a&e(vinayaka) cardiac arrest dr. prakash mohanasundaram emergency & critical care physician...
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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 CENTRAL
PULSE
CHECK FOR CENTRAL PULSEGIVE 2 RESCUE BREATHS
NO BREATHING
KEEP DEFIB PADDLESCHECK 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
VF/VT Aystole/PEA
Shockable Not Shockable
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VF/Pulseless VT
Give 1 shockBiphasic: 120 to 200 JMonophasic: 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 shockResume CPRGive 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 hrs0.5 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 5-20 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
Hypo / hyperkalemia
Hypoxia
Hypothermia
H+ ion - acidosis
Hypoglycemia Hypovolemia
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5Ts
Toxins
Tamponade - cardiac Thrombosis
Tension Pneumothorax Trauma
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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 activityForce of contractions not enough to produce a perfusing rhythmOften caused by reversible conditionsTreat the cause(6Hs and 5Ts)
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What to do if you see this?
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Asystole
Check the pulseCheck the leads first!Change the leadsIncrease 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
May give 1 dose of vasopressin 40IU to replace 1st or 2nd dose of
adrenaline
A,B,C, start CPR IV/IO give inj.adrenaline 1mg(repeat
every 3-5 mins)Atropine 1mg IV when slow PEA /
AsystoleMax 3 doses
Check rhythm after 5 cycles of CPR
PEA / Asystole Go to shockable
rhythm management
VF / VT
If NSR go to post resuscitation care
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Management of PEA / Asystole
Focus on high quality CPRAirway ASAPMinimize interruptions in chest compressionsDeliver IV/IO medications once CPR is startedEpinephrine every 3-5 minsAtropine is 1mg , max of 3 dosesVasopressin can replace adrenaline during the first or second dose
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Causes of Pulseless arrest
HypovolemiaHypoxiaHydrogen ionHypo/ hyperkalemiaHypoglycemiaHypothermia
ToxinsTamponade ,cardiacTension pneumothoraxThrombosis (coronary/pulmonary)Trauma
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The drugs in cardiac arrest
EpinephrineVasopressinAtropineAmiodarone Magnesium Lidocaine
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Classification of ACLS drugs
Class I Class II -a Class II - b Class -
Indeterminate Class III
Definitely usefulProbably usefulPossibly usefulNo supporting
evidenceHarmful
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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 thumpProcainamide in VFNor adrenaline - worse neurologic outcomesVolume expansion with IV fluids
Pacing in asystole
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Be prepared
Emergency drugs kitAirway kitRegular drillsTeam workDebriefing
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Summary
AnticipateRemember to change leads and increase gain in AsystoleBasics of CPRPlease don’t shock Asystole / PEAConstant update
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DEAD but STILL ALIVE
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Thank you !