primary care out of hospital cardiac emergency (cardiac arrest) in adult - bambang herwanto, md,...

8/18/2019 Primary Care Out of Hospital Cardiac Emergency (Cardiac Arrest) in Adult - Bambang Herwanto, MD, FIHA.pdf

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CARDIOVASCULAR EMERGENCIES COURSEBumi Surabaya Hotel, November 7-8th, 2015

Primary Care Out of Hospital cardiac

emergency (Cardiac Arrest) in Adult

Bambang HerwantoIrien Eko Hermawati


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INTRODUCTION

Cardiac emergencies should berecognized quickly

Cardiac

Arrest

• America approximately 300,000/yr

and 92% died

• The prevalence of cardiac arrest inIndonesia unclear, but is estimated

at about 30 people per day

Out of hospital cardiac Arrest

Elshazly M&Nissen 2014,Chugh S et al

2008,DepKes 2006e


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• Survival rates out of hospital

cardiac arrest until arriving at

the hospital approximately

23.8% and until hospital

discharge 7.6%.

• From the reports of various

countries, obtained anaverage survival to hospital

discharge 6.4%

• Other data showed 21.6% of

people died although CPR

performed by bystanders

Out of hospital

Cardiac Arrest


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PATOPHYSIOLOGY

Cardiac Cause of Out of hospital Cardiac Arrest :

1. Coronary Heart Disease

2. Cardiomyopathies

3. Other heart abnormality:

- congenital heart structure abnormalities :

• Coronary artery anomalies

• Cyanotic and acyanotic heart disease

- Electrical abnormalities and genetic

• Long QT Syndrome ( LQTS)

• Brugada Syndrome

• Cathecolaminergic Polymorphic Ventricular

Takikardia (CPVT)

• Short QT Syndrome (SQTS)


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Coronary Heart Disease


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Atherosclerosis

Plaque

Rupture

Platelet activation Coagulation casade

Trombus

Partial

Occlusion

Total

occlusion


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Cardiomyopathies

Hypertrophic Cardiomyiopathy, Dilated Cardiomyopathy,

Arrhytmogenic right ventricular displasia, myocardial

infiltratifve disease

Myocardial disorganization + small scar tissue

VT/VF


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CLINICAL EXAMINATION

The most important sign of cardiac

arrest in adults is :

• unconscious

• no breathing

The presence of these sign showed

that no blood and oxygen reaching

the brain and vital organs


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SUPPORTING EXAMINATION

• Heart rhythm

• During cardiac arrest : VF, VT without

a pulse, PEA and asystole.

• VF and VT > 70% of patients

who experienced cardiac arrest.

Defibrillator and monitor :

• 200-360 J for monophasic

• 120-200 J for biphasic.

The success rate after the first shock:

• biphasic 96%

• monophasic 54-77%.

Better neurological status

• biphasic 87%

• monophasic 53% .


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MANAGEMENT

First Aid

• Assessment and actions that can be

performed by bystanders or victims with

minimal equipment or no equipment

• Everyone should be able “to help”

• First aid competencies include, at any

level of training:• Recognizing, assessing, and

prioritizing the need for first aid

• Providing care by using appropriate

knowledge, skills, and behaviors

• Recognizing limitations and seeking

additional care when needed


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CASE


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Basic Life Support Sequence

Lay Rescuer Not Trained

Lay Rescuer Trained

HealthcareProvider

Kleinman E M et al 2015


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Lay Rescuer Not Trained

Ensure Scene Safety

Check for response

Look for no breathing or only

gasping, at the direction of thedispatcher.

Follow the dispatchers

instructions

Shout for nearby help. Phone or

ask someone to phone 9-1-1 (the

phone or caller with the phone

remains at the victims side, with

the phone on speaker).

Follow the dispatchers instructions


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Lay Rescuer Trained

Ensure Scene Safety

Check for response

Answer the dispatchers

questions, and follow the

dispatchers instructions.

Check for no breathing or onlygasping; if none, begin CPR with

compressions.

Shout for nearby help and activate

the emergency response system

(9-1-1, emergency response). If someone responds, ensure that

the phone is at the side of the

victim if at all possible.

Send the second person to retrieve an

AED, if one is available.


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Healthcare Provider

Ensure Scene Safety

Check for response

Check for no breathing or only gasping

and check pulse (ideally simultaneously).

Activation and retrieval of the

AED/emergency equipment by either the

lone healthcare provider or by the second

person sent by the rescuer must occur nolater than immediately after the check for

no normal breathing and no pulse

identifies cardiac arrest.

Shout for nearby help/activate the

resuscitation team; can activatethe resuscitation team at this time

or after checking breathing and

pulse.


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Healthcare Provider

Immediately begin CPR, and use

the AED/ defibrillator when

available.

When the second rescuer arrives,

provide 2-person CPR and use

AED/defibrillator


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Chain of Survival

• Immediate recognition of sudden cardiac arrestand activation of the emergency response

system

• Early CPR

• Rapid defibrillation with an automated external

defibrillator (AED)• EMS and transitional to the hospital

• Post Cardiac Arrest Care

System-specific Chain of

Survival


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Immediate recognition of sudden cardiac arrest

and activation of the emergency response system

• Time is very important in witnessed cardiac

arrest

• Recognition and immediately activate theemergency system by people around the

victim becomes very important.

• A frequent mistake abnormal

breathing or gasping no action


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Early CPR

High-quality CPR improves survival from cardiac arrest,

including : – Ensuring chest compressions of adequate rate

– Ensuring chest compressions of adequate depth

– Allowing full chest recoil between compressions

– Minimizing interruptions in chest compressions

– Avoiding excessive ventilation

• In adult victims of cardiac arrest, it is reasonable for

rescuers to perform chest compressions at a rate of 100 to120/min

• During manual CPR, rescuers should perform chest

compressions at a depth of at least 2 inches or 5 cm for an

average adult, while avoiding excessive chest compression

depths (greater than 2.4 inches [6 cm])


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Rapid defibrillation with an automated external

defibrillator (AED)

1. Turn on AED

2. Open and wipe the victim’s

chest3. Place AED pad in the victims

chest

4. Plug AED connector

5. AED analyze the rhythm

6. Do as AED instruction


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If the AED instructs “shock”:

- Make sure there are no people, including helper touching the patient.

- Shout "everyone, stay away"

- Give the shock by pressing the "shock“ botton- After giving shock or no shock instruction:

• Perform CPR for 2 minutes

• Continue as AED directed


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EMS and transitional to the

hospital

If the EMS personnel arrive advanced life

support + immediately sent to hospital.


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Post Cardiac Arrest Care

• ROSC post-cardiac arrest care should

be given.

• The important thing is the handling of hypoxemia

and hypotension• early diagnosis and treatment of underlying

disease that causes cardiac arrest

• In ROSC patients > 70% of victims in Europe

performed coronary angiography immediately

(1) to identify and treat the underlying etiology of the

cardiac arrest,

(2) to mitigate ischemia-reperfusion injury and

prevent secondary organ injury, and

(3) to make accurate estimates of prognosis to guide

the clinical team and to inform the family when

selecting goals of continued care

Emergency Coronary

angigraphy


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PROGNOSTIC

• The survival rate of patients who experienced

OHCA > 50% is obtained when the initial

documented rhythm is ventricular fibrillation or

ventricular tachycardia.• When the initial rhythm was PEA or asystole

survival rate 6-10%.

• Neurological recovery as previously occurred>

50% of victims, severe neurological

abnormalities occurred in


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SUMMARY

• Cardiac Arrest is a heart emergency that must be handled

immediately.

• The prevalence in the United States range from 180000-

250000 every year, and most of it was out of hospital

cardiac arrest.

• In the America approximately 300,000 people experience

cardiac arrest out of hospitals each year, and 92% died.

• Etiology of cardiac arrest are coronary heart disease,

cardiomyopathy and other cardiac abnormalities.


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• Cardiac arrest first aid continue update.

• Guideline Updates stressed that first aid should be done bypeople who are surround the victim ( bystanders)

• The chain of survival unchange

• AHA guideline for cardiopulmonary resuscitation and

emergency cardiovascular care in 2015 even stressed

about the existence of mobile phones everywhere, whichcan be used to call the dispatcher’s helper to go to the side

of the victim.

• If the initial rhythm documented ventricular fibrillation or

ventricular tachycardia prognosis will be better (50%)

compared to the PEA or asystole (6-10%).


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THANK YOU

primary care out of hospital cardiac emergency (cardiac arrest) in adult - bambang herwanto, md,...

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