST-elevation myocardial infarction

SVT supraventricular tachycardia

TEE transesophageal echocardiography

TCP transcutaneous pacing

TIA transient ischemic attack

TIMI Thrombolysis in Myocardial Infarction risk score

UA unstable angina

VF ventricular tachycardia

VS vital signs (TPR, BP, SpO

, glucose)

VT ventricular tachycardia

WBC white blood cell

WPW Wolff Parkinson White pre-excitation syndrome

References

1. American Heart Association. Out-of-Hospital (Sudden) Cardiac Arrest Statistics. (2009). Retrieved from http://

www.americanheart.org/downloadable/heart/1236978541670OUT_OF_HOSP.pdf

2. Barill, T. & Dare, M. (2006). Managing Cardiac Emergencies. North Vancouver, BC: SkillStat Press.

3. BC Stroke Strategy. A proposed algorithm for identifying patients with acute cerebrovascular syndrome.

(December, 2010). Retrieved from http://www.bcstrokestrategy.ca/documents/BCACVSAlgorithmFinal.pdf .

4. BC Stroke Strategy. Evaluation of TIA Rapid Assessment Clinics. (December, 2010). Retrieved from http://

www.bcstrokestrategy.ca/documents/EvaluationofTIAClinicsFinal.pdf .

5. Cairns, J.A., Connolly, S., McMurtry, S. et al. (2011). Canadian Cardiovascular Society Atrial Fibrillation

Guidelines 2010: Prevention of stroke and systemic thromboembolism in atrial fibrillation and flutter.

Canadian

Journal of Cardiology

, 27, 74-90.

6. Desbiens, Norman A. (2008). Simplifying the Diagnosis and Management of Pulseless Electrical Activity in

Adults: A Qualitative Review.

Critical Care Medicine

. 36(2), 391-396.

7. Ewy, Gordon A. (2005). Cardiocerebral Resuscitation: The new Cardiopulmonary Resuscitation. Circulation, 111,

2134-2142.

8. Gausche-Hill, M., Fuchs, S. & Yamamoto, L. (Eds.). (2004).

APLS: The Pediatric Emergency Medicine Resource

Toronto: Jones and Bartlett Publishers.

9. Hazinski, Mary F. & Field, John M. (Eds.). (2010). 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

Circulation

, 122 (Suppl. 3).

10. Heart and Stroke Foundation of BC and Yukon.

BC Stroke Strategy: Provincial Stroke Action Plan

. (November

2010). Retrieved from http://www.bcstrokestrategy.ca/documents/ProvincialStrokeActionPlanAppendixA.pdf

11. Hommers, Clare. (2010). Oxygen therapy post-cardiac arrest? THE’ GOLDILOCKS’ PRINCIPLE?.

Resuscitation

, 81,

1605-1606.

12. Kory, P., Weiner, J., Mathew, J. et al. (2011). European Resuscitation Council Guidelines for Resuscitation 2010.

Resuscitation

, 82(1), 15-20.

13. Kushner, F., Hand, M., King, S.B. et al. (2009). 2009 ACC/AHA guidelines for the management of patients with

ST-elevation myocardial infarction and ACC/AHA/SCAI guidelines on percutaneous coronary intervention.

Journal

of the American College of Cardiologists

, 54, 2205-2241.

14. Levy M.M., Fink M.P., Marshall J.C. et al. (2003). 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis

Definitions Conference.

Critical Care Medicine

. 31(4),1250-6.

15. Lindsay, P., Bayley, M., Hellings, C. et al. (2008). Canadian best practice recommendations for stroke care

(updated 2008).

Canadian Medical Association Journal

, 179(Suppl. 12), S1-S25.

16. Meaney, P., Nadkarni, V., Kern, K. et al. (2010). Rhythms and outcomes of adult in-hospital cardiac arrest.

Journal of Critical Care Medicine

, 38(1), 101-108.

17. Nolan, J.P., Hazinski, M.F., Billi, J.E. et al. (2010). 2010 International Consensus on Cardiopulmonary

Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations .

Resuscitation

81(Supplement e).

18. Nolan, J.P., Soar, J., Deakin, C.D. et al. (2010). European Resuscitation Council Guidelines for Resuscitation

2010.

Resuscitation

, 81(10).

ECC 2011

19. Nolan, J.P., Neumar, R.W., Adrie, C. et al. (2008). Post-cardiac arrest syndrome: Epidemiology,

pathophysiology, treatment, prognostication. A Scientific Statement from the International Liaison Committee on

Resuscitation; the American Heart Association Emergency Cardiovascular Care Committee; the Council on

Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmonary, Perioperative, and Critical Care; the

Council on Clinical Cardiology; the Council on Stroke et al.

Resuscitation

, 79(9), 350-379.

20. Parkash, R., Verma, A. & Tang, A.S.L. (2010). Persistent atrial fibrillation: current approach and controversies.

Current Opinion in Cardiology

, 25m 1-7.

21. Pinto, D.S., Kirtane, A.J., Nallamothu, B.K. et al. (2006). Hospital Delays in Reperfusion for ST-Elevation

Myocardial Infarction: Implications when selecting a reperfusion strategy.

Circulation

, 114, 2019-2025.

22. Ralston, M. & Hazinski, M.F. & Schexnayder, S. et al. (2007).

Pediatric Emergency Assessment, Recognition, and

Stabilization

. Dallas, TX: American Heart Association.

23. Ralston, M. & Hazinski, M.F. & Zaritsky, A. et al. (2006).

Pediatric Advanced Life Support

. Dallas, TX:

American Heart Association.

24. Rothwell, P., Giles, M., Chandratheva, A. et al. Effect of urgent treatment of transient ischaemic attack and minor

stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison.

Lancet

370, 1432-42.

25. Sandroni, C., Nolan, J., Cavallaro, F. & Antonelli, M. (2007). In-hospital cardiac arrest: incidence, prognosis and

possible measures to improve survival.

Intensive Care Medicine

, 33, 237-245.

26. Smith, Stephen W. & Whitwam, W. (2006). Acute Coronary Syndromes.

Emergency Medical Clinics of North

America

, 24, 53-89.

27. Stiell, Ian G., Macle, Laurent et al. (2011). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010:

Management of Recent-Onset Atrial Fibrillation and Flutter in the Emergency Department.

Canadian Journal of

Cardiology

, 27, 38-46.

28. Van de Werf, F.J. (2006). Fine-tuning the selection of a reperfusion strategy.

Circulation

, 114, 2002-2003.

29. Wann, S., Curtis, A., January, C. et al. (2011). 2011 ACCF/AHA/HRS Focused update on the management of

patients with atrial fibrillation (Updating the 2006 Guideline): A Report of the American College of Cardiology

Foundation/American Heart Association Task Force on Practice Guidelines.

Circulation

, 123, 104-123.

30. Wijesinghe, M., Perrin, K., Ranchord, A. et al. (2008). Routine use of oxygen in the treatment of myocardial

infarction: systematic review.

Heart

, 95, 198-202.

31. Wright, R.S., Anderson, J.L., Adams, C.D. et al. (2011). 2011 ACCF/AHA Focused Update incorporated into the

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial

infarction.

Journal of the American College of Cardiologists

, 57 (Suppl. E), e215-e367.

References

ECC 2011

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