Cardiac arrest

Cardiac arrest

By: A. Taskin

by : A.taskin ( [email protected] )

• Cardiac arrest :

is an abrupt cessation of cardiac pump function that may be reversible but will progress to death without prompt intervention.

• The four rhythms that produce pulseless cardiac arrest are :

• ventricular fibrillation, • pulseless ventricular tachycardia • Asystole• Pulseless electrical activity


Clinical features :

A patient who is :

1. unconscious,

2. apneic, and

3. pulseless

fulfills the cardiac arrest diagnosis criteria


Clinical features :

• In ventricular fibrillation : • loss of consciousness occurs within 15 seconds, • but agonal gasping may persist for around 60 seconds following

collapse. • Brief seizure may occur, caused by cessation of cerebral blood

flow

•Cardiac arrest secondary to respiratory arrest causes :• loss of consciousness, bradycardia, and absent pulse within 5

minutes


Clinical features :

Symptoms : ( may be present )

New or changing angina

Fatigue

Palpitations

Dyspnea

Chest pain


often results from reversible causes that must be rapidly identified and treated.

5 Ts':

• Tamponade, cardiac

• Toxins

• Tension pneumothorax

• Thrombosis, pulmonary

• Thrombosis, coronary

'5 Hs :

• Hypovolemia

• Hypothermia

• Hypoxia

• Hypo- or hyperkalemia

• Hydrogen ion (acidosis)


Coronary artery disease with myocardial infarction is the most common structural heart disease predisposing to cardiac arrest.


physical examination factors :

• immediate CPR and rapid defibrillation take precedent over examination in the cardiac arrest victim.

• Ensure adequacy of airway. Note the presence of any blood, vomitus, or secretions


• Absent respiratory effort

• presence of only agonal gasps are characteristic of cardiac arrest.

•Unilateral breath sounds may indicate:• tension pneumothorax or • aspiration.

•Wheezing and rales• underlying pulmonary edema or• aspiration


• Heart tones may be heard in patients with :• pulmonary embolus, tension pneumothorax, or

hypovolemia

• Jugular venous distension may be noted in :• tension pneumothorax, cardiac tamponade, or pulmonary

embolus

• A distended, dull abdomen may be noted in patients with a

• ruptured abdominal aortic aneurysm or ruptured ectopic pregnancy


Investigations:

• Rapid rhythm assessment

• End-tidal carbon dioxide partial pressure

• Central venous oxygen saturation

• Arterial relaxation pressure

• Echocardiogram

• Serum electrolytes

• 12-lead electrocardiogram

• Serum lactate


Differential diagnosis :

• Supraventricular tachycardia with aberration

•Choking


Choking• a person choking on a piece of food may be mistakenly thought to be

suffering acardiac arrest

• Choking commonly occurs during a meal, often when the person is talking or laughing

• Food lodges in the oropharynx, causing sudden cyanosis and collapse

• May cause primary respiratory arrest with absence of respiratory efforts or severe stridor with persistence of a pulse

• The Heimlich maneuver usually dislodges the piece of food, allowing immediate recovery

• Choking may progress to cardiac arrest if the piece of food or other foreign body is not dislodged


Causes :


Causes : • Respiratory causes :

• mechanical airway obstruction, submersion injury, and respiratory failure originating from asthma, pulmonary edema, or sedative overdose.

• Metabolic abnormalities :

• commonly hyperkalemia, which is most frequently seen in patients with renal failure.

• Less commonly, hypokalemia, hypermagnesemia, hypomagnesemia and hypercalcemia .


Causes : • Toxins :

• overdose of prescription medications or • illicit drugs e.g. digitalis, β-blockers, cocaine, and heroin .

• Electrical currents of 100 mA to 1 A usually cause ventricular fibrillation; currents above 10 A can cause asystole

• Brugada syndrome:

• which is an inherited disorder affecting cardiac membrane channels that is associated with polymorphic ventricular tachycardia and ventricular fibrillation.

• ECG showing a right bundle branch block with ST segment elevation in leads V1 to V3


Causes :

Long QT syndrome :

• characterized by prolonged QT interval (repolarization) on resting ECG .


Algorithms & management


CPR :

• Initiate CPR with 30 chest compressions.

•For all adults:

provide cycles of 30 chest compressions

followed by 2 breaths.


CPR :

• In the pediatric :

30 compressions:2 breaths for 1 rescuer CPR

15 compressions: 2 breaths for 2 or more rescuers.


CPR :

• push hard, push fast (≥ 100 compressions/min) while allowing full recoil of the chest between compressions.

• Compressions should be delivered over the lower half of the sternum to a depth of 2 inches in adults and

• at least one-third of anterior-posterior diameter of the chest ininfants and children


CPR :

• Immediately resume CPR after each defibrillation attempt and continue for 2 minutes before rechecking rhythm .


Immediate action : • 1- Begin high-quality CPR & defibrillation .

• Perform rapid rhythm assessment with quick-look paddles, electrode pads, or limb leads

• Patients with ventricular tachycardia or ventricular fibrillation require immediate defibrillation

• Patients with PEA or asystole should have continued CPR while attempts are made to diagnose and treat the underlying cause

• 2- Administer supplemental oxygen as soon as it is available

• 3- Establish intravenous or intraosseous access as soon as possibleby : A.taskin ( [email protected] )

Immediate action : • After 2 minutes of CPR, reassess rhythm. If a shockable rhythm is

present, shock again

• Administer epinephrine 1 mg intravenously or intraosseously. • Repeat every 3 to 5 minutes.

• Administer amiodarone 300 mg intravenously or intraosseously. Repeat once at 150 mg in 3 to 5 minutes .

• A single dose of vasopressin 40 units intravenously or intraosseously may be substituted for the first or second dose of epinephrine


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Immediate action : • Magnesium sulfate

• 1 to 2 g intravenously or intraosseously may be considered for suspected hypomagnesemia or torsade de pointes associated with a long QT interval.

• It is not recommended for routine use in cardiac arrest

• sodium bicarbonate• Routine use of for the treatment of cardiac arrest is not

recommended.• May beneficial for tricyclic antidepressant overdose,

severe cocaine toxicity, hyperkalemia, and pre-existing acidosis . by : A.taskin ( [email protected] )



Immediate action : • Atropine is no longer recommended for routine use in the

management of asystole/PEA

• Electrical pacing is not recommended for the treatment of:• PEA or asystole

•Norepinephrine can be used as adjunctive treatment for patients with profound hypotension



In a non-ventricular fibrillation/ventricular tachycardia pulseless rhythm:

•Continue with CPR

•Add epeniphrine

•Continue CPR for 2 minutes, then recheck rhythm.

• If shockable rhythm is present, defibrillate


Bradycardia (heart rate < 50 beats/min):• If perfusion is inadequate and thought to be due to

bradycardia:• Administer a 0.5-mg intravenous bolus of atropine; repeat

every 3 to 5 minutes to a maximum of 3 mg• If atropine is inadequate :1. proceed to transcutaneous pacing or

administer dopamine 2 to 10 μg/kg/min or epinephrine 2 to 10 μg/min by intravenous infusion.

2. Intravenous infusion of chronotropic agents is an equally effective alternative to external pacing in this setting Consider transvenous pacing


Tachycardia (heart rate typically greater than or equal to 150 beats/min):

• If there is no evidence of inadequate perfusion,

• obtain a 12-lead ECG to assess whether rhythm is

• wide-complex tachycardia (QRS ≥ 0.12 s) or• narrow-complex tachycardia (QRS < 0.12 s)

• If there is evidence of inadequate perfusion, perform immediate synchronized cardioversion


In wide-complex tachycardia:( V-tach , (SVT) with aberrancy, pre-excitation tachycardia, and ventricular paced rhythms )

If the rhythm is regular with a monomorphic QRS waveform,

•adenosine can be used for diagnosis and treatment.

• Administer a 6-mg rapid intravenous push

• followed by a flush to deliver the drug as a rapid bolus.

• If there is no conversion, give a 12-mg rapid intravenous push of adenosine; the 12-mg dose may be given once more.



Cont, complex tach :

Consider an antiarrythmic infusion of amiodarone.

• Administer 150 mg intravenously over 10 minutes.

• repeat as needed to a maximum dose of 1.1 g/24 h.

• Follow with a maintenance infusion of 1 mg/min for the first 6 hours. Alternatives include procainamide and sotalol

• Prepare for synchronized cardioversion


For irregular rhythm:

• Consider atrial fibrillation with aberrancy and treat as for atrial fibrillation.

• If there is pre-excitation atrial fibrillation, such as Wolff-Parkinson-White syndrome, consider a consultation with a cardiologist.

• Avoid atrioventricular nodal blocking agents (adenosine, digoxin, diltiazem, verapamil), which may paradoxically increase ventricular rate. Consider amiodarone .


In narrow-complex tachycardiafor regular rhythm:

• Attempt vagal maneuvers

• Administer a 6-mg rapid intravenous push of adenosine.

• If there is no conversion, give a 12-mg rapid intravenous push of adenosine. The 12-mg dose may be given once more

• If the rhythm converts, • it is likely to be re-entrant SVT; • consider diltiazem or β-blockers to prevent recurrence


If rhythm does not convert :

• consider possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia.

• Consider expert consultation, and consider diltiazem or β-blockers to control rate

Implantable cardioverter-defibrillators (ICDs) are:

indicated for patients surviving cardiac arrest resulting from ventricular fibrillation or ventricular tachycardia

that is not due to a transient or reversible cause . by : A.taskin ( [email protected] )

Cardiac arrest

Health & Medicine

Transcript of Cardiac arrest