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