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

2. 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

3. NO Central Pulse

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

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

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

7. Identify the rhythm

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

9. Identify the rhythm

10. Ventricular tachycardia(VT)
QRS has a wide morphology
Rate is typically from bpm
P waves are hidden if present
Can deteriorate rapidly to VF

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

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

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

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

16. PADDLE PLACEMENT

17. 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

18. If rhythm persists Consider antiarrhythmics

19. 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

20. 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

21. 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 mins

22. Reduce interruptions as much as possible !!!!!!!

23. 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

24. 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.

25. 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.

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

27. 5Ts
Tension Pneumothorax
Toxins
Trauma
Tamponade - cardiac
Thrombosis

28. 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

30. 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)

31. What to do if you see this?

32. 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

33. 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

34. 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

35. 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

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

37. The drugs in cardiac arrest
Epinephrine
Vasopressin
Atropine
Amiodarone
Magnesium
Lidocaine

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

39. 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

40. 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

41. 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

42. 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

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

44. 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.

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

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

47. 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

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

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

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

52. DEAD but STILL ALIVE

54. Thank you !