Download Episode 9 Show Notes

Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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CrackCast Episode 9 – Adult Resuscitation
Episode Overview:
1) List 10 etiologies of non-traumatic cardiac arrest
2) List the two most important determinants of good outcomes in cardiac arrest
3) List the components of good quality CPR
4) List 6 ways to monitor CPR
5) What are 3 hard indicators of adequate perfusion during CPR?
6) What are your post-cardiac arrest goals?
Wisecracks:
1) List 4 contraindications to CPR
2) ACLS algorithms talk through - you must know!
a. pulseless VT or VF
b. PEA
- list all the 5H’s and 5T’s
c. asystole
d. respiratory arrest
e. brain arrest / cognitive arrest
3) Sleuthing out why the patient arrested? (our approach to the hx and physical)
Rosen’s in Perspective: Cardiac Arrest
 out of hospital cardiac arrests: 3-16% survival rates



<1/3 are due to VF
those who achieve ROSC have a 19-50% survival
○ only 1/3 of those who survive to discharge return to near baseline pre-arrest
function
therapeutic hypothermia appeared to improve survival in comatose cardiac arrest
survivors to near 50%
*But the key point is:
 all the highest survival rates occur within a comprehensive system of healthcare from
pre-arrest, to intra-arrest, to post-arrest care*
1) List 10 etiologies of non-traumatic cardiac arrest
Rosen’s breaks it down into broad categories:
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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
Cardiac
 primarily a shockable rhythm: VF or VT (less likely)
 75% of the time due to CAD (30% due to acute MI)
 other possible causes:
 hypertrophic cardiomyopathy
 structural disease (valves)
 deterioration to PEA/asystole after defibrillation
 Respiratory
 usually progresses: hypertension > tachychardia > hypotension > bradycadia >
PEA/VT/asystole
 foreign body / asthma / tension pneumothorax / PE / pneumosepsis
 Circulatory/Obstructive
 tension pneumothorax / cardiac tamponade / PE
 hemorrhage, sepsis, neurogenic shock
 Metabolic
 hyperkalemia
 hyper/hypoMg /hypokalemia – rare
 Toxic
 Digoxin / CCB
 TCAs /
 Cocaine / Heroin / CO / monoxide
 Environmental
 electrocution
 100 mA = can cause VF if reach heart
 >2000mA = asystole and apnea (*reverse triage at lightning strikes)
 hypothermia:
 requires external and internal rewarming
 allow for prolonged resuscitation
 drowning
 results in bradycardic arrest
Alternatively you can just go through all the causes of shock.
2) List the two most important determinants of good outcomes in cardiac
arrest?
●
TWO most important determinants of outcome:
○ time to defibrillation
○ quality CPR
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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Interestingly, there is:
● no evidence to support transporting someone in arrest to the ER, or using advanced life
support if it interrupts CPR/defibrillation
○ patients should be pronounced dead at the scene if no ROSC
○ * recent trials and use of resuscitative ECMO may change this paradigm
(CHEER trial)
3) List the components of good quality CPR
According to the 2015 AHA guidelines the components of good quality CPR are:
1. place two hands on the lower half of the sternum
2. perform chest compressions at a rate of 100-120/min
3. compress to a depth of at least 2 inches (5 cm)
4. allow full recoil after each compression
5. minimize pauses in compressions (intubation/US)
6. ventilate adequately (2 breaths after 30 compressions, each breath delivered over 1
second, each causing chest rise)
So in summary, think about these P’s next time you do or see CPR: placement, pace,
pressure, pauses, and puffs (don’t over ventilate)
4) List 6 ways to monitor CPR
1. EtCO2 > 10 mmHg (minimum)
■ can be a reliable indicator of cardiac output in a cardiac arrest
■ levels greater than 10 indicate decent CPR, ideally around 20
■ helpful to detect ROSC when a pulse is too weak to be palpated (severe
shock - in need of pressors)
■ don’t be misled by EtCO2, a rapid rise could come from:
● new person doing CPR
● a bolus of bicarb
● response to treatment of tension pneumothorax; fluids;
paracentesis etc.
● ROSC
2. palpable carotid or femoral pulse
 wave-form present on arterial line or pulse oximetry
4. diastolic pressure > 40
■ Need an arterial line to get this (check out emcrit.org for more!)
5. ScVO2 >40%
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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■
only really used in ICUs long ago
6. coronary perfusion pressure > 15 mmHg
■ minimum of 15 is needed to achieve ROSC
5) What are 3 HARD indicators of adequate perfusion during CPR?
1. ET CO2 >10 mmHg
2. Diastolic pressure on intra-arterial monitoring > 40
3. SCVO2 > 40%
6) What are your post cardiac-arrest care goals?
Generally speaking what’s good for the brain is good for the post-arrest patient. (Check out
episode 8 for more info)
General Physiologic Parameters:
1.
2.
3.
4.
5.
6.
7.
8.
9.
MAP 70-90 mmHg
CVP 10-15 mmHg
Hemoglobin >100
Lactate < 2
Temperature 32-24 degrees?* (360C?)
Sa02 94-98%
ScVO2 >65%
D02 400-500 ml/min
VO2 > 90 ml/min
Rosen’s does flesh out the discussion around post-cardiac arrest by discussing the indications,
contraindications, and controversies around hypothermia:
● some advocate the initiation of therapeutic hypothermia in cases of witnessed out of
hospital VF arrest (some have expanded this to include PEA/asystole arguing the
underlying cardiac rhythm does not influence the physiologic mechanism by which
targeted temperature management should work)
There are some relative contraindications to therapeutic hypothermia to know about:
■ severe cardiogenic shock
■ uncontrolled bleeding (worsens coagulopathy)
■ pregnancy
■ coagulopathy / ESRD
■ drug overdose / status epilepticus
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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However, the most controversial aspect is how low to go. See episode 8’s wisecracks essential
evidence for discussion of the 330C vs 360C Targeted Temperature Management Trial –
(Nielsen et al., 2013)
Ultimately it depends on your local centre, but if your centre is cool:
○ cooling efforts:
■ ice packs to pits/folds
■ fan / misting
■ internal cooling if needed
■ commercial external cooling devices
○ prevent shivering with:
● sedation
● NMBA's
○ consider continuous EEG monitoring
○ gradual rewarming after 24 hrs
Bottom line, don’t let them go febrile.
Wisecracks:
Another Rosen’s in Perspective:
● cardiopulmonary arrest:
○ definition: "triad of unconsciousness, apnea, pulselessness"
○ in VF loss of consciousness occurs in 15 seconds
 brief seizures may occur for a few seconds due to decreased cerebral
flow (hypoxic etiology)
○ respiratory arrest often may progress to cardiac arrest
1) List 4 contraindications to CPR
1. do not resuscitate (DNR) order
2. unwitnessed cardiopulmonary arrest in a patient who appears frozen/cold to touch or in
rigor mortis (and no shockable rhythm)
3. traumatic arrest
4. unsafe to perform CPR due to an unsafe scene (bombs, hazardous chemicals, etc.)
Also, no CPR with an LVAD (some it may be ok if ABSOLUTELY necessary), but others you
should use a hand-pump/crank and CPR should never be done according to the manufacturers
(see www.mylvad.com)
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
www.crackcast.org
2) ACLS algorithms talk through – you must know these
Ventricular Fibrillation / Pulseless Ventricular Tachycardia
●
●
●
●
●
●
start CPR immediately
single monophasic defibrillation at 360 Joules (biphasic at 200 Joules)
if patient is on a monitor while in VT or VF may perform "cough CPR" to keep them alive
for several seconds while defibrillator comes
if unwitnessed arrest (>5 mins) then brief 90 secs of CPR prior to first shock increases
chances of successful defibrillation
immediately resume CPR after shock then pulse check at 2 mins
refractory VF: (check out emcrit/emrap for more)
○ continued shocks
■ ?double pad shock at the same time?
○ continue CPR
○ epinephrine q 3-5 mins
○ MgSO4 2g for torsades
○ amiodarone (little evidence)
○ lidocaine bolus
○ CaCl and sodium bicarbonate for hyperkalemia and TCA overdose
○ ?beta blockers (esmolol)
○ consider ECMO in ECMO capable center
Pulseless Electrical Activity
There are at least three ways of approaching the PEA patient:
1. Using Rosen’s approach of pseudo-EMD or true-EMD
2. Use the QRS complex approach
3. Systematically go through the H’s and T’s
What is PEA?
Rosen’s defines it as:
● "coordinated/organized electrical activity of the heart without a palpable pulse”
The EMD approach
● may be pseudo-EMD (no pulse despite mechanical contractions) or true-EMD (no pulse
and no mechanical)
● true electromechanical-dissociation (EMD) - asystole
○ primary cardiac disorder of myocytes due to global myocardial energy loss and
acidosis
○ due to ischemia, toxins, hyperkalemia, hypothermia, etc.
● pseudo-EMD – severe shock
○ may occur with papillary muscle rupture or free wall rupture
○ hypovolemia / tamponade / PE / pneumothorax
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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○
treatment underlying causes
The QRS approach:
● Narrow QRS
○ Mechanical problem - fix the obstruction or flow
● Wide QRS
○ Cellular problem
■ Acidosis
■ Oxygen
■ Toxins / overdose
■ Potassium
■ Massive MI
The H’s and T’s approach:
● MUST know the 5 H’s and 5 T’s:
H’s
■ Hypovolemia
■ Hypoxia
■ Hydrogen ion (acidosis)
■ Hypothermia
■ Hypo/HyperK
○ T’s
■ Thrombosis cardiac
■ Thrombosis pulmonary
■ Toxins
■ Tamponade
■ Tension pneumothorax
Asystole
●
●
●
●
●
●
●
●
"no organized cardiac activity"
usually electric
must be confirmed with at least TWO leads
○ you should confirm no pericardial effusion with echo (massive PCE can cause
low voltage)
does not respond to pacing
does not respond to atropine
epi is an option
CPR and intubation
very low (~0%) chance of survival
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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Respiratory arrest//failure
You show up to a code and find that the person is not breathing adequately, but they have a
pulse.
First: help them breath using a BVM and probably intubation (if you can’t reverse them quickly)
Second: figure out why they aren’t breathing
Many different approaches: this is a fairly intuitive one
1. Won’t breathe
a. CNS problem: tumour, stroke, bleed, toxin induced (benzo, opioids, sedatives,
TCAs)
2. Can’t breathe
a. nerve problem (phrenic nerve, high C-Spine injury, GBS, myasthenia gravis,
botulinum toxin)
b. muscle problem (electrolytes, drugs blocking muscle function (NMBAs), high
doses of magnesium, environmental toxins, tick paralysis, etc.)
c. chest wall dysfunction (flail chest, tension pneumothorax, burns)
d. upper airway disorder (vocal cord, foreign body, anaphylaxis, angioedema)
3. Can’t breathe enough
a. diffusion problem at the level of the lungs: (shunt, VQ mismatch)
i.
bad COPD
ii.
atelectasis
iii.
asthma
The best thing you can do is address any quickly treatable cause immediately:
● give naloxone (opioid overdose)
● decompress tension pneumothorax
● treat anaphylaxis
● control the airway
Brain arrest / Cognitive arrest
You show up to a code or patient is wheeled in who is comatose, but breathing and a pulse…
(more in Episode 17 – Coma)
Bottom line you think of something affecting both hemispheres using an approach like DIMS:
● Drugs
● Infection
● Metabolic
● Structural
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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Approach this similarly to the post-ROSC patient and you won’t miss much.
3) Describe your approach to the post-cardiac arrest patient
One great approach to the post arrest patient is from Dr. David Sweet (Emergency Physician/
Intensivist at Vancouver General Hospital)
His memory aid for the post arrest patient is: 1:2:2:3
1: one full set of vitals including glucose
2: two machines that you should call for ASAP - ECG and CXR
2: two bloods: full cardiac labs (CBC, troponin, lytes etc.) and an ABG
3: three basics: take a history, do a physical exam, and look at the old charts
4) Sleuthing out why the patient arrested: an approach to the history and
physical
History
○
○
family, bystanders, EMS
key questions
 exact time of arrest – this is absolutely crucial!**
 witnessed vs un-witnessed arrest
 what was the patient doing at the time (exercise? eating? sitting?)
 Bystander CPR
 CPR duration – crucial
 ECG rhythm – crucial (cath lab vs. no cath lab)
 interventions by EMS providers
 past medical/psychiatric history
 drug ingestion or environmental exposures? do we need to give an
antidote?
 allergies
Physical Exam
○ General exam
 pallor or cyanosis
○ Head to toe:
 signs of trauma
 airway secretions and ease of ventilation
 abdominal exam
 rectal exam (r/o massive GI bleed)
 extremity exam - focal deficits
Crack Cast Show Notes – Adult Resuscitation – Feb 2016
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
skin for track marks or signs of trauma
PEARLS:
○ 1) ensure airway and ventilations
○ 2) confirm dx of cardiac arrest
 ***look with ultrasound***
● is it severe shock (a beating heart with no BP)
● or asystole (no organized beating heart)
○ 3) confirm dx of cause