Cardiac Arrest Arrhythmias

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Cardiac Arrest Arrhythmias

• EMS Professions
• Temple College

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Cardiac Arrest

• Mechanisms
• Ventricular Fibrillation
• Pulseless Ventricular Tachycardia
• Asystole
• Pulseless Electrical Activity (PEA)
• A condition Not an ECG rhythm

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Cardiac Arrest

• Most common rhythms
• Adults ventricular fibrillation
• Children Asystole, Bradycardic PEA
• Pediatric V-fib suggests
• Drug toxicity
• Electrolyte imbalance
• Congenital heart disease

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Cardiac Arrest

• ABCs come first!
• Airway - unobstructed? ? manually open
• Breathing - no or inadequate ? ventilate
• Circulation - no pulse in 5 sec ? chest
  compressions
• Do NOT wait on equipment
• Assure effective BLS before going to ALS
• Rise and fall of chest
• Air movement in lung fields
• Pulse with compressions

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Cardiac Arrest

• First ALS priority is defibrillation
• Only cure for v-fib is defib
• The quicker the better
• Probability of resuscitation decreases 7-10 with
  each passing minute

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Cardiac Arrest

• Vascular access
• Antecubital space
• Arm, EJ, Foot (last resort)
• IO in peds lt 6 y/o
• 14 or 16 gauge
• LR or NS
• 30 sec - 60 sec of CPR to circulate drug

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Cardiac Arrest

• Intubation as time allows
• Less emphasis today as compared to past
• Epi, atropine, lidocaine may be administered down
  tube
• 2x IV dose
• IV is preferred

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Analyze the Rhythm
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Ventricular Fibrillation (VF)

• Characteristics
• Chaotic, irregular, ventricular rhythm
• Wide, variable, bizarre complexes
• Fast rate of activity
• Multiple ventricular foci
• No cardiac output
• Terminal rhythm if not corrected quickly
• Most common rhythm causing sudden cardiac death
  in adults

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Ventricular Fibrillation (VF) Treatment

• ABCs
• Witnessed arrest Precordial thump
• Little demonstrated value but worth a try
• CPR until defibrillator available
• Quick Look for VF or pulseless VT
• Treat pulseless VT as if it were VF
• Defibrillate
• 200 J, 300 J, 360 J
• Quickly and in rapid succession
• Identify cause if possible

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Ventricular Fibrillation Treatment

• If still in VF/VT arrest, continue CPR for 1
  minute
• Establish IV access and Intubate
• If sufficient personnel, attempt both
  simultaneously
• If not, quick attempt at IV access then attempt
  ETT
• Vasopressor Medication
• Epinephrine
• 1 mg 110,000 IVP
• Repeat every 3-5 mins as long as arrest persists
• Vasopressin (alternative to Epinephrine)
• 40 units IVP one time only

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Ventricular Fibrillation Treatment

• Shock _at_ 360 J after each medication given as long
  as VF/VT arrest persists
• Alternate epi-shock antidysrhythmic-shock
  sequence
• Antidysrhythmic Medication
• amiodarone 300 mg IVP single dose
• lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg
  total
• procainamide 100 mg IV, q 5 min, max 17 mg/kg
  total
• magnesium 10 1-2 g IV
• if hypomagnesemic or prolonged QT

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Ventricular Fibrillation Treatment

• Consider NaHCO3 if prolonged
• Only after effective ventilations
• In many EMS systems, consider terminating
  resuscitation efforts in consult with med control

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Ventricular Fibrillation

• The ultimate unstable tachycardia
• Shock early-Shock often
• Sequence is drug-shock-drug-shock
• Sequence of drugs is epi-antiarrhythmic-epi-antiar
  rhythmic

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Analyze the Rhythm
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Asystole

• Characteristics
• The ultimate unstable bradycardia
• A terminal rhythm
• poor prognosis for resuscitation
• best hope if ID treat cause
• No significant positive or negative deflections

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Asystole

• Possible Causes
• Hypoxia ventilate
• Preexisting metabolic acidosis Bicarbonate 1
  mEq/kg
• Hyperkalemia Bicarbonate 1 mEq/kg, Calcium 1 g
  IV
• Hypokalemia 10mEq KCl over 30 minutes
• Hypothermia rewarm body core

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Asystole

• Possible Causes
• Drug overdose
• Tricyclics Bicarbonate
• Digitalis Digibind (Digitalis antibodies)
• Beta-blockers Glucagon
• Ca-channel blockers Calcium

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Asystole PEA Differentials (The 5Hs 5Ts)

• Hypovolemia
• Hypoxia
• Hydrogen ions (Acidosis)
• Hyper/hypo-kalemia
• Hypothermia

• Tablets (Drug OD)
• Tamponade
• Tension Pneumothorax
• Thrombosis, Coronary
• Thrombosis, Pulmonary

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Asystole Treatment

• Primary ABCD
• Confirm Asystole in two leads
• Reasons to NOT continue?
• Secondary ABCD
• ECG monitor/ET/IV
• Differential Diagnosis (5Hs 5Ts)
• TCP (if early)
• Epinephrine 110,000 1 mg IV q 3-5 min.
• Atropine 1 mg IV q 3-5 min, max 0.04 mg/kg
• Consider Termination

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Analyze the Rhythm
What are you going to do for this patient?
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Case Presentation
The patient is a 16-year-old male who was stabbed
in the left lateral chest with a butcher knife.
He responds only to pain. His respirations are
rapid, shallow, and labored. Central cyanosis is
present. Breath sounds are absent on the left
side. The neck veins are distended. The trachea
deviates to the right. Radial pulses are absent.
Carotids are rapid and weak.
Now, what are you going to dofor this patient?
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PEA

• Possibilities
• Massive pulmonary embolus
• Massive myocardial infarction
• Overdose
• Tricyclics - Bicarbonate
• Digitalis - Digibind
• Beta-blockers - Glucagon
• Ca-channel blockers - Calcium

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PEA

• Identify, correct underlying cause if possible
• Possibilities
• Hypovolemia volume
• Hypoxia ventilate
• Tension pneumo decompress
• Tamponade pericardiocentesis
• Acute MI vasopressor
• Hyperkalemia Bicarbonate 1mEq/kg
• Preexisting metabolic acidosis Bicarbonate
  1mEq/kg
• Hypothermia rewarm core

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PEA Treatment

• ABCDs
• ETT/IV/ECG monitor
• Differential Diagnosis
• Find the cause and treat if possible
• Epinephrine 110,000 1 mg q 3-5 min.
• If bradycardic,
• Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg
• TCP
• In many systems, consider termination of efforts

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Hypothermia-Initial Therapy

• Remove wet garments
• Protect against heat loss wind chill
• Maintain horizontal position
• Avoid rough movement and excess activity

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Hypothermia No Pulse

• CPR
• Defibrillate X 3 if VF/VT
• ETT with warm, humidified O2
• IV access with warm fluids
• Temp gt30C/86F
• Continue as usual with longer intervals
• Repeat defibrillation as temp rises
• Temp lt30C/86F
• Continue CPR
• Withhold medications and further defibrillation
• Transport for core warming

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Hypothermia No Pulse
Remember A hypothermic patient is not dead
until he is WARM DEAD!!!
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Managing Cardiac Arrest

• Check pulse after any treatment or rhythm change

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Post-resuscitation Care

• If pulse present
• Assess breathing
• Present?
• Air moving adequately?
• Equal breath sounds?
• Possible flail chest?

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Post-resuscitation Care

• If pulse present
• Protect airway
• Position to prevent aspiration
• Consider intubation
• 100 Oxygen via BVM or NRB
• Vascular access

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Post-resuscitation Care

• Assess perfusion
• Evaluate
• Pulses
• Skin color
• Skin temperature
• Capillary refill
• BP
• Key is perfusion, not pressure

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Post-resuscitation Care

• Management of Decreased Perfusion
• Fluid challenge
• Catecholamine infusion
• Dopamine, or
• Norepinephrine
• Titrate to BP 90 to 100 systolic

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Post-resuscitation Care

• Suppression of ventricular irritability
• If VT or VF converted before lidocaine given,
  lidocaine bolus and drip
• If lidocaine or bretylium worked, begin infusion
• Suppress irritability before giving vasopressors