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Cardiac Arrest-2_backup

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Cardiac Arrest

Dr. Nasr Eldin Yousif Ahmed Associate Professor of Medicine and Cardiology department of Medicine

DEFINITION

Cardiac arrest is the cessation of normal circulation of the blood due to failure of the heart to contract effectively. Medical personnel can refer to an unexpected cardiac arrest as a sudden cardiac arrest or SCA

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Dr. Nasr Eldin Yousif

CLASSIFICATION

Cardiac arrest is classified based upon the ECG rhythm into:

  • Shockable (Ventricular fibrillation and Pulseless ventricular tachycardia)
  • Non-shockable (Asystole and Pulseless electrical activity).

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img-2.jpeg VENTRICULAR TACHYCARDIA

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VENTRICULAR FIBRILLATION

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VENTRICULAR STANDSTILL (Asystole)

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Cardiac causes

a) Coronary heart disease

  • Approximately 60–70% of SCD is related to coronary heart disease.
  • Among adults, ischemic heart disease is the predominant cause of arrest.

b) Non ischemic heart disease

  • cardiomyopathy,
  • cardiac rhythm disturbances (VT/VF/ Asystole/PEA)
  • hypertensive heart disease
  • congestive heart failure.

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Hs and Ts

“Hs and Ts” is the name for a mnemonic used to aid in remembering the possible treatable or reversible causes of cardiac arrest.

Hs

  • Hypovolemia
  • Hypoxia
  • Hydrogen ions
  • Hyperkalemia
  • Hypokalemia
  • Hypothermia
  • Hypoglycemia

Ts

  • Tablets or Toxins
  • Cardiac Tamponade
  • Tension
  • Pneumothorax
  • Thrombosis
  • Thromboembolism
  • Trauma.

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SIGNS & SYMPTOMS

The most reliable sign is absence of pulse.

  • Unconsciousness
  • No breathing
  • No Blood Pressure
  • Pupils begin dialating within 45 seconds
  • Seizures may/maynot occur
  • Death – like appearance
  • Lips & nail buds turn blue

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DIAGNOSIS

  • Cardiac arrest is synonymous with clinical death.
  • Lack of carotid pulse is the gold standard for diagnosing cardiac arrest.
  • Cardiac arrest is usually diagnosed clinically by the absence of a pulse, but lack of a pulse (particularly in the peripheral pulses) may be a result of other conditions (e.g. shock), or simply an error on the part of the rescuer.

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MANAGEMENT Sudden cardiac arrest may be treated via attempts at resuscitation.

This is usually carried out based upon:

  • Basic life support (BLS)
  • Advanced cardiac life support (ACLS)
  • Pediatric advanced life support (PALS)
  • Neonatal resuscitation program (NRP)

MANAGEMENT (cont’d)

  • Cardiopulmonary resuscitation (CPR)
  • Defibrillation
  • Medications
  • Therapeutic hypothermia
  • Extracorporeal membrane oxygenation devices

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Cardio-Pulmonary Resuscitation (CPR)

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STEPS IN RESUSCITATION (DRSCABD)

  • Check for Danger
  • Check for Response
  • Send for help
  • Chest compressions
  • Open the Airway
  • Check Breathing
  • D stands for AED

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STEPS IN CPR

  • Recognition of the arrest
  • Compressions
  • Managing the airway
  • Rescue breaths

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RECOGNITION OF ARREST

  • check for response
  • , tap the victim on the shoulder and shout, “Are you all right?”
  • no more than 10 seconds to check for a pulse
  • Adults – Carotid artery
  • Infants – Brachial artery

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COMPRESSIONS

  • Push hard & fast(100/min)
  • Compressions to relaxation ration 50:50
  • To Ensure full chest recoil
  • Minimal interruption

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C. Circulation

Restore the circulation, start external cardiac massage

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Dr. Nasr Eldin Yousif

HOW CPR WORKS

  • Effective CPR provides 1/4 to 1/3 normal blood flow
  • Rescue breaths contain 16% oxygen (21%)

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Using an AED (1 of 8)

  • Assess responsiveness.
  • Stop CPR if in progress.
  • Check breathing and pulse.
  • If patient is unresponsive and not breathing adequately, give two slow ventilations.

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AIRWAY MANAGEMENT

HEAD TILT- CHIN LIFT

  • Place one hand on the victim’s forehead $ push with your plam to tilt the head back.
  • Place the fingers of the other hand under the bony part of the lower jaw near the chin.
  • Lift the jaw to bring the chin forward.

JAW THRUST

INDICATION:

  • Cervical spine injury
  • Place one hand on each side of the victim’s head, resting your elbows on the surface on which the victim is lying.
  • Place your fingers under the angle’s of the victim’s lower jaw $ lift with both hands, displacing the jaw forward.
  • If the lips close, retract the lower lip with your thumb.

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Checking Vital Signs

  • ☐ A – Airway
  • > Open the airway
  • > Head tilt chin lift

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A (Airway) ensure open airway

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A (Airway) ensure open airway

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RESCUE BREATHS

  • Deliver each rescue breath over 1 second
  • visible chest rise
  • compression to ventilation ratio of 30 chest compressions to 2 ventilations.
  • Advanced airway
  • give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions
  • 8 to 10 breaths/min

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MOUTH-TO-MOUTH RESCUE BREATHING

  • Hold the victim’s airway open with a head tilt-chin-lift
  • Pinch the nose closed with your thumb $ index finger (using the hand on the forehead)
  • Take a regular breath (not deep) $ seal your lips around the victim’s mouth, creating an airtight seal
  • Give 1 breath over 1 sec $ watch for chest rise.
  • If the chest doesn’t rise, repeat the head tilt-chin-lift
  • Give a second breath $ watch for chest rise.

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B (Breathing)

img-19.jpeg Place your mouth over the victim’s mouth and exhale

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TWO-RESCUER

  • One should kneel down at the victim’s side and perform CPR, while the other kneel at the opposite side near the victim’s head and deliver artificial breaths.
  • Switch roles every 2 minutes.

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STOP CPR

  • The person revives and starts breathing again on their own.
  • Medical help, such as ambulance paramedics, arrive to take over.
  • The person performing the CPR is forced to stop from physical exhaustion.
  • Death of the victim.
  • CPR continued for 30min if the time to onset of CPR is <6min.
  • Onset of CPR >6min CPR can be terminated after 15min

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Advanced Cardiac Life Support

Defibrillation

External depolarization of the heart to stop Vfib or Vtach (that has not responded to other maneuvers)

Automated External Defibrillator

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Defibrillation Procedure

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  • Position paddles
  • “Clear” the patient
  • Shock and then resume CPR for 5 cycles then re-analyze after each shock
  • Prepare drug therapy

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Adult BLS

  1. Call for help and an AED
  2. Open the victim’s airway, check for breathing, give two breaths
  3. Start CPR - 30 compressions to 2 ventilations (100 compressions/minute)
  4. On arrival of a defibrillator or AED, check for a shockable rhythm
  5. Give one shock if indicated then resume CPR for another 5 cycles
  6. If no shock is indicated continue another 5 cycles of CPR

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Dr. Nasr Eldin Yousuf

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Amiodarone (Cordarone)

  • Indications:

  • Like Lidocaine – Vtach, Vfib

  • IV Dose:

  • 300 mg in 20-30 ml of N/S or D5W

  • Supplemental dose of 150 mg in 20-30 ml of N/S or D5W

  • Followed with continuous infusion of 1 mg/min for 6 hours then 0.5mg/min to a maximum daily dose of 2 grams

  • Contraindications:

  • Profound Sinus Bradycardia

  • 2nd and 3rd degree heart block

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Atropine

  • Indications:

  • Symptomatic sinus bradycardia

  • Second Degree Heart Block Mobitz I

  • May be tried in asystole

  • Organophosphate poisoning

  • IV Dose:

  • 0.5 – 1 mg every 3-5 minutes

  • Max dose is 0.04mg/kg

  • Can be given down ET tube

  • Side Effects:

  • May worsen ischemia

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Epinephrine

  • Because of alpha, beta-1, and beta-2 stimulation, it increases heart rate, stroke volume and BP
  • Helps convert fine Vfib to coarse Vfib
  • May help in asystole
  • Also EMD/PEA and symptomatic bradycardia
  • IV Dose:
  • 1 mg every 3-5 minutes
  • Can be given down the ET tube
  • Can also be given intracardiac
  • May increase ischemia because of increased O2 demand by the heart

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Norepinephrine

  • Similar in effect to epinephrine
  • Used for severe hypotension that is NOT due to hypovolemia
  • Cardiogenic shock
  • Administered as a continuous infusion
  • Adult rate is usually 2-12 micrograms/min
  • Range is 0.5-1 microgram up to 30 microgram
  • Side effects:
  • Like epinephrine, it may worsen ischemia
  • Extravasation causes tissue necrosis

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Dopamine

  • Used for hypotension (not due to hypovolemia)
  • Usually tried before norepinephrine
  • Has alpha, beta, and dopaminergic properties
  • Dopaminergic dilates renal and mesenteric arteries
  • Second choice for bradycardia (after Atropine)
  • IV Dose:
  • 1-20 micrograms/kg
  • Side effects:
  • Ectopic beats

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Dobutamine

  • Actions similar to Dopamine
  • Used for CHF with hypotension
  • IV Dose:
  • 2-20 micrograms/minute
  • Side effects:
  • Tachycardia
  • N & V
  • Headache
  • Tremors

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