Based on :

2010 American Heart Association Guidelines

www.circ.ahajournals.org

Elham Pishbin . M.D

Assistant Professor of Emergency Medicine

MUMS

Management of Cardiac Arrest

Advanced Life SupportAdvanced Life Support

A B CA B C

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Defibrillator attachedCHESTCOMp

Check Rhythm

VT , VF PEA, Asystole

Asystole / PEA

PEA : a heterogeneous group of organized electric

rhythms , with either absence of mechanical

ventricular activity or mechanical ventricular

activity that is insufficient to generate a

clinically detectable pulse.

Asystole : absence of detectable ventricular electric

activity with or without atrial electric activity.

DON’T INTERRUPTCHEST COMPRESSION

DON’T INTERRUPTCHEST COMPRESSIONPeriodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway.

High quality CPR

Monitoring and optimizing

quality of CPR on the basis of

1- Mechanical parameters:

(rate & depth of compressions ,

relaxation, and minimization

of pauses)

2- Physiologic parameters :

(PETCO2 , arterial pressure

during the relaxation phase

of chest compressions, or ScvO2 )

Coronary Perfusion Pressure =(Aortic Relaxation P.) – (R.A Relaxation P)

It correlate with both Myocardial blood flow & ROSC.

Asystole / PEA (cont…)

The ability to achieve a good resuscitation outcome depends on:

1-Provide effective CPR

2-Identify and correct a cause of PEA / Asystole

All resuscitation team members must simultaneously Conduct a search for a underlying and treatable cause of the PEA in addition to performing their assigned role.

Asystole / PEA (cont…)

Asystole :

It is should be confirm that:

-Not another rhythm masquerading as a flat line

-Not the result of an operator error that is creating a flat line

Causes of an Isoelectric ECG:-Loose leads or leads not connected to the patient or defibrillator/monitor

-No power-Signal gain too low

Drug Therapy in Asys / PEA

A vasopressor can be given as soon as feasible with the

primary goal of increasing myocardial and cerebral blood

flow during CPR and achieving ROSC .

Available evidence suggests that the routine use of

atropine during PEA or asystole is unlikely to have a therapeutic benefit, SO

Atropine has been removed from

the cardiac arrest algorithm.

Rhythm

Shockable Nonshockable

VF AsystolePulseless VT PEA

V.F / Pulse-less V.T

The foundation of successful ACLS is : high quality CPR,

and, for VF/pulseless VT, attempted defibrillation

within minutes of collapse.

For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.

In comparison,

other ACLS therapies such as medications & advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge and should be performed without compromising quality of CPR or timely defibrillation.

V.F / Pulse-less V.T

In other words :

vascular access , drug delivery , and advanced airway

should not cause significant

interruptions in chest compression

or delay defibrillation.

There is insufficient evidence to

recommend a specific timing or sequence (order) of drug administration and advanced airway placement during cardiac arrest.

Chest comp

V.F / Pulse-less V.T

When VF is present for more than a few minutes, myocardium is depleted of oxygen and metabolic substrates.

A brief period of chest compressions can deliver oxygen

and energy and “unload” the volume- overloaded R.V ,

increasing the likelihood of returning a perfusing rhythm

after shock.

Performing CPR while a defibrillator is readied for use is

strongly recommended for all patients in cardiac arrest

V.F / Pulse-less V.T

The shorter the time interval between the last chest compression and shock delivery, the more likely the shock will be successful.

A reduction of even a few seconds in the interval from pausing compressions to shock delivery can increase the probability of shock success

V.F / Pulse-less V.T

The value of intentionally delaying defibrillation to perform CPR is less clear.

At this time the benefit of delaying defibrillation to perform CPR before defibrillation is unclear

Shock ?

Monophasic 360 J / at beginning

Biphasic 120 J / then 200 J

Children first 2 J/kg then 4 J/kg

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Drug Therapy in V.F / Pulse-less V.T

When VF/pulseless VT persists after at least 1 shock and a

2-minute CPR period, a vasopressor can be given with the

primary goal of increasing myocardial blood flow during

CPR and achieving ROSC.

If a shock fails to generate a perfusing rhythm, then giving

a vasopressor soon after the shock will optimize the

potential impact of increased myocardial blood flow before the next shock.

Drug Therapy in V.F / Pulse-less V.T Amiodarone is the first-line antiarrhythmic agent given

during cardiac arrest because it has been clinically demonstrated to improve the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT.

Amiodarone considered when VF/VT is unresponsive to CPR, defibrillation, and vasopressor therapy .

If amiodarone is unavailable, lidocaine may be considered.

Magnesium sulfate should be considered only for torsades de point.

As A Rule :

All drugs in CPR are given I.V Push.and then 20 cc N.S.

During cardiac arrest, provision of high-quality CPR and

rapid defibrillation are of primary importance

and

drug administration is of secondary importance.

After beginning CPR and attempting defibrillation for

identified VF or pulseless VT, providers can establish

IV or IO access.

This should be performed without interrupting chest compressions.

If IV or IO access cannot be established, epinephrine,

vasopressin, and lidocaine may be administered by the

endotracheal route during cardiac arrest .

The optimal endotracheal dose of most drugs is unknown, but typically the dose is 2 to 21⁄2 times of the recommended IV dose.

Do not check pulse untilThe rhythm changed

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DrugsAntiarrhythmic:

Amiodarone : 300 mg first doseif needed after 15-20 min, 150 mg

max, 450 mg

Lidocaine : 1.5 mg/kg first doseif needed Q 10 min--- 0.75 mg/kgfor 2 doses max. 3 mg/kg

Vasopressors

Epinephrine hydrochloride: S & NS rhythms1 mg- IV, IO, ET

Q 3-5 min/ cont to END

Atropine: Forget about it …!

Drug rout

As a law:Drugs injections in CPR must be:

PUSHETT administration:

2 - 2.5 times as IV dosesplus

5-10 ml distilled water

As a law:Drugs injections in CPR must be:

PUSHETT administration:

2 - 2.5 times as IV dosesplus

5-10 ml distilled water

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Prolonged CPRProlonged CPR

HypothermiaToxicity

Drowning

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Post Cardiac Arrest Care

Post–cardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury.

Subsequent objectives of post– cardiac arrest care are :

● Control body temperature to optimize survival and

neurological recovery

● Identify and treat acute coronary syndromes (ACS)

● Optimize mechanical ventilation to minimize lung injury

● Reduce the risk of multi-organ injury and support organ

function if required

● Objectively assess prognosis for recovery

●Assist survivors with rehabilitation services when

required

1- Ventilation

2- Hemodynamics

3- Cardiovascular

4- Neurological

5- Metabolic

Multi System Approach to Post Cardiac Arrest Care