1. Cardiac arrest resuscitation made easy
Tony Smith
Medical Director, St John
Intensive Care Medicine Specialist, Auckland City Hospital

2. Cardiac arrest resuscitation
Talking about cardiac arrest in the accident and medical clinic setting, not in the emergency department setting
General overview of out of hospital cardiac arrest
Guidelines
The evolving emphasis on chest compressions
Airway
Drugs
Defibrillation
Decision making with regard to starting and stopping
Cases for discussion
Questions

3. Take home messages Continually emphasise doing the basic things well
Good BCLS saves more lives than ACLS does
Chest compressions are the most important part of CPR for most patients
Focus on keeping things simple

4. Out of hospital cardiac arrest: overview
3 cardiac arrests in NZ per day (resuscitation attempted)
One per 4000 people per year
80% are primary
Obvious cardiac cause or no obvious cause
20% are secondary
Due to another obvious non-cardiac cause (drowning, trauma, hanging, poisoning)
For primary cardiac arrest
Median age is 65
70% male
80% occur in the home
50% receive bystander CPR

5. Out of hospital cardiac arrest: overview
Initial rhythm in primary cardiac arrest
50% VF
30% Asystole
18% PEA
2% VT
Overall 20% reach hospital and 8% survive
Outcomes are very rhythm dependent
Rhythm % Reach Hospital % Survival
VT 80% 70%
VF 40% 20%
PEA 10% 1%
Asystole 5% 1%

6. Out of hospital cardiac arrest: overview
Paediatric cardiac arrest
A completely different disease to adult cardiac arrest
5% of out of hospital cardiac arrest
90% secondary and 70% asystole
15% reach hospital and 1% survive
ROSC with BCLS is a marker of survival
Secondary cardiac arrest
A completely different disease to primary cardiac arrest
20% of out of hospital cardiac arrest
60% asystole and 30% PEA
10% reach hospital and 1% survive
Cardiac arrest in presence of personnel, immediately reversible cause, quick ROSC (within a few minutes) is a marker of survival

7. Guidelines There are lots Which guideline you follow is not important
NZRC, ARC, AHA, ERC, ILCOR….
They are all subtly different…
These differences often cause confusion
But the differences are not important
Which guideline you follow is not important
Keeping it simple is…
We (St John Clinical Management Group) have made a decision not to align with any one guideline
We have chosen to do some things differently where there is no evidence and we can simplify things
For example: ratios, joules and drug doses

8. Emphasis on chest compressions
Chest compressions are the most important part of CPR
CCR rather than CPR (flow is more important than content)
Particularly in primary cardiac arrest
Particularly early in cardiac arrest (the first 4-6 minutes)
Ratio has changed from 15:2 to 30:2 for non-intubated
No evidence for either ratio
The principle is more important than the exact ratio
Focus on the chest compressions
Minimise pauses, continuous whenever possible
Rate of approx 100/min
Adequate depth
Frequent change of person doing the compressions (every two minutes)

9. The airway
The LMA has a rapidly evolving role for airway management, including cardiac arrest
You do not need a cuffed ETT
The LMA has a high success rate in inexperienced hands (and ETT a low success rate)
I would recommend removing ETTs from clinics and replacing them with LMAs
Ventilation rates are important and often overlooked
8-10 breaths a minute
Higher rates cause blood flow to fall during CPR

10. Drugs No evidence that drugs improve survival from cardiac arrest
High dose adrenaline is no better than normal dose
Amiodarone improves ROSC rates in recurrent VF
My view: keep it simple
Don’t use atropine, calcium, bicarbonate, vasopressin, magnesium
The benefit of using amiodarone is very small and probably isn’t worthwhile in a clinic where cardiac arrest is rare
Give 1 mg (adults) adrenaline every four minutes
Use a decent flush (the easiest is a running line)
Keep paediatric dosing simple

11. Paediatric dosing
There is no evidence for current paediatric doses of drugs in cardiac arrest
They are hard to remember
They are hard to calculate in a rush
The St John approach
All children 50kg and above get adult doses
All other children are rounded off to the nearest of 10, 20, 30 or 40kg and dosed accordingly
Take the adult dose, draw it up to a total of 5ml and give 1ml for every 10kg
Works for all emergency drugs, including cardiac arrest
Dose differs a little from guidelines, but this doesn't matter and it simplifies dosing and reduces error

12. Defibrillation All moving away from stacked shocks to single shocks
Reduces pauses in chest compressions
Still role for initial stacked shocks if cardiac arrest occurs in presence of defibrillator
All recommend immediate CPR after defibrillation (without rhythm or pulse check)
Different recommendations on joules ( J)
Between guidelines
Between manufacturers
Between monophasic and biphasic
There may be a role for CPR before defibrillation in some
Particularly if in VF for more than a few minutes
Right heart dilation an impediment to defibrillation
Confused?

13. Defibrillation We (St John CMG) recommend a simple approach
Start with one round of stacked shocks if cardiac arrest occurs in presence of defibrillator, then go to single shocks
Always use maximum joules
Opt for defibrillation first
Round kids off to nearest 10kg and use 5J/kg

14. Defibrillation Manual defibrillators are $15,000-$20,000
AEDs are $3000-$5000
In clinics I would recommend an AED rather than a manual defibrillator
All clinical staff should know how to use it

15. Starting and stopping These decisions can be difficult
A resuscitation attempt should begin in most patients
Except where the patient is clearly dead (livedo, rigor mortis)
Or where they are clearly dying and it would be inappropriate
A competent patient can decline therapy but neither a patient nor their family can demand therapy that is medically inappropriate
Some scenarios have >99% mortality rates
Unwitnessed cardiac arrest with initial rhythm of asystole

16. Starting and stopping The chances of survival fall rapidly with time
Exponential falling curve
There is no absolute cut off when mortality becomes zero
Resuscitation attempts requiring longer than 20 minutes of CPR have a very high mortality rate
We recommend stopping at around 20 minutes unless there is a clinical reason to continue for longer
Transport to hospital with CPR enroute usually has no role

17. Cases for discussion Cases Invite audience participation
Reinforce the take home messages

18. Case #1 A 40 year old man is delivered by car to your clinic
He was found collapsed by his family in the toilet
He is in cardiac arrest
You begin a resuscitation attempt and a defibrillator is attached
He is in asystole…
What are you going to do?

19. Case #1 – my thoughts Check the leads and check the gain
It could be fine VF
Make sure it isn’t bradycardia
Which can look like asystole at a quick glance
Concentrate on good chest compressions
This is unwitnessed cardiac arrest with asystole
Predicted mortality is > 99.9%
The tiny number who survive have a high chance of severe disability
I would not continue for very long (around 5 minutes) if truly asystolic
I would then declare him dead

20. Case #2 A 70 year old man attends your clinic with chest pain
Soon after arrival he has a cardiac arrest VF
What are you going to do?

21. Case #2 – my thoughts This is about as good as it gets
Precordial thump unless you can shock in next five seconds
Start with stacked shocks, then go to single shocks (followed by immediate CPR without rhythm check)
Focus on good chest compressions (uninterrupted if possible), that is: CCR rather than CPR
Place an LMA (keep ventilation 8-10/min)
Drugs not an initial high priority
I would continue with a vigorous resuscitation attempt
I would be prepared to continue for twenty to thirty minutes

22. Case #3 Imagine case #2 again
This time however, the patient has a medic alert on his wrist which you notice for the first time as you are attaching the defibrillator
It says “not for resuscitation in the event of cardiac arrest”…
What would you do?

23. Case #3 – my thoughts This is a very difficult situation
It is very hard not to shock VF
You could pretend you haven’t seen the bracelet…
However, this man has made a clear advanced directive
A competent patient has the right to decline treatment
A patient is competent unless proven otherwise
I would stop resuscitation attempts
I wouldn’t shock him
If others insisted on a resuscitation attempt I would politely decline to be involved

24. Case #4 A 42 year old woman attends your clinic with asthma
She has a long history of asthma, with severe attacks requiring hospitalisation
Despite continuous nebulised salbutamol she rapidly gets worse over about ten minutes with severe respiratory distress, she is unable to talk and is becoming increasingly confused…
Why is she becoming confused?
What do you do?

25. Case #4
She develops a falling level of consciousness and becomes rapidly comatose with agonal gasps and ineffective breathing
The rhythm on the monitor is sinus tachycardia at a rate of 140/min, but the rate is rapidly slowing…
What do you do?

26. Case #4 – my thoughts
This has a high mortality rate if handled badly and a low mortality rate if handled well
She isn’t in cardiac arrest yet, but could be soon
I would prioritise
Avoiding dynamic hyperinflation, use a very low ventilation rate of around 6/min (focusing on oxygenation rather than ventilation)
Treating her asthma aggressively (adrenaline a high priority)
Chest compressions not initially high on my list
Tension pneumothorax is rare in this setting
Signs are predominantly in the circulation
Drainage technique important if you think it is present
If she goes on to become asystolic the mortality rate becomes 99%

27. Summary: take home messages
Individual guidelines are not important
Keeping it simple is
The chest compressions are the most important part of CPR
CCR rather than CPR
The LMA can replace the ETT in most cardiac arrests
Adrenaline is the only drug you need to remember
Paediatric dosing can be made easy
Defibrillation
Defibrillation first
Max joules, stacked followed by single shocks
Immediate chest compressions without rhythm check
AEDs have many advantages over manual defibrillators

28. St John Clinical Procedures
Developed by the St John CMG
Issued to St John clinical staff
Very popular with medical and nursing staff
$15 a copy

29. St John Clinical Procedures

30. St John Clinical Procedures

31. Thank you