2. CARDIAC ARREST By Gamal faheim, MD Associate professor of cardiovascular medicine

3. DEFINITIONS CARDIAC ARREST: Abrupt cessation of cardiac pump function which may be reversible by a rapid intervention but will lead to death in its absence. CARDIAC ARREST: Abrupt cessation of cardiac pump function which may be reversible by a rapid intervention but will lead to death in its absence. DEATH: Irreversible cessation of all biologic functions DEATH: Irreversible cessation of all biologic functions

4. MECHANISMS OF CARDIAC ARREST 50-80%: VF and PULSLESS VT 50-80%: VF and PULSLESS VT 20-30%: Asystole, severe bradycardia and pulseless electrical activity 20-30%: Asystole, severe bradycardia and pulseless electrical activity

5. Background USA - 250 000 to 330000 estimated annual SCA deaths per year USA - 250 000 to 330000 estimated annual SCA deaths per year Survival < 6% worldwide average Survival < 6% worldwide average Trials - short term outcomes Trials - short term outcomes - underpowered, small - underpowered, small - not randomized - not randomized - design limitations - design limitations Informed consent Informed consent

7. 7 Decision to start CPR: Decision to start CPR is made if a victim is unresponsive and not breathing normally. Decision to start CPR is made if a victim is unresponsive and not breathing normally. Pulse check is no longer required, and is NOT recommended for lay persons. Pulse check is no longer required, and is NOT recommended for lay persons. Pulse check has been shown to be unreliable, with unacceptably high rates of false positives and negatives. Pulse check has been shown to be unreliable, with unacceptably high rates of false positives and negatives.

8. Cardio-pulmonary resuscitation (CPR) is a means to provide temporary support to the coronary and cerebral circulation, till normal cardiac output is restored

9. Adult Basic Life Support PERSON COLLAPSES Check if he is unresponsive. Call Emergency number. Get AED (automatic Electric Defibrillator) Begin the ABCD’s

10. Adult Basic Life Support Basic life support consists of the following sequence of actions: Make sure the victim, any bystanders, and you are safe. Make sure the victim, any bystanders, and you are safe. Check the victim for a response. Check the victim for a response. Gently shake his shoulders and ask loudly, ‘Are you all right?’ Gently shake his shoulders and ask loudly, ‘Are you all right?’ If he responds: – Leave him in the position in which you find him provided there is no further danger. – Try to find out what is wrong with him and get help if needed. – Reassess him regularly. If he does not respond: – Shout for help. – Turn the victim supine aligned position or stable side position.

11. CONFIRM LOSS OF CONSCIOUSNESS Shout Loudly! Shout Loudly! Shake Gently!! Shake Gently!!

12. Adult Basic Life Support START THE ABCD’s Airway: Open Airway. Breathing: (Look, Listen &Feel) Circulation:. Monitor and check the pulse.

13. Adult Basic Life Support Defibrillator: An important advance in providing BLS is the availability of AED, which can be used to deliver defibrillation. improving survival outcomes in cardiac arrest cases.

14. Open airway – signs of life? Head tilt / chin lift Head tilt / chin lift Check breathing and pulse for 10 sec Check breathing and pulse for 10 sec If no breathing & no pulse or unsure of pulse assume cardiac arrest If no breathing & no pulse or unsure of pulse assume cardiac arrest Caution of agonal breathing Caution of agonal breathing

15. Adult Basic Life Support Breathing: Keeping the airway open, look, listen, and feel for normal breathing. Look for chest movement. Look for chest movement. Listen at the victim's mouth for breath sounds. Listen at the victim's mouth for breath sounds. Feel for air on your cheek. Feel for air on your cheek. In the first few minutes after cardiac arrest, a victim may be barely breathing, taking infrequent, noisy, gasps. Do not confuse this with normal breathing. Look, listen, and feel for no more than 10 sec to determine if the victim is breathing normally. If you have any doubt whether breathing is normal, act as if it is not normal.

16. Pocket mask vs bag-valve mask

17. If signs of life present Signs of life... Signs of life... Normal breathing Normal breathing Coughing Coughing Movement Movement Palpable pulse Palpable pulse Assess ABCDE Assess ABCDE Call expert help immediately Call expert help immediately

18. Adult Basic Life Support If he is breathing normally: If he is breathing normally: Turn him into the recovery position. Turn him into the recovery position. Send or go for help, or call for an ambulance. Send or go for help, or call for an ambulance. Check for continued breathing. Check for continued breathing. If he is not breathing normally: If he is not breathing normally: Ask someone to call for an ambulance or, if you are on your own, do this yourself; you may need to leave the victim. Ask someone to call for an ambulance or, if you are on your own, do this yourself; you may need to leave the victim. Start chest compression as follows: Start chest compression as follows: Kneel by the side of the victim. Kneel by the side of the victim. Place the heel of one hand in the centre of the victim’s chest. Place the heel of one hand in the centre of the victim’s chest.

19. Adult Basic Life Support Place the heel of your other hand on top of the first hand. Place the heel of your other hand on top of the first hand. Interlock the fingers of your hands and ensure that pressure is Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone). Position yourself vertically above the victim's chest and, with Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum 4 - 5 cm. After each compression, release all the pressure on the chest After each compression, release all the pressure on the chest without losing contact between your hands and the sternum. Repeat at a rate of about 100 times a minute (a little less than Repeat at a rate of about 100 times a minute (a little less than 2 compressions a second). Compression and release should take an equal amount of time. Compression and release should take an equal amount of time.

20. 20 Chest compressions Place hands on the center of the chest, rather than the ‘rib margin’ method. Place hands on the center of the chest, rather than the ‘rib margin’ method. 100/min for all victims (except newborns). 100/min for all victims (except newborns). Allow chest to recoil to normal position after each compression. Allow chest to recoil to normal position after each compression. Use equal compression and relaxation times. Use equal compression and relaxation times. Limit interruptions in chest compressions, even for rhythm check, shock delivery, advanced airway, or vascular access. Limit interruptions in chest compressions, even for rhythm check, shock delivery, advanced airway, or vascular access.

21. 30 chest compressions Heel of hand in centre of chest Heel of hand in centre of chest Interlock fingers Interlock fingers Keep arms straight Keep arms straight Compress 4-5 cm depth Compress 4-5 cm depth Rate of 100 min-1 Rate of 100 min-1 Allow chest to recoil Allow chest to recoil

22. Adult Basic Life Support Combine chest compression with rescue breaths: Combine chest compression with rescue breaths: After 30 compressions open the airway again using head tilt and chin lift. After 30 compressions open the airway again using head tilt and chin lift. Pinch the soft part of the victim’s nose closed, using the index finger and thumb of your hand on his forehead. Pinch the soft part of the victim’s nose closed, using the index finger and thumb of your hand on his forehead. Allow his mouth to open, but maintain chin lift. Allow his mouth to open, but maintain chin lift. Take a normal breath and place your lips around his mouth, making sure that you have a good seal. Take a normal breath and place your lips around his mouth, making sure that you have a good seal. Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his chest rise as in normal breathing; this is an effective rescue breath. Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his chest rise as in normal breathing; this is an effective rescue breath. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out. Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out.

23. Adult Basic Life Support Take another normal breath and blow into the victim’s mouth once more to give a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions. Take another normal breath and blow into the victim’s mouth once more to give a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions. Continue with chest compressions and rescue breaths in a ratio of 30:2. Continue with chest compressions and rescue breaths in a ratio of 30:2. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

24. Adult Basic Life Support If your rescue breaths do not make the chest rise as in normal breathing, then before your next attempt: If your rescue breaths do not make the chest rise as in normal breathing, then before your next attempt: Check the victim's mouth and remove any visible obstruction. Check the victim's mouth and remove any visible obstruction. Recheck that there is adequate head tilt and chin lift. Recheck that there is adequate head tilt and chin lift. Do not attempt more than two breaths each time before returning to chest compressions. Do not attempt more than two breaths each time before returning to chest compressions. If there is more than one rescuer present, another should take over CPR about every 2 min to prevent fatigue. If there is more than one rescuer present, another should take over CPR about every 2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers. Ensure the minimum of delay during the changeover of rescuers.

25. Adult Basic Life Support Chest-compression-only CPR: If you are not able, or are unwilling, to give rescue breaths, give chest compressions only. If you are not able, or are unwilling, to give rescue breaths, give chest compressions only. If chest compressions only are given, these should be continuous at a rate of 100 a minute. If chest compressions only are given, these should be continuous at a rate of 100 a minute. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation. Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

26. Adult Basic Life Support Continue resuscitation until: Continue resuscitation until: Qualified help arrives and takes over, Qualified help arrives and takes over, The victim starts breathing normally, or The victim starts breathing normally, or You become exhausted. You become exhausted.

27. RECOVERY POSITION Adult Basic Life Support

29. HIGH QUALITY CPR RATE - push hard, push fast 100/min RATE - push hard, push fast 100/min DEPTH - 1.5 TO 2 inches DEPTH - 1.5 TO 2 inches COMPLETE CHEST RECOIL COMPLETE CHEST RECOIL MINIMISE INTERRUPTIONS MINIMISE INTERRUPTIONS CHANGE REGULARLY CHANGE REGULARLY Restore Coronary & Cerebral Blood Flow Restore Coronary & Cerebral Blood Flow

30. Technique of CPR Push Hard and Push Fast Push Hard and Push Fast Complete Chest Recoil Complete Chest Recoil Minimal Interruptions <10s Minimal Interruptions <10s Change Regularly Change Regularly

31. The Shocking Facts

32. Bundle Branch Reentrant VT

33. Ventricular Flutter Spontaneous conversion to NSR (12-lead ECG)

34. VF with Defibrillation (12-lead ECG)

35. Torsades de Pointes Spontaneous conversion to NSR (continuous lead II monitor strip)

36. Wide QRS Irregular Tachycardia: Atrial Fibrillation with antidromic conduction in patient with accessory pathway – Not VT

37. 37 AED was turned on and attached. The rhythm is labeled “coarse VF. ECG shows negative effect of delaying chest compressions after shock delivery. (From an AED record).

38. 38 Shock is advised and delivered, 22 sec after pads were attached. The shock eliminates the VF; the initial post-shock rhythm is asystole. The AED then analyzes the rhythm after the first shock.

39. 39 Post-shock rhythm through the next 21 sec. Asystole is present, and the AED is analyzing the rhythm so no CPR is provided and there is no blood flow.

40. 40 Re-fibrillation 25 sec after the first shock eliminated VF. No CPR performed during the 25 sec. AED then analyzes rhythm and recommends shock. Shock is delivered, asystole follows, and the AED then analyzes those rhythms. CPR is finally recommended and begins a total of 1:17 min after the first shock. The victim survived…

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42. Thank You Thank You