DR. PRAKASH MOHANASUNDARAM CARDIAC ARREST DR. PRAKASH MOHANASUNDARAM Emergency & Critical care Physician Vinayaka Mission University SALEM

What is cardiac arrest? which may be reversible by a prompt Abrupt cessation of cardiac pump function which may be reversible by a prompt intervention but will lead to death in its absence

NO Central Pulse

Scenario 1 He was about to be shifted to the cathlab when he suddenly became drowsy and then unconscious

CALL FOR HELP CHECK FOR RESPONSE OPEN THE AIRWAY CHECK FOR BREATHING

NO BREATHING NO CENTRAL PULSE GIVE 2 RESCUE BREATHS CHECK FOR CENTRAL PULSE NO CENTRAL PULSE KEEP DEFIB PADDLES CHECK RHYTHM

Identify the rhythm

What is VF? Coarse fibrillatory waves Chaotic electrical activity If flatline increase gain - fine VF

Identify the rhythm

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

Polymorphic VT The QRS morphology keeps varying If preceded by a prolonged QT interval when in sinus rhythm – Torsades de pointes

Primary ABCD Survey Basic Life Support: Airway Breathing Circulation Attach monitor/defibrillator

Check rhythm VF/VT Aystole/PEA Shockable Not Shockable VF/VT Aystole/PEA Not Shockable

VF/Pulseless VT Give 1 shock Biphasic: 120 to 200 J Monophasic: 360 J Give the highest energy in that equipment Resume CPR immediately

PADDLE PLACEMENT

Persistent VF/Pulseless VT Give 1 shock Resume CPR Give vasopressor Epinephrine 1 mg IV repeat every 3 to 5 minutes OR Vasopressin 40 U IV

If rhythm persists Consider antiarrhythmics

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 hrs 0.5 mg for next 18 hrs Preferred through central line

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

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

Reduce interruptions as much as possible !!!!!!!

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

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.

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.

Causes of pulseless arrest-6Hs Hypovolemia Hypoglycemia Hypoxia H+ ion - acidosis Hypothermia Hypo / hyperkalemia

5Ts Tension Pneumothorax Toxins Trauma Tamponade - cardiac Thrombosis

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

Pulseless Electrical Activity (PEA) Pulseless patients with minimal electrical activity Force of contractions not enough to produce a perfusing rhythm Often caused by reversible conditions Treat the cause(6Hs and 5Ts)

What to do if you see this?

PLEASE DON’T DELIVER SHOCK Asystole Check the pulse Check the leads first! Change the leads Increase the gain. Why? PLEASE DON’T DELIVER SHOCK

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

PEA and Asystole A,B,C, start CPR IV/IO give inj.adrenaline 1mg(repeat every 3-5 mins) Atropine 1mg IV when slow PEA / Asystole Max 3 doses May give 1 dose of vasopressin 40IU to replace 1st or 2nd dose of adrenaline PEA / Asystole VF / VT Go to shockable rhythm management Check rhythm after 5 cycles of CPR If NSR go to post resuscitation care

Management of PEA / Asystole Focus on high quality CPR Airway ASAP Minimize interruptions in chest compressions Deliver IV/IO medications once CPR is started Epinephrine every 3-5 mins Atropine is 1mg , max of 3 doses Vasopressin can replace adrenaline during the first or second dose

Causes of Pulseless arrest Toxins Tamponade ,cardiac Tension pneumothorax Thrombosis (coronary/pulmonary) Trauma Hypovolemia Hypoxia Hydrogen ion Hypo/ hyperkalemia Hypoglycemia Hypothermia

The drugs in cardiac arrest Epinephrine Vasopressin Atropine Amiodarone Magnesium Lidocaine

Classification of ACLS drugs Class II -a Class II - b Class - Indeterminate Class III Definitely useful Probably useful Possibly useful No supporting evidence Harmful

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

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

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

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

How does it work Corrects acidosis, improves vascular response Decreases defibrillation threshold Post resuscitation- increases myocardial contractility

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.

Pediatric arrest 2 rescuers 15 : 2 CPR technique Drugs: No atropine in PEA/ Asystole 2 Joules / kg then 4 joules/ kg

DRUGS Adrenaline 0.01mg/kg IV/IO 0.1 mg/kg ET Amiodarone 5mg/kg upto 15/mg/kg max of 300 mg.

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

Definite NO NOs Precordial thump Procainamide in VF Nor adrenaline - worse neurologic outcomes Volume expansion with IV fluids Pacing in asystole

Be prepared Emergency drugs kit Airway kit Regular drills Team work Debriefing

Summary Anticipate Remember to change leads and increase gain in Asystole Basics of CPR Please don’t shock Asystole / PEA Constant update

DEAD but STILL ALIVE

Thank you !