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As you are moving through your algorithms during ACLS and PALS, it is important to also

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

symptoms of low volume


Slow heart rate

Ringers lactate
Airway management and

Low amplitude QRS on the ECG

effective oxygenation
Hyperventilation; consider

Hypoglycemia*

Bedside glucose testing

sodium bicarbonate bolus


IV bolus of dextrose

Hypokalemia

Flat T waves and appearance of a U wave on the ECG

IV Magnesium infusion

Hydrogen ion excess


(acidosis)

Hyperkalemia

Peaked T waves and wide QRS complex on the ECG

Consider calcium chloride,


sodium bicarbonate, and an

Hypothermia

insulin and glucose protocol


Typically preceded by exposure to a cold environment Gradual rewarming

Tension pneumothorax

Slow heart rate and narrow QRS complexes on the

Thoracostomy or needle

Tamponade Cardiac

ECG; difficulty breathing


Rapid heart rate and narrow QRS complexes on the

decompression
Pericardiocentesis

Toxins

ECG
Typically will be seen as a prolonged QT interval on

Based on the specific toxin

Thrombosis

the ECG; may see neurological symptoms


Rapid heart rate with narrow QRS complexes on the

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.

The common set of first drawer medications might be:

Alcohol swabs

Amiodarone 150 mg/3ml vial

Atropine 1mg/10 ml syringe

Sodium bicarbonate 50mEq/50 ml syringe

Calcium chloride 1gm/10 ml syringe

Sodium chloride 0.9% 10 ml vial Inj. 20 ml vial

Dextrose 50% 0.5 mg/ml 50 ml syringe

Dopamine 400 mg/250 ml IV bag

Epinephrine 1 mg/10 ml (1:10,000) syringe

Sterile water

Lidocaine 100 mg 5ml syringes

Lidocaine 2 gm/250 ml IV bag

Povidone-Iodine swabstick

Vasopressin 20 units/ml 1 ml vial

If the crash cart also contains pediatric medications these may be contained in the second drawer.
Often these would include:

Atropine 0.5 mg/ 5 ml syringe

Sodium bicarbonate 10 mEq/10 ml syringe

Saline flush syringes

Sodium chloride 0.9% 10 ml flush syringe

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:

Endotracheal tubes of various sizes,

Nasopharyngeal and perhaps oropharyngeal airways,

Laryngoscope handle and blades of different sizes,

A flashlight with extra batteries,

A syringe of sufficient size to inflate the cuff on it endotracheal tube,

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:

2.5 mm uncuffed endotracheal tube

3.0 mm 5.5 mm microcuff endotracheal tubes

Pediatric Stylet (8 Fr)

Neonatal Stylet (6 Fr)

Nasopharyngeal and perhaps oropharyngeal airways,

Laryngoscope blades

Disposable Miller blades

Disposable Macintosh blades

Armboards of various sizes

Vacutainers for blood collection

Spinal needles

Suction catheters of various sizes

Bone marrow needles of various sizes

Feeding tubes

Umbilical vessel catheter

Disinfectants (swab sticks)

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

Disinfectants (Chloraprep, Betadine, povidone-iodine)

Luer lock syringes of various sizes

Tourniquet tubing

Insyte autoguards of various sizes

Vacutainers

Blue top

Purple top

Green top

Red top

Spinal needles of various sizes

Regular needles of various sizes

3-Way stopcock

Tape

Armboards

ABG syringes and sampling kits

Catheter tips

Tubing

IV solutions may also be kept in this drawer

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

Sterile gloves of various sizes

Sutures of various sizes and materials

Suction supplies

Salem pump

Cricothyroidotomy kit

Adult and pediatric cut down pack

Yankauer suction

Drapes to create a sterile field

Large bore needle and syringe (for tension pneumothorax)

Suction Cath Kit 14 Fr & 18 Fr

Lumbar puncture kit

Normal Values in Children


As you are conducting the Primary Assessment in PALS, it is critical to know the normal
values of heart rate, breathing, and blood pressure for a given age. Decisions of what is
normal and what needs to be treated are based on these normal values. For example, an
adolescent breathing 40 times a minute is abnormal, but would be normal for an infant.
A -> Airway
Advanced interventions for keeping the airway open may include:
Laryngeal mask airway
Endotracheal intubation
Continuous Positive Airway Pressure (CPAP)
Foreign body removal if one can be visualized
Cricothyrotomy in which a surgical opening is made into the trachea
B -> Breathing
The childs respiratory rate is an important assessment that should be made early in the
primary assessment process. The clinician must be aware of normal respiratory ranges by
age:
Age Category

Age Range

Normal Respiratory Rate

Infant

0-12 months

30-60 per minute

Toddler

1-3 years

24-40 per minute

Preschooler

4-5 years

22-34 per minute

School Age

6-12 years

18-30 per minute

Adolescent

13-18 years

12-16 per minute

Normal Respiratory Rates


C -> Circulation
The childs heart rate is another important assessment that should be made in the primary
assessment. The normal heart rates by age are:

Age Category
Newborn

Age Range
0-3 months

Normal Heart Rate


80-205 per minute

Infant/Young child

4 months to 2 years

75-190 per minute

Child/School Age

2-10 years

60-140 per minute

Older child/ Adolescent

Over 10 years

50-100 per minute

Normal Heart Rates


The childs blood pressure should be another part of the primary assessment. Normal
blood pressures by age range are:

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

Localizes with pain


Flexion and withdrawal
Abnormal flexion

Abnormal extension

None

Crying with pain only


Moaning with pain only
None
Spontaneous movement
Withdraws when touched
Withdraws with pain
Abnormal flexion
Abnormal extension
None

Total Possible Score 3-15


Pediatric Glasgow Coma Scale
E -> Exposure
Any abnormal symptoms in this category should initiate the shock sequence.
During the primary assessment, if the child is stable and does not have a potentially lifethreatening problem, continue with the Secondary Assessment.

Quantitative waveform capnography


Quantitative waveform capnography is the continuous measurement of carbon dioxide (CO2),
specifically end-tidal CO2. The capnography device uses a sensor that detects CO2 levels in
expired air. This device can be part of a nasal cannula filter line or be attached to a bag mask
device or ET tube. Of course, when a patient is being ventilated either a rescuer or a ventilator
machine is assisting those expirations. This is precisely why quantitative waveform capnography
is useful in life support situations.
Why do we produce carbon dioxide?
CO2 is a product of cellular respiration. As cells create energy they consume oxygen and give off
CO2 as a waste product. Therefore, if we can detect CO2 in exhaled breath it provides us with
some very important information about our life support efforts. It means that:
Cellular respiration is taking place
That the ventilation is being delivered
That we are creating some form of circulation
If cardiac output is insufficient, carbon dioxide returning from the tissues through the veins is not
reaching the lungs. The capnography device can also provide the means of quantifying
respiration rate that is more accurate than simply counting ventilations. Specifically, if the
rescuer is delivering ventilations but the end-tidal carbon dioxide is too low, then ventilation is
insufficient and these should not be considered actual ventilations.

Am I delivering adequate CPR?


Normal end-tidal carbon dioxide (ETCO2) usually falls in the range of 35 to 45 mmHg in adults.
In an unconscious patient or in someone who is in cardiopulmonary arrest, ETCO2 may be
undetectable. Rescuers should strive to deliver high-quality chest compressions that keep
ETCO2 levels at least 10 mmHg and preferably 20 mmHg or higher.
If the rescuer began the intervention by delivering high-quality compressions and achieving
satisfactory ETCO2 but CO2 levels dropped over time, its important to consider whether rescuer
fatigue is setting in. A drop-in ETCO2 may prompt rescuers to switch roles and give the person
delivering chest compressions a chance to recover.
Did my patients achieve ROSC?
Another use for quantitative waveform capnography is to identify patients who have achieved a
return of spontaneous circulation or ROSC. Even under the best circumstances, it will be rare for
a person delivering CPR to achieve 35 to 45 mmHg of ETCO2. So if during the course of
advanced cardiovascular life support a patients ETCO2 increases rather dramatically (e.g., from
15 to 35 mmHg) this is consistent with the return of spontaneous circulation.
Why cant I just use pulse oximetry?
Quantitative waveform capnography provides many details about resuscitation efforts that pulse
oximetry cannot. Moreover, pulse oximetry is a delayed assessment of the patients oxygenation
status. The detection system used in pulse oximetry is slow to respond to changes in the oxygen
levels of blood. Quantitative waveform capnography, on the other hand, immediately responds to
changes in the level of CO2 in expired air. Therefore it provides a real-time monitor for apnea
and an assessment of effectiveness of cardiopulmonary resuscitation.

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.