Cardiac Arrest Arrhythmias Terry White, RN

Cardiac Arrest Mechanisms Ventricular Fibrillation Pulseless Ventricular Tachycardia Asystole Pulseless Electrical Activity (PEA) A condition; Not an ECG rhythm

Cardiac Arrest Most common rhythms Adults: ventricular fibrillation Children: Asystole, Bradycardic PEA Pediatric V-fib suggests: Drug toxicity Electrolyte imbalance Congenital heart disease

Cardiac Arrest ABCs come first! Do NOT wait on equipment Airway - unobstructed?  manually open Breathing - no or inadequate  ventilate Circulation - no pulse in 5 sec  chest compressions Do NOT wait on equipment Assure effective BLS before going to ALS Rise and fall of chest Air movement in lung fields Pulse with compressions

Cardiac Arrest First ALS priority is defibrillation Only cure for v-fib is defib The quicker the better Probability of resuscitation decreases 7-10% with each passing minute

Cardiac Arrest Vascular access Antecubital space Arm, EJ, Foot (last resort) IO in peds < 6 y/o 14 or 16 gauge LR or NS 30 sec - 60 sec of CPR to circulate drug

Cardiac Arrest Intubation as time allows Less emphasis today as compared to past Epi, atropine, lidocaine may be administered down tube 2x IV dose IV is preferred

Analyze the Rhythm

Ventricular Fibrillation (VF) Characteristics Chaotic, irregular, ventricular rhythm Wide, variable, bizarre complexes Fast rate of activity Multiple ventricular foci No cardiac output Terminal rhythm if not corrected quickly Most common rhythm causing sudden cardiac death in adults

Ventricular Fibrillation (VF) Treatment ABC’s Witnessed arrest: Precordial thump Little demonstrated value but worth a try CPR until defibrillator available Quick Look for VF or pulseless VT Treat pulseless VT as if it were VF Defibrillate 200 J, 300 J, 360 J Quickly and in rapid succession Identify cause if possible

Ventricular Fibrillation Treatment If still in VF/VT arrest, continue CPR for 1 minute Establish IV access and Intubate If sufficient personnel, attempt both simultaneously If not, quick attempt at IV access then attempt ETT Vasopressor Medication Epinephrine 1 mg 1:10,000 IVP Repeat every 3-5 mins as long as arrest persists Vasopressin (alternative to Epinephrine) 40 units IVP one time only

Ventricular Fibrillation Treatment Shock @ 360 J after each medication given as long as VF/VT arrest persists Alternate epi-shock & antidysrhythmic-shock sequence Antidysrhythmic Medication amiodarone 300 mg IVP single dose lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total procainamide 100 mg IV, q 5 min, max 17 mg/kg total magnesium 10% 1-2 g IV if hypomagnesemic or prolonged QT

Ventricular Fibrillation Treatment Consider NaHCO3 if prolonged Only after effective ventilations In many EMS systems, consider terminating resuscitation efforts in consult with med control

Ventricular Fibrillation The ultimate unstable tachycardia Shock early-Shock often Sequence is drug-shock-drug-shock Sequence of drugs is epi-antiarrhythmic-epi-antiarrhythmic

Analyze the Rhythm

Asystole Characteristics The ultimate unstable bradycardia A terminal rhythm poor prognosis for resuscitation best hope if ID & treat cause No significant positive or negative deflections

Asystole Possible Causes Hypoxia: ventilate Preexisting metabolic acidosis: Bicarbonate 1 mEq/kg Hyperkalemia: Bicarbonate 1 mEq/kg, Calcium 1 g IV Hypokalemia: 10mEq KCl over 30 minutes Hypothermia: rewarm body core

Asystole Possible Causes Drug overdose Tricyclics: Bicarbonate Digitalis: Digibind (Digitalis antibodies) Beta-blockers: Glucagon Ca-channel blockers: Calcium

Asystole & PEA Differentials (The 5Hs & 5Ts) Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hyper/hypo-kalemia Hypothermia Tablets (Drug OD) Tamponade Tension Pneumothorax Thrombosis, Coronary Thrombosis, Pulmonary

Asystole Treatment Primary ABCD Secondary ABCD Confirm Asystole in two leads Reasons to NOT continue? Secondary ABCD ECG monitor/ET/IV Differential Diagnosis (5Hs & 5Ts) TCP (if early) Epinephrine 1:10,000 1 mg IV q 3-5 min. Atropine 1 mg IV q 3-5 min, max 0.04 mg/kg Consider Termination

Analyze the Rhythm What are you going to do for this patient?

Now, what are you going to do for this patient? Case Presentation The patient is a 16-year-old male who was stabbed in the left lateral chest with a butcher knife. He responds only to pain. His respirations are rapid, shallow, and labored. Central cyanosis is present. Breath sounds are absent on the left side. The neck veins are distended. The trachea deviates to the right. Radial pulses are absent. Carotids are rapid and weak. Now, what are you going to do for this patient?

PEA Possibilities Massive pulmonary embolus Massive myocardial infarction Overdose: Tricyclics - Bicarbonate Digitalis - Digibind Beta-blockers - Glucagon Ca-channel blockers - Calcium

PEA Identify, correct underlying cause if possible Possibilities: Hypovolemia: volume Hypoxia: ventilate Tension pneumo: decompress Tamponade: pericardiocentesis Acute MI: vasopressor Hyperkalemia: Bicarbonate 1mEq/kg Preexisting metabolic acidosis: Bicarbonate 1mEq/kg Hypothermia: rewarm core

PEA Treatment In many systems, consider termination of efforts ABCDs ETT/IV/ECG monitor Differential Diagnosis Find the cause and treat if possible Epinephrine 1:10,000 1 mg q 3-5 min. If bradycardic, Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg TCP In many systems, consider termination of efforts

Hypothermia-Initial Therapy Remove wet garments Protect against heat loss & wind chill Maintain horizontal position Avoid rough movement and excess activity

Hypothermia – No Pulse CPR Defibrillate X 3 if VF/VT ETT with warm, humidified O2 IV access with warm fluids Temp >30C/86F: Continue as usual with longer intervals Repeat defibrillation as temp rises Temp <30C/86F Continue CPR Withhold medications and further defibrillation Transport for core warming

Hypothermia – No Pulse Remember: A hypothermic patient is not dead until he is WARM & DEAD!!!

Managing Cardiac Arrest Check pulse after any treatment or rhythm change

Post-resuscitation Care If pulse present: Assess breathing Present? Air moving adequately? Equal breath sounds? Possible flail chest?

Post-resuscitation Care If pulse present: Protect airway Position to prevent aspiration Consider intubation 100% Oxygen via BVM or NRB Vascular access

Post-resuscitation Care Assess perfusion Evaluate Pulses Skin color Skin temperature Capillary refill BP Key is perfusion, not pressure

Post-resuscitation Care Management of Decreased Perfusion Fluid challenge Catecholamine infusion Dopamine, or Norepinephrine Titrate to BP ~ 90 to 100 systolic

Post-resuscitation Care Suppression of ventricular irritability If VT or VF converted before lidocaine given, lidocaine bolus and drip If lidocaine or bretylium worked, begin infusion Suppress irritability before giving vasopressors