Transcript CARDIAC ARREST - ISAKanyakumari

CARDIAC ARREST
DR. PRAKASH MOHANASUNDARAM
Emergency & Critical care Physician
Vinayaka Mission University
SALEM
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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
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NO Central Pulse
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Scenario 1
He was about to be shifted to the cathlab
when he suddenly became drowsy and
then unconscious
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CHECK FOR RESPONSE
OPEN THE AIRWAY
CALL FOR HELP
CHECK FOR BREATHING
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NO
BREATHING
GIVE 2 RESCUE BREATHS
CHECK FOR CENTRAL PULSE
NO
CENTRAL
PULSE
KEEP DEFIB PADDLES
CHECK RHYTHM
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Identify the rhythm
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What is VF?
Coarse fibrillatory waves
Chaotic electrical activity
If flatline increase gain - fine VF
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Identify the rhythm
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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
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Polymorphic VT
The QRS morphology keeps varying
If preceded by a prolonged QT interval when in sinus
rhythm – Torsades de pointes
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Primary ABCD Survey
Basic Life Support:
 Airway
 Breathing
 Circulation
Attach monitor/defibrillator
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Check rhythm
Shockable
VF/VT
Not Shockable
Aystole/PEA
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VF/Pulseless VT
Give 1 shock
 Biphasic: 120 to 200 J
 Monophasic: 360 J
Give the highest energy in that
equipment
Resume CPR immediately
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PADDLE PLACEMENT
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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
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If rhythm persists
Consider antiarrhythmics
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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
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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
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Magnesium – Class IIa
Polymorphic VT associated with
prolonged QT interval (torsades de
pointes)
1-2gm IV/IO in 10 ml of 5D over 520 mins
If with pulse same 1-2gm in 100ml of
5D over 20-60 mins
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Reduce interruptions as much as
possible !!!!!!!
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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
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Vasopressor to be delivered only after 1 or 2 shocks
Palpate for pulse if organized rhythm appears.
If patient in hypothermic(< 30 deg C) with hold
vasopressors until rewarmed.
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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.
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Causes of pulseless arrest-6Hs
Hypovolemia
Hypoxia
Hypo / hyperkalemia
Hypoglycemia
H+ ion - acidosis
Hypothermia
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5Ts
Toxins
Trauma
Tamponade - cardiac
Tension Pneumothorax
Thrombosis
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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
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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)
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What to do if you see this?
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Asystole
Check the pulse
Check the leads first!
Change the leads
Increase the gain. Why?
PLEASE DON’T DELIVER SHOCK
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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
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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
VF / VT
Check rhythm after 5 cycles
of CPR
If NSR go to post
resuscitation care
Go to
shockable
rhythm
management
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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
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Causes of Pulseless arrest
Hypovolemia
Hypoxia
Hydrogen ion
Hypo/ hyperkalemia
Hypoglycemia
Hypothermia
Toxins
Tamponade ,cardiac
Tension pneumothorax
Thrombosis
(coronary/pulmonary)
Trauma
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The drugs in cardiac arrest
Epinephrine
Vasopressin
Atropine
Amiodarone
Magnesium
Lidocaine
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Classification of ACLS drugs
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Class I
Class II -a
Class II - b
Class - Indeterminate
Class III
Definitely useful
Probably useful
Possibly useful
No supporting evidence
Harmful
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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
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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
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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
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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
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How does it work
Corrects acidosis, improves vascular response
Decreases defibrillation threshold
Post resuscitation- increases myocardial
contractility
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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.
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Pediatric arrest
2 rescuers 15 : 2
CPR technique
Drugs:
 No atropine in PEA/
Asystole
2 Joules / kg then 4
joules/ kg
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DRUGS
Adrenaline 0.01mg/kg IV/IO
0.1 mg/kg ET
Amiodarone 5mg/kg upto 15/mg/kg max of 300 mg.
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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
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Definite NO NOs
Precordial thump
Procainamide in VF
Nor adrenaline - worse neurologic
outcomes
Volume expansion with IV fluids
Pacing in asystole
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Be prepared
Emergency drugs kit
Airway kit
Regular drills
Team work
Debriefing
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Summary
Anticipate
Remember to change leads and increase
gain in Asystole
Basics of CPR
Please don’t shock Asystole / PEA
Constant update
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DEAD but STILL ALIVE
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Thank you !
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