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consider reversible causes for the emergent condition. Pulseless electrical activity (PEA),
asystole, ventricular fibrillation (VFib or VF), and ventricular tachycardia (VTach or VT) may
have a reversible cause in your patient (though most often PEA). The reversible causes of PEA
can be remembered with a mnemonic of sorts, the Hs and Ts.
The Hs and Ts are 12 reversible conditions, 7 that start with H and 5 that start with T.
Hypovolemia
Hypoxia
Hydrogen ion excess (acidosis)
Hypoglycemia
Hypokalemia
Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade Cardiac
Toxins
Thrombosis (pulmonary embolus)
Thrombosis (myocardial infarction)
While it is important to continue to deliver compressions, ventilation, and medications according
to the algorithm, it is always best to treat underlying causes of PEA and related conditions as
soon as possible.
*Hypoglycemia is not officially one of the Hs and Ts for adults, but it still can be an important
cause of PEA, especially in children. If another reversible cause has not been discovered or if the
patient is known to be susceptible to hypoglycemia (e.g., brittle diabetes, past surreptitious use of
insulin) then this potential cause of PEA should be considered.
Potential Cause
Hypovolemia
How to Identify
Rapid heart rate and narrow QRS on ECG; other
Treatments
Infusion of normal saline or
Hypoxia
Ringers lactate
Airway management and
effective oxygenation
Hyperventilation; consider
Hypoglycemia*
Hypokalemia
IV Magnesium infusion
Hyperkalemia
Hypothermia
Tension pneumothorax
Thoracostomy or needle
Tamponade Cardiac
decompression
Pericardiocentesis
Toxins
ECG
Typically will be seen as a prolonged QT interval on
Thrombosis
Surgical embolectomy or
Thrombosis
ECG
ECG will be abnormal based on the location of the
administration of fibrinolytics
Dependent on extent and age o
(myocardial infarction)
infarction
MI
(pulmonary embolus)
CRASH CART
The crash cart is the commonly used term to describe a self-contained, mobile unit that contains
virtually all of the materials, drugs, and devices necessary to perform a code. The configuration
of crash carts may vary, but most will be a waist high or chest high wheeled cart with many
drawers. Many hospitals will also keep a defibrillator and heart monitor on top of the crash cart
since these devices are also needed in most codes. Since the contents and organization of crash
carts may vary, it is a good idea for you to make yourself aware of the crash cart that you are
most likely going to encounter during a code.
What is in a crash cart?
The size, shape, and contents of crash cart may be different between hospitals and between
different departments within the same hospital. For example, an adult crash cart is set up
differently than a pediatric crash cart or crash cart on the medical service may be different than
the one on a surgical service.
Medications
Medications are usually kept in the top drawer of most crash carts. These need to be accessed
and delivered as quickly as possible in emergent situations. Therefore, they need to be available
to providers very easily. The medications are usually provided in a way that makes them easy to
measure and dispense quickly.
Alcohol swabs
Sterile water
Povidone-Iodine swabstick
If the crash cart also contains pediatric medications these may be contained in the second drawer.
Often these would include:
The second drawer the crash cart might also contain saline solution of various sizes like 100 mL
or 1 L bags. A crash cart in the surgery department may include Ringers lactate solution.
Intubation
Many crash carts will also include most of the materials necessary to perform in intubation.
These may be contained in the third or fourth drawers depending on the setup of the particular
crash cart.
The adult intubation drawer will contain:
Stylets
Bite block
Tongue depressors
Newer setups may also include the materials needed to start quantitative waveform
capnography like a nasal filter line
Pediatric intubation materials may be in a separate cart or if they are included in the adult crash
cart they may occupy their own drawer. The pediatric intubation supply drawer may contain the
following:
Laryngoscope blades
Spinal needles
Feeding tubes
Pediatric IV kits
Intravenous lines
It is usually the case that the equipment necessarily to start an IV is in a separate drawer from
materials needed to maintain an IV, such as the fluids in the tubing. The IV drawer(s) usually
contain the following:
IV Start Kit
Angiocatheters 14 Ga and/or 16 Ga
Tourniquet tubing
Vacutainers
Blue top
Purple top
Green top
Red top
3-Way stopcock
Tape
Armboards
Catheter tips
Tubing
Procedure drawer
The bottom drawer on crash carts is usually devoted to keeping prepackaged kits available for
various urgent and emergent procedures (or it is where the IV solutions are kept). In any case, the
following kits may be found in the procedure drawer:
ECG electrodes
Suction supplies
Salem pump
Cricothyroidotomy kit
Yankauer suction
Age Range
Infant
0-12 months
Toddler
1-3 years
Preschooler
4-5 years
School Age
6-12 years
Adolescent
13-18 years
Age Category
Newborn
Age Range
0-3 months
Infant/Young child
4 months to 2 years
Child/School Age
2-10 years
Over 10 years
Age Category
Age Range
Neonate
Neonate
Infant
Infant
Infant
1 Day
4 Days
To 1 month
1-3 months
4-6 months
7-12
months
Infant
Systolic
Blood
Pressure
60-76
67-84
73-94
78-103
82-105
Diastolic
Blood
Pressure
30-45
35-53
36-56
44-65
46-68
67-104
20-60
Preschool
2-6 years
70-106
25-65
School Age
7-14 years
79-115
38-78
Adolescent
15-18 years
93-131
45-85
Normal Blood Pressure
Abnormally Low
Systolic Pressure
<60
<60
<70
<70
<70
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<70 + (age in years
x 2)
<90
D -> Disability
One of the assessments of level of consciousness in a child is the Glasgow Coma Scale.
RESPONSE
Eye Opening
Verbal Response
SCORE
VERBAL CHILD
Spontaneously
3
2
1
5
4
To verbal command
To pain
None
Oriented and talking
Confused but talking
PREVERBAL CHILD
Spontaneously
To speech
To pain
None
Cooing and babbling
Crying and irritable
3
2
1
6
Motor Response
Inappropriate words
Sounds only
None
Obeys commands
5
4
3
Abnormal extension
None
BASIC ECG
The information contained within a single, 12-lead electrocardiogram can be extensive. Learning
how to interpret the subtle differences in characteristic changes that can arise is a specialized
skill that can take years to learn. Fortunately, basic ECG interpretation can be rather
straightforward, as long as you know the basics.
An electrocardiogram is a tracing of the electrical activity that is taking place within the heart.
Under normal circumstances, an electrical impulse will travel from the sinoatrial node, spread
across the atrium, to the atrioventricular node and through the ventricular septum of the heart.
This electrical impulse causes the four chambers of the heart to contract and relax in a
coordinated fashion. Studying these electrical impulses allows us to understand how the heart is
functioning.
P Wave
The P wave represents the depolarization of the left and right atrium and also corresponds to
atrial contraction. Strictly speaking, the atria contract a split second after the P wave begins.
Because it is so small, atrial repolarization is usually not visible on ECG. In most cases, the P
wave will be smooth and rounded, no more than 2.5 mm tall, and no more than 0.11 seconds in
duration. It will be positive in leads I, II, aVF and V1 through V6.
QRS Complex
As the name suggests, the QRS complex includes the Q wave, R wave, and S wave. These three
waves occur in rapid succession. The QRS complex represents the electrical impulse as it spreads
through the ventricles and indicates ventricular depolarization. As with the P wave, the QRS
complex starts just before ventricular contraction.
It is important to recognize that not every QRS complex will contain Q, R, and S waves. The
convention is that the Q wave is always negative and that the R wave is the first positive wave of
the complex. If the QRS complex only includes an upward (positive) deflection, then it is an R
wave. The S wave is the first negative deflection after an R wave.
Under normal circumstances, the duration of the QRS complex in an adult patient will be
between 0.06 and 0.10 seconds. The QRS complex is usually positive in leads I, aVL, V5, V6
and II, III, and aVF. The QRS complex is usually negative in leads aVR, V1, and V2.
The J-point is the point where the QRS complex and the ST segment meet. It can also be thought
of as the start of the ST segment. The J-point (also known as Junction) is important because it
can be used to diagnose an ST segment elevation myocardial infarction. When the J-point is
elevated at least 2 mm above baseline, it is consistent with a STEMI.
T Wave
A T wave follows the QRS complex and indicates ventricular repolarization. Unlike a P wave, a
normal T wave is slightly asymmetric; the peak of the wave is a little closer to its end than to its
beginning. T waves are normally positive in leads I, II, and V2 through V6 and negative in aVR.
A T wave will normally follow the same direction as the QRS complex that preceded it (positive
or negative/up or down). When a T wave occurs in the opposite direction of the QRS complex, it
generally reflects some sort of cardiac pathology.
If a small wave occurs between the T wave and the P wave, it could be a U wave. The biological
basis for a U wave is unknown.
Heart Rate
There are many ways to determine a patients heart rate using ECG. One of the quickest ways is
called the sequence method. To use the sequence method, find an R wave that lines up with one
of the dark vertical lines on the ECG paper. If the next R wave appears on the next dark vertical
line, it corresponds to heart rate of 300 beats a minute. The dark vertical lines correspond to 300,
150, 75, 60, and 50 bpm. For example, if there are three large boxes between R waves, the
patients heart rate is 75 bpm. There are more accurate ways to determine heart rate from ECG,
but in life-saving scenarios, this method provides a quick estimate.
Atrial fibrillation
Atrial fibrillation is the most common cardiac arrhythmia. The pulse of the patient was
experiencing atrial fibrillation is said to be irregularly irregular meaning that the pulse does not
repeat in any discernible way. On an electrocardiogram, atrial fibrillation is seen as an absence of
distinct P waves. By contrast, atrial flutter appears on ECG as a sawtooth pattern. While it is
difficult to quantify, the atrial contraction rate may exceed 300 bpm.
Atrial fibrillation can reduce cardiac output, since the atria are not contributing to the ventricular
filling. Instead, the blood tends to stagnate or even coagulate inside of the atrium. This
coagulation can be a problem because it can lead to thrombus formation, particularly in the atrial
appendage. Once a thrombus forms, it can break apart and send emboli throughout the
vasculature, perhaps to the lungs or the brain depending on which side of the heart is affected.
Symptoms
Atrial fibrillation can cause a number of symptoms or it may cause few symptoms at all. Patients
will often report feeling chest palpitations, feeling as if their heart is racing, fatigue, dizziness or
lightheadedness, weakness, and perhaps shortness of breath. In severe cases, atrial fibrillation
may cause shortness of breath (dyspnea), chest pain (angina), low blood pressure (hypertension),
or pre-syncope (dizziness, about to pass out). In rare instances, atrial fibrillation may prompt
myocardial infarction (heart attack), syncope (passing out), or pulmonary edema (fluid in the
lungs). Rarely, atrial fibrillation will be detected in a routine electrocardiogram or ECG
performed for some other purpose.
Management of new onset atrial fibrillation
Is cardioversion needed?
If you encounter patient with atrial fibrillation for the first time, the most important question you
can ask is does this patient need immediate cardioversion? Cardioversion is the use of an
electrical impulse applied to the chest to shock the atria back into a normal rhythm. Generally
speaking, there are four indications for urgent cardioversion:
1. Ischemia (lack of blood flow through the coronary arteries; myocardial infarction)
2. Organ hypoperfusion (lack of blood flow to the organs; decreased urine output due to
reduced blood flow to the kidney, for example)
3. Congestive heart failure
4. A preexcitation syndrome by electrocardiogram (rhythm that could switch to ventricular
fibrillation or ventricular tachycardia without warning)
If any of these situations exist, then you should seek to use cardioversion immediately. In fact,
this is more important than waiting to use anticoagulants before cardioversion. If possible, the
patient should receive a bolus of heparin prior to emergent cardioversion, though this should not
delay cardioversion. When cardioversion is not possible, one may consider using procainamide
intravenously.
When none of the four indications exist, then it is most often better to wait for appropriate
anticoagulation before attempting cardioversion. This is especially true if the abnormal cardiac
rhythm has been occurring for 48 hours or more, because the chance of thrombus increases
significantly.
How do I control the rate?
If there is no evidence of heart failure (e.g., no pulmonary edema by chest x-ray; no crackles
on lung exam) then the drugs of choice are beta-blockers or calcium channel blockers. If patients
are experiencing heart failure, or if the atrial fibrillation is due to heart failure, then patients may
be given digoxin.
How do I anticoagulate?
In a hospital or emergency department setting, the most common initial anticoagulant used is
either low molecular weight or unfractionated heparin. This is given first as a bolus followed by
a continuous intravenous drip. This can be transitioned to oral warfarin for outpatient
management. Alternatively, patients can be transitioned to a non-warfarin oral anticoagulant such
as dabigatran or apixaban. In most cases (non-emergent situations), patients should be
sufficiently anticoagulated before cardioversion. It may take several weeks for the blood to be
sufficiently anticoagulated.
If a transesophageal echocardiogram shows that there is no thrombus in the heart, patients may
be preceded to cardioversion. If the onset of atrial fibrillation can be determined definitively and
the start was less than 48 hours before presentation, patients may not need anti-coagulation
before cardioversion.
Note: the above describes the management of initial onset atrial fibrillation. The management of
chronic atrial fibrillation differs substantially.