CARDIAC ARREST

1
CARDIAC ARREST

• DR. PRAKASH MOHANASUNDARAM
• Emergency Critical care
  Physician
• Vinayaka Mission University
• SALEM

2
What is cardiac arrest?

• Abrupt cessation of cardiac pump function
• which may be reversible by a prompt
• intervention
• but will lead to death in its absence

3
NO Central Pulse
4
Scenario 1

• He was about to be shifted to the cathlab when he
  suddenly became drowsy and then unconscious

5
CALL FOR HELP
CHECK FOR RESPONSE
OPEN THE AIRWAY
CHECK FOR BREATHING
6
NO BREATHING
CHECK FOR CENTRAL PULSE
GIVE 2 RESCUE BREATHS
NO CENTRAL PULSE
KEEP DEFIB PADDLES CHECK RHYTHM
7
Identify the rhythm
8
What is VF?

• Coarse fibrillatory waves
• Chaotic electrical activity
• If flatline increase gain - fine VF

9
Identify the rhythm
10
Ventricular tachycardia(VT)

• QRS has a wide morphology
• Rate is typically from 100-200 bpm
• P waves are hidden if present
• Can deteriorate rapidly to VF

11
(No Transcript)
12
Polymorphic VT

• The QRS morphology keeps varying
• If preceded by a prolonged QT interval when in
  sinus rhythm Torsades de pointes

13
Primary ABCD Survey

• Basic Life Support
• Airway
• Breathing
• Circulation
• Attach monitor/defibrillator

14
Check rhythm

Shockable
Not Shockable
VF/VT
Aystole/PEA
15
VF/Pulseless VT

• Give 1 shock
• Biphasic 120 to 200 J
• Monophasic 360 J
• Give the highest energy in that equipment
• Resume CPR immediately

16
PADDLE PLACEMENT
17
Persistent VF/Pulseless VT

• Give 1 shock
• Resume CPR
• Give vasopressor
• Epinephrine 1 mg IV repeat every 3 to 5
  minutes
• OR
• Vasopressin 40 U IV

18

• If rhythm persists
• Consider antiarrhythmics

19
Amiodarone Class II b

• Na ,K and Ca channel blocker Also alpha and beta
  adrenergic effects
• 300 mg IV bolus followed by 1 dose of 150 mg
  IV
• If perfusing rhythm achieved
• 1 mg/min for next 6 hrs
• 0.5 mg for next 18 hrs
• Preferred through central line

20
Lidocaine Class Indeterminate

• The initial dose 1 to 1.5 mg/kg IV push
• If VF / pulseless VT persists additional doses
  0.5 to 0.75 mg/kg IV push 5 to 10min interval
• Maximum dose of 3 mg/kg

21
Magnesium Class IIa

• Polymorphic VT associated with prolonged QT
  interval (torsades de pointes)
• 1-2gm IV/IO in 10 ml of 5D over 5-20 mins
• If with pulse same 1-2gm in 100ml of 5D over
  20-60 mins

22
Reduce interruptions as much as possible !!!!!!!
23
Key points of CPR

• Provide CPR while the defib is charging
• Push hard and push fast
• Allow chest recoil
• Minimize interruption during chest compressions
• Check rhythm only after delivery of 5 cycles /
  2mins of CPR after shock delivery

24

• Vasopressor to be delivered only after 1 or 2
  shocks
• Palpate for pulse if organized rhythm appears.
• If patient in hypothermic(lt 30 deg C) with hold
  vasopressors until rewarmed.

25

• With advanced airway, compressions at 100/min
  ventilations at 8-10 breaths /min
• Avoid fatigue by rotation
• Drugs in peripheral lines- 20 ml chase fluids and
  elevate limb.
• Rule out the 6Hs and 5Ts.

26
Causes of pulseless arrest-6Hs
Hypoglycemia
Hypovolemia
Hypoxia
H ion - acidosis
Hypothermia
Hypo / hyperkalemia
27
5Ts
Tension Pneumothorax
Toxins
Trauma
Tamponade - cardiac
Thrombosis
28
Scenario 2

• A 65 year old male was admitted in the ICU with a
  diagnosis of hemorrhagic stroke, on ventilator
  support
• Suddenly nurse noticed a fall in the GCS and
  alerted you
• You find that there is no central pulse and the
  monitor shows this rhythm

29
(No Transcript)
30
Pulseless Electrical Activity (PEA)

• Pulseless patients with minimal electrical
  activity
• Force of contractions not enough to produce a
  perfusing rhythm
• Often caused by reversible conditions
• Treat the cause(6Hs and 5Ts)

31
What to do if you see this?
32
Asystole

• Check the pulse
• Check the leads first!
• Change the leads
• Increase the gain. Why?
• PLEASE DONT DELIVER SHOCK

33
Evidence for no shock

• In 1989 Losek- 49 children in asystole delivered
  shock with no positive results
• 1993 Nine city high dose epinephrine study group-
  no benefit from shock for asystole
• CIRCULATION 2005

34
PEA and Asystole
A,B,C, start CPR IV/IO give inj.adrenaline
1mg(repeat every 3-5 mins) Atropine 1mg IV when
slow PEA / Asystole Max 3 doses

• May give 1 dose of vasopressin 40IU to replace
  1st or 2nd dose of adrenaline

PEA / Asystole
Go to shockable rhythm management
VF / VT
Check rhythm after 5 cycles of CPR
If NSR go to post resuscitation care
35
Management of PEA / Asystole

• Focus on high quality CPR
• Airway ASAP
• Minimize interruptions in chest compressions
• Deliver IV/IO medications once CPR is started
• Epinephrine every 3-5 mins
• Atropine is 1mg , max of 3 doses
• Vasopressin can replace adrenaline during the
  first or second dose

36
Causes of Pulseless arrest

• Toxins
• Tamponade ,cardiac
• Tension pneumothorax
• Thrombosis (coronary/pulmonary)
• Trauma

• Hypovolemia
• Hypoxia
• Hydrogen ion
• Hypo/ hyperkalemia
• Hypoglycemia
• Hypothermia

37
The drugs in cardiac arrest

• Epinephrine
• Vasopressin
• Atropine
• Amiodarone
• Magnesium
• Lidocaine

38
Classification of ACLS drugs

• Class I
• Class II -a
• Class II - b
• Class - Indeterminate
• Class III

• Definitely useful
• Probably useful
• Possibly useful
• No supporting evidence
• Harmful

39
Epinephrine Class II b

• Alpha adrenergic effects- beneficial
• But Beta adrenergic effects increase myocardial
  oxygen demand and also reduces subendocardial
  perfusion
• 1mg IV/IO every 3-5 mins
• If IO/IV unable to get, ET tube dose of 2-2.5mg

40
Vasopressin Class Indeterminate

• Noradrenergic peripheral vasoconstrictor that
  also causes coronary and renal vasoconstriction
• Benefit no better than epinephrine in survival
• Significantly less neurological deficit
• 40 IU IV / IO

41
Atropine Class Indeterminate

• Atropine reverses cholinergic mediated, decrease
  in heart rate
• Asystole could be precipitated by excessive vagal
  tone
• 1 mg every 3-5 mins upto max of 3 mg

42
Buffers

• Adequate Oxygenation Ventilation is the best
  buffer
• Soda bicarb - only buffer authorised for use
• (Class II b)
• Acidosis accumulation of CO2 and lactate
• No adequate tissue perfusion during prolonged CPR
  or late start

43
How does it work

• Corrects acidosis, improves vascular response
• Decreases defibrillation threshold
• Post resuscitation- increases myocardial
  contractility

44
Cont

• Currently no evidence for empirical use!
• Supported only in hyperkalemia(CRF), TCA
  overdose or preexisting metabolic acidosis
• 0.5-1 meq/kg over 10 mins or ABG guided.

45
Pediatric arrest

• 2 rescuers 15 2
• CPR technique
• Drugs
• No atropine in PEA/ Asystole
• 2 Joules / kg then 4 joules/ kg

46
DRUGS

• Adrenaline 0.01mg/kg IV/IO
• 0.1 mg/kg ET
• Amiodarone 5mg/kg upto 15/mg/kg max of 300 mg.

47
Neonate arrest

• Start CPR when HR
• Less than 60 bpm
• Ratio is 3 1
• Turn the mask
• Adrenaline 0.01mg/kg IV
• 0.1 mg/kg in ET

48
Definite NO NOs

• Precordial thump
• Procainamide in VF
• Nor adrenaline - worse neurologic outcomes
• Volume expansion with IV fluids
• Pacing in asystole

49
Be prepared

• Emergency drugs kit
• Airway kit
• Regular drills
• Team work
• Debriefing

50
Summary

• Anticipate
• Remember to change leads and increase gain in
  Asystole
• Basics of CPR
• Please dont shock Asystole / PEA
• Constant update

51
(No Transcript)
52
DEAD but STILL ALIVE
53
(No Transcript)
54
Thank you !