1. Cardiac Arrest Arrhythmias
Terry White, RN

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

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

4. 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

5. 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

6. 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

7. 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

8. Analyze the Rhythm

9. 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

10. 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

11. 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

12. Ventricular Fibrillation Treatment
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 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

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

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

15. Analyze the Rhythm

16. 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

17. 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

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

19. 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

20. 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

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

22. 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?

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

24. 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

25. 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

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

27. 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

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

29. Managing Cardiac Arrest
Check pulse after any treatment or rhythm change

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

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

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

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

34. 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