DR. NAJAH YOUSUF ICU RESIDENT

MGH September 2014

Describe the relationship of the chain of survival to successful resuscitation of the cardiac arrest patient.

Review AHA BLS guidelines. Demonstrate cardiac arrest management

following ACLS guidelines. Discuss the interventions required to ensure good

outcomes with Return of Spontaneous Circulation.

Cardiovascular disease is the number one cause of death in the U.S., and many times the first indication of this disease is an acute coronary event

Cardiac arrest is the most severe manifestation of an acute coronary syndrome, and with rapid intervention EMS providers can make the difference between life and death

However, not every cardiac arrest is preceded by chest pain or discomfort, nor do all patients with chest discomfort or pain proceed to cardiac arrest, but for those who do, rapid intervention is vital. Without it, such patients will almost surely die. As such, the EMT must be prepared to treat all patients with signs and symptoms of cardiac compromise as cardiac emergencies.

Few cardiac arrest patients survive outside a hospital without a rapid sequence of events.◦ Chain of survival:

Early recognition and activation of EMS Immediate bystander CPR Early defibrillation Early advanced cardiac life support Integrated post-arrest care

Why is CPR Important◦ Studies have shown that the general population

will start CPR only 1/3 of the time and only 15% of that total is done correctly

◦ Chest Compressions can be started within 18 seconds of arriving at the patient, whereas airway management first can delay compressions by 1-2 minutes or more

◦ CPR prolongs the period during which defibrillation can be effective

Ventricular fibrillation is the most frequent rhythm found in cardiac arrest

Defibrillation is the most effective treatment for VF

Probability of successful defibrillation diminishes with time

VF will lead to asystole quickly without proper treatment

“Hearts and Brains are going to die”◦ Peter Safar MD

EMS has the most opportunity to perform CPR, so we should be good at performing good, quality CPR

2010 AHA Guidelines2010 AHA Guidelines

1. Make sure the scene is SAFE!2. Check responsiveness and breathing..!3. If alone call for help and announce for

code blue4. Check for a pulse and if no pulse present

begin CPR Always start CPR with Compressions First!

Always start CPR with Compressions First!

Push hard and fast Rate should be at least 100 per minute&

depth B/W 3-5 cm Provide 30 compressions then 2 breaths Make sure the chest is allowed to re-expand

completely at the end of each compression

Chest compressions and breaths are the same for adults, child, and infant if you are alone◦Adult age starts at the onset of puberty (12-14 years of age)◦Child is age 1year to the onset of puberty◦Infant is anyone under the age of 1year

5. Open the airway with head tilt-chin lift6. Place the mask on the patient’s face7. Use the E-C clamp technique8. Deliver each breath over 1 second

Adult Cardiac Arrest

1. Initiate CPR and attach monitor/defibrillator2. Defibrillate at 360j or equivalent biphasic shock3. Resume CPR immediately following defibrillation and

continue for 2 minutes4. Initiate vascular access; manage airway5. Reevaluate rhythm; defibrillate if needed; resume

CPR6. Administer Epinephrine 1mg every 3-5 minutes7. Defibrillate if needed; resume CPR8. Administer Amiodarone 300mg; may repeat at

150 mg IV/IO in 5 minutes if needed. 9. Continue cycles of CPR and defibrillation as needed

1. Initiate CPR and attach monitor/defibrillator

2. Initiate vascular access; manage airway3. Administer Epinephrine 1mg every 3-5

minutes4. Consider possible causes and treatments

• “H’s and T’s”

1)1) HHypoxia.ypoxia.2)2) HHypotension.ypotension.3)3) HHypothermia.ypothermia.4)4) HHypoglycemia.ypoglycemia.5)5) Acidosis (Acidosis (HH++).).6)6) HHypokalemia ypokalemia

(electrolyte (electrolyte disturbance).disturbance).

1)1) Cardiac Cardiac TTamponade.amponade.2)2) TTension ension

pneumothorax.pneumothorax.3)3) TThromboembolism hromboembolism

((pulmonarypulmonary, , coronarycoronary).).

4)4) TToxicity oxicity (eg. digoxin, local anesthetics, TCA, insecticides).

IMMEDIAT & URGENT … IS URGENT & PRIOR TO DISCHARGE ADEQUAT …

Optimize ventilation and oxygenation O2 Saturation > 94% Advanced Airway

10-12 per minute PETCO2 35-40 mm/Hg Do not hyperventilate

< cerebral perfusion Oxygen toxic

◦ Treat hypotension (SBP <90 mm Hg) Fluid Bolus –1-2 liters Vasopressors

Epinephrine 0.1-0.5 mcg/kg/minute Dopamine 5-20 mcg/kg/minute

◦ Induced Hypothermia If not following commands Improved neurological recovery 32º - 34º C for 12-24 hours

◦ Coronary reperfusion by emergent coronary intervention (PCI) If STEMI May do concurrently with hypothermia AGGRESSIVE Control of hyperglycemia Early weaning from M.V

GOOD NEWS IS AGGRESSIVE POST RESUCITATION CARE

LONG TERM NEUROLOGICAL INTACT …

44 year old male Haji at Meqaat mosque sitting to performing prayer complaining of chest pain. As you begin your assessment, he loses consciousness and becomes pulseless and apneic. The cardiac monitor shows this rhythm:

1. According to the Region 6 protocols, what is the appropriate next step in treating this patient?

A. Provide 2 minutes of CPR prior to defibrillation.

B. Initiate CPR, secure the airway and establish vascular access

C. Immediately defibrillate at 360j or equivalent biphasic shock

D. Deliver a synchronized shock at 200j

2. True/False: After defibrillation you should immediately resume CPR and continue for 2 minutes.

3. According to the Region 6 protocols, what is the maximum dose of amiodarone that may be given to this patient?

92 year old man in the nursing home. Found in cardiac arrest. No DNR present. The cardiac monitor shows this rhythm:

4. According to the Region 6 protocols, what is the appropriate next step in treating this patient?

A. Begin CPR, initiate vascular access and manage the airway

B. Immediately defibrillate and then resume CPRC. Begin CPR and prepare to pace the rhythmD. Do not start resuscitation

5. What is the appropriate ratio of compressions to breaths in adult CPR with 2 rescuers?

6. What medication(s) would be appropriate for treating this rhythm?

7. According to the 2010 ACLS guidelines, what are the 4 components of Post Cardiac Arrest Care following return of spontaneous circulation?