Principles of Principles of Cardiac Arrest Cardiac Arrest ManagementManagement

Richard Lake 10/2003Richard Lake 10/2003

Background InformationBackground Information

40% of deaths under the age of 75yrs in 40% of deaths under the age of 75yrs in Europe are due to cardiovascular diseaseEurope are due to cardiovascular disease

One third of people who suffer a myocardial One third of people who suffer a myocardial infarction die before reaching hospitalinfarction die before reaching hospital

Most die within an hour of the onset of acute Most die within an hour of the onset of acute symptomssymptoms

The majority of these deaths the presenting The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)Ventricular Tachycardia, (VF/ pulseless VT)

The only treatment for VF/ pulseless The only treatment for VF/ pulseless VT is attempted defibrillationVT is attempted defibrillation

With each minute’s delay the chance With each minute’s delay the chance of a successful outcome fall by 7-of a successful outcome fall by 7-10%10%

Once in hospital the incidence of VF Once in hospital the incidence of VF after Myocardial Infraction is after Myocardial Infraction is approximately 5%approximately 5%

Most likely presentation of in hospital Most likely presentation of in hospital cardiac arrest is asystole or pulseless cardiac arrest is asystole or pulseless electrical activity (PEA).electrical activity (PEA).

The Chain of SurvivalThe Chain of Survival

Early Access to emergency services Early Access to emergency services or cardiac arrest teamor cardiac arrest team

Out of hospital summon EMSOut of hospital summon EMS

by dialling 999/112by dialling 999/112 In hospital call cardiac arrestIn hospital call cardiac arrest

team ring 2222 (check team ring 2222 (check

number when on placement)number when on placement)

External chest compressions and External chest compressions and

ventilation will slow down the ventilation will slow down the

rate of deterioration of the brain rate of deterioration of the brain

and heartand heart Basic Life Support should be Basic Life Support should be

performed immediatelyperformed immediately

Basic Life SupportBasic Life Support

DangerDanger ResponseResponse Shout for HelpShout for Help AirwayAirway BreathingBreathing If no help arrived leave victim, go for If no help arrived leave victim, go for

helphelp CirculationCirculation

DangerDanger

Check for danger to:Check for danger to: YourselfYourself BystandersBystanders VictimVictim Even clinical areas can have dangers, Even clinical areas can have dangers,

so so ALWAYS CHECKALWAYS CHECK

ResponseResponse Check the victim for Check the victim for

responseresponse Ask a question, ‘hello are you Ask a question, ‘hello are you

alright?’alright?’ Give a command, ‘open your Give a command, ‘open your

eyes!’eyes!’ Give a painful stimulus; pinch Give a painful stimulus; pinch

the shoulderthe shoulder If no response shout for helpIf no response shout for help

Checking for responseChecking for response

AirwayAirway

Check the airwayCheck the airway Open the airway, place one hand on Open the airway, place one hand on

the victims forehead and gently tilt the victims forehead and gently tilt head backhead back

Remove any visible obstruction from Remove any visible obstruction from the victims mouth, including dislodged the victims mouth, including dislodged dentures. Leave well fitting dentures in dentures. Leave well fitting dentures in placeplace

DO NOT ATTEMPT ANY FINGER SWEEPSDO NOT ATTEMPT ANY FINGER SWEEPS

Opening the airwayOpening the airway

Jaw thrust technique may be Jaw thrust technique may be needed if C-spine injuryneeded if C-spine injury

If available use airway If available use airway adjunctsadjuncts

Nasopharyngeal airway Nasopharyngeal airway insertioninsertion

Oropharyngeal airway Oropharyngeal airway insertioninsertion

BreathingBreathing

Keeping the airway open:Keeping the airway open: Look –Look – for chest movements for chest movements Listen – Listen – at the victims mouth for breath at the victims mouth for breath

soundssounds Feel – Feel – for air on your cheekfor air on your cheek Look, listen and feel for Look, listen and feel for no more than 10 no more than 10

secondsseconds to determine if the victim is not to determine if the victim is not breathing.breathing.

If not breathing If not breathing and no help has arrivedand no help has arrived

Leave the victim and go to summon helpLeave the victim and go to summon help

Turn the victim onto his back if he is not Turn the victim onto his back if he is not already in that positionalready in that position

Give 2 effective rescue breaths, each of which Give 2 effective rescue breaths, each of which should make the chest rise and fall should make the chest rise and fall

If you have difficulty achieving an effective If you have difficulty achieving an effective breath:breath:

Recheck the victims mouth and remove any Recheck the victims mouth and remove any obstructionobstruction

Recheck there is head tilt and chin lift Recheck there is head tilt and chin lift Make up to 5 attempts to achieve 2 effective Make up to 5 attempts to achieve 2 effective

breathsbreaths Even if unsuccessful move onto check Even if unsuccessful move onto check

circulationcirculation

If available use a pocket If available use a pocket maskmask

Bag valve mask device may be Bag valve mask device may be usedused

CirculationCirculation

Look, listen and feel for normal Look, listen and feel for normal breathing, coughing, swallowing, eye breathing, coughing, swallowing, eye flickering, or any movement by the flickering, or any movement by the victimvictim

If you feel confident check for a If you feel confident check for a carotid pulsecarotid pulse

You should take no more than 10 You should take no more than 10 seconds to do thisseconds to do this

Always check pulse same side Always check pulse same side as youas you

If no breathing If no breathing but signs of circulation but signs of circulation

Continue rescue breaths at a rate of Continue rescue breaths at a rate of 10 breaths per minute10 breaths per minute

After every 10 breaths (every 1 After every 10 breaths (every 1 minute) recheck for signs of minute) recheck for signs of circulationcirculation

This should take no longer than 10 This should take no longer than 10 seconds to checkseconds to check

If no breathing and If no breathing and no signs of circulationno signs of circulation

Commence CPR at a ratio ofCommence CPR at a ratio of

15 Compressions 15 Compressions

to 2 ventilationsto 2 ventilations

Ensure correct hand Ensure correct hand positionposition

The Chain of SurvivalThe Chain of Survival

Out of hospital the aim is toOut of hospital the aim is to

deliver a shock within deliver a shock within

5 minutes of the EMS receiving5 minutes of the EMS receiving

a calla call In hospital the first healthcare In hospital the first healthcare

responder should be trained andresponder should be trained and

authorised to use a defibrillatorauthorised to use a defibrillator

immediatelyimmediately

Automated External Automated External DefibrillatorDefibrillator

AED hands off padsAED hands off pads

Automated External Automated External Defibrillators Defibrillators may be usedmay be used

Manual DefibrillatorManual Defibrillator

Manual Defibrillator PaddlesManual Defibrillator Paddles

DefibrillationDefibrillation

Defibrillation should be Defibrillation should be performed promptlyperformed promptly

Often defibrillation restores a Often defibrillation restores a

perfusing heart rhythm, this isperfusing heart rhythm, this is

often inadequate to sustain often inadequate to sustain

circulation and further circulation and further

advanced life support is advanced life support is

required to improve the required to improve the

chances of long term survivalchances of long term survival

Remember the chain of Remember the chain of survivalsurvival

The Universal Treatment The Universal Treatment AlgorithmAlgorithm

An important part of An important part of

Advanced Cardiac Life Advanced Cardiac Life SupportSupport

ObjectivesObjectives

Recognise the four cardiac arrest Recognise the four cardiac arrest rhythmsrhythms

Identify correctly the appropriate Identify correctly the appropriate algorithm for each of the rhythmsalgorithm for each of the rhythms

Discuss the potential reversible Discuss the potential reversible causes of cardiac arrestcauses of cardiac arrest

BLS Algorithm

if appropriate

Precordial Thump

Attach Monitor/Defib

Assess rhythm

During CPR Correct reversible causes

+/- Pulse Check

VF / VT NON VF/VT

DEFIB X 3 as necessary

CPR 1 MIN

CPR 3 min

Re-assess one minute after defibrillationCheck electrode / paddle positions

Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

BLS Algorithmif appropriate

Attach Monitor/Defib

Assess rhythm

+/- Pulse Check

VF / VT Non VF / VT

?

Precordial Thumpif appropriate

BLS Algorithm

if appropriate

Precordial Thump

Attach Monitor/Defib

Assess rhythm

During CPR Correct reversible causes

+/- Pulse Check

VF / VT

DEFIB X 3 as necessary

CPR 1 MIN

Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

BLS Algorithm

if appropriate

Precordial Thump

Attach Monitor/Defib

Assess rhythm

During CPR Correct reversible causes

+/- Pulse Check

NON VF/VT

CPR 3 min

Re-assess one minute after defibrillation

Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

Potentially Reversible CausesPotentially Reversible Causes

HHypoxiaypoxia

HHypovolemiaypovolemia

HHyper/ Hypokalemia and metabolic yper/ Hypokalemia and metabolic disturbancesdisturbances

HHypothermiaypothermia

TTension pneumothoraxension pneumothorax

TTamponadeamponade

TToxic/ therapeutic disturbancesoxic/ therapeutic disturbances

TThrombo-embolic/ mechanical obstructionhrombo-embolic/ mechanical obstruction

BLS Algorithm

if appropriate

Precordial Thump

Attach Monitor/Defib

Assess rhythm

During CPR Correct reversible causes

+/- Pulse Check

VF / VT NON VF/VT

DEFIB X 3 as necessary

CPR 1 MIN

CPR 3 min

Re-assess one minute after defibrillationCheck electrode / paddle positions

Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

Drugs used commonly Drugs used commonly during resuscitationduring resuscitation

Epinephrine (Adrenaline)Epinephrine (Adrenaline) AtropineAtropine AmiodaroneAmiodarone Magnesium SulphateMagnesium Sulphate Lidocaine (Lignocaine)Lidocaine (Lignocaine) Sodium BicarbonateSodium Bicarbonate CalciumCalcium

Epinephrine (Adrenaline)Epinephrine (Adrenaline)

First line cardiac arrest drug, given after First line cardiac arrest drug, given after every 3 minutes of CPRevery 3 minutes of CPR

Dose 1mg (10ml of 1 in 10,000) IVDose 1mg (10ml of 1 in 10,000) IV Causes vasoconstriction, increased Causes vasoconstriction, increased

systemic vascular resistance increasing systemic vascular resistance increasing cerebral and coronary perfusioncerebral and coronary perfusion

Increases myocardial excitability, when Increases myocardial excitability, when the myocardium is hypoxic or ischaemicthe myocardium is hypoxic or ischaemic

AtropineAtropine

Given for asystole or pulseless Given for asystole or pulseless electrical activity with a rate less electrical activity with a rate less than 60 beats per minutethan 60 beats per minute

3mg is given as a single intravenous 3mg is given as a single intravenous dosedose

It blocks the activity of the vagus It blocks the activity of the vagus nerve on the SA and AV nodes, nerve on the SA and AV nodes, increasing sinus automaticity and increasing sinus automaticity and facilitating AV node conductionfacilitating AV node conduction

AmiodaroneAmiodarone

For Refractory VF/VT; haemodynamically stable For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmiasVT and other resistant tachyarrhythmias

If VF or pulseless VT persists after the first 3 If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered.shocks then Amiodarone 300mg is considered.

If not pre-diluted, must be diluted in 5% dextrose If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline)to 20ml. (Will crystallise is mixed with saline)

Should be given centrally but in an emergency Should be given centrally but in an emergency can be given peripherallycan be given peripherally

Increases the duration of the action potential in Increases the duration of the action potential in the atrial and ventricular myocardiumthe atrial and ventricular myocardium

Magnesium SulphateMagnesium Sulphate

For refractory VF when For refractory VF when hypomagnesaemia is possible; hypomagnesaemia is possible; ventricular tachyarrhythmias when ventricular tachyarrhythmias when hypomagnesaemia is possiblehypomagnesaemia is possible

In refractory VF – 1 to 2g (2-4ml of In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) 50% magnesium sulphate) peripherally over 1 to 2 minutes. peripherally over 1 to 2 minutes.

Other circumstances 2.5g (5ml of 50% Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutesmagnesium sulphate) over 30 minutes

Lidocaine (Lignocaine)Lidocaine (Lignocaine)

For Refractory VF/ pulseless VT For Refractory VF/ pulseless VT (when Amiodarone is unavailable(when Amiodarone is unavailable

100mg for VF/ pulseless VT that 100mg for VF/ pulseless VT that persists after three shocks. Another persists after three shocks. Another 50mg can be given if necessary50mg can be given if necessary

Sodium BicarbonateSodium Bicarbonate

Given for severe metabolic acidosis Given for severe metabolic acidosis and Hyperkalaemiaand Hyperkalaemia

50mmol (50ml of 8.4% solution), 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac where there is an acidosis or cardiac arrest associated with arrest associated with HyperkalaemiaHyperkalaemia

CalciumCalcium

Administered when pulseless electrical Administered when pulseless electrical activity caused by: activity caused by:

HyperkalaemiaHyperkalaemia HypocalcaemiaHypocalcaemia Overdose of Calcium channel blocking Overdose of Calcium channel blocking drugsdrugs Dose 10ml of 10% calcium chloride Dose 10ml of 10% calcium chloride

repeated according to blood resultsrepeated according to blood results

SummarySummary

Cardiac arrest can Cardiac arrest can have a variety of have a variety of causes causes

The chain of The chain of survival is essential survival is essential to improve to improve outcome from outcome from cardiac arrestcardiac arrest

Awareness of the universal treatment Awareness of the universal treatment algorithm is important algorithm is important

A knowledge of the drugs used in A knowledge of the drugs used in cardiac arrest, their routes and cardiac arrest, their routes and dilution is also essentialdilution is also essential

QuestionsQuestions

ReferencesReferences

Resuscitation Council (UK). (2000) Resuscitation Council (UK). (2000) Advanced Life Advanced Life Support Provider Course ManualSupport Provider Course Manual . 4 . 4thth Edition. Edition. Resuscitation Council (UK).:LondonResuscitation Council (UK).:London

Resuscitation Council (UK). (2002) Resuscitation Council (UK). (2002) Immediate Life Immediate Life Support Course ManualSupport Course Manual . 1 . 1stst Edition. Edition. Resuscitation Council (UK).:LondonResuscitation Council (UK).:London