cardiac arrest arrhythmias

Cardiac Arrest ArrhythmiasCardiac Arrest Arrhythmias

EMS ProfessionsEMS Professions

Temple CollegeTemple College

Cardiac ArrestCardiac Arrest

MechanismsMechanisms Ventricular FibrillationVentricular Fibrillation Pulseless Ventricular TachycardiaPulseless Ventricular Tachycardia AsystoleAsystole Pulseless Electrical Activity (PEA)Pulseless Electrical Activity (PEA)

A condition; Not an ECG rhythmA condition; Not an ECG rhythm

Cardiac ArrestCardiac Arrest Most common rhythmsMost common rhythms

Adults: ventricular fibrillationAdults: ventricular fibrillation Children: Asystole, Bradycardic PEAChildren: Asystole, Bradycardic PEA Pediatric V-fib suggests:Pediatric V-fib suggests:

Drug toxicityDrug toxicity Electrolyte imbalanceElectrolyte imbalance Congenital heart diseaseCongenital heart disease

Cardiac ArrestCardiac Arrest ABCs come first!ABCs come first!

Airway - unobstructed? Airway - unobstructed? manually open manually open Breathing - no or inadequate Breathing - no or inadequate ventilate ventilate Circulation - no pulse in 5 sec Circulation - no pulse in 5 sec chest chest

compressionscompressions Do NOT wait on equipmentDo NOT wait on equipment Assure effective BLS before going to ALSAssure effective BLS before going to ALS

Rise and fall of chestRise and fall of chest Air movement in lung fieldsAir movement in lung fields Pulse with compressionsPulse with compressions


First ALS priority is defibrillationFirst ALS priority is defibrillation Only cure for v-fib is defibOnly cure for v-fib is defib The quicker the betterThe quicker the better

Probability of resuscitation Probability of resuscitation decreasesdecreases 7-10% with each passing minute7-10% with each passing minute


Vascular accessVascular access Antecubital spaceAntecubital space

Arm, EJ, Foot (last resort)Arm, EJ, Foot (last resort) IO in peds < 6 y/oIO in peds < 6 y/o

14 or 16 gauge14 or 16 gauge LR or NSLR or NS 30 sec - 60 sec of CPR to circulate drug30 sec - 60 sec of CPR to circulate drug


Intubation as time allowsIntubation as time allows Less emphasis today as compared to Less emphasis today as compared to

pastpast Epi, atropine, lidocaine may be Epi, atropine, lidocaine may be

administered down tubeadministered down tube 2x IV dose2x IV dose IV is preferredIV is preferred

Analyze the RhythmAnalyze the Rhythm

Ventricular Fibrillation (VF)Ventricular Fibrillation (VF) CharacteristicsCharacteristics

Chaotic, irregular, ventricular rhythmChaotic, irregular, ventricular rhythm Wide, variable, bizarre complexesWide, variable, bizarre complexes Fast rate of activityFast rate of activity Multiple ventricular fociMultiple ventricular foci No cardiac outputNo cardiac output Terminal rhythm if not corrected quicklyTerminal rhythm if not corrected quickly Most common rhythm causing sudden Most common rhythm causing sudden

cardiac death in adultscardiac death in adults

Ventricular Fibrillation (VF) Ventricular Fibrillation (VF) TreatmentTreatment ABC’sABC’s Witnessed arrest: Precordial thumpWitnessed arrest: Precordial thump

Little demonstrated value but worth a tryLittle demonstrated value but worth a try

CPR until defibrillator availableCPR until defibrillator available Quick Look for VF or pulseless VTQuick Look for VF or pulseless VT

Treat pulseless VT as if it were VFTreat pulseless VT as if it were VF

DefibrillateDefibrillate 200 J, 300 J, 360 J200 J, 300 J, 360 J Quickly and in rapid successionQuickly and in rapid succession

Identify cause if possibleIdentify cause if possible

Ventricular Fibrillation Ventricular Fibrillation TreatmentTreatment If still in VF/VT arrest, continue CPR for 1 If still in VF/VT arrest, continue CPR for 1

minuteminute Establish IV access and IntubateEstablish IV access and Intubate

If sufficient personnel, attempt both simultaneouslyIf sufficient personnel, attempt both simultaneously If not, quick attempt at IV access then attempt ETTIf not, quick attempt at IV access then attempt ETT

Vasopressor MedicationVasopressor Medication EpinephrineEpinephrine

1 mg 1:10,000 IVP1 mg 1:10,000 IVP Repeat every 3-5 mins as long as arrest persistsRepeat every 3-5 mins as long as arrest persists

Vasopressin (alternative to Epinephrine)Vasopressin (alternative to Epinephrine) 40 units IVP one time only40 units IVP one time only

Ventricular Fibrillation Ventricular Fibrillation TreatmentTreatment

Shock @ 360 J after each medication given as Shock @ 360 J after each medication given as long as VF/VT arrest persistslong as VF/VT arrest persists Alternate epi-shock & antidysrhythmic-shock sequenceAlternate epi-shock & antidysrhythmic-shock sequence

Antidysrhythmic MedicationAntidysrhythmic Medication amiodarone 300 mg IVP single doseamiodarone 300 mg IVP single dose lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg totallidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total procainamide 100 mg IV, q 5 min, max 17 mg/kg totalprocainamide 100 mg IV, q 5 min, max 17 mg/kg total magnesium 10% 1-2 g IV magnesium 10% 1-2 g IV

if hypomagnesemic or prolonged QTif hypomagnesemic or prolonged QT

Ventricular Fibrillation Ventricular Fibrillation TreatmentTreatment

Consider NaHCOConsider NaHCO33 if prolonged if prolonged Only after effective ventilationsOnly after effective ventilations

In many EMS systems, consider terminating In many EMS systems, consider terminating resuscitation efforts in consult with med controlresuscitation efforts in consult with med control

Ventricular FibrillationVentricular Fibrillation

The ultimate unstable tachycardiaThe ultimate unstable tachycardia Shock early-Shock oftenShock early-Shock often Sequence is drug-shock-drug-shockSequence is drug-shock-drug-shock

Sequence of drugs is epi-Sequence of drugs is epi-antiarrhythmic-epi-antiarrhythmicantiarrhythmic-epi-antiarrhythmic

AsystoleAsystole CharacteristicsCharacteristics

The ultimate unstable bradycardiaThe ultimate unstable bradycardia A terminal rhythmA terminal rhythm

poor prognosis for resuscitationpoor prognosis for resuscitation best hope if ID & treat causebest hope if ID & treat cause

No significant positive or negative No significant positive or negative deflectionsdeflections

AsystoleAsystole Possible CausesPossible Causes

Hypoxia: ventilateHypoxia: ventilate Preexisting metabolic acidosis: Bicarbonate Preexisting metabolic acidosis: Bicarbonate

1 mEq/kg1 mEq/kg Hyperkalemia: Bicarbonate 1 mEq/kg, Hyperkalemia: Bicarbonate 1 mEq/kg,

Calcium 1 g IVCalcium 1 g IV Hypokalemia: 10mEq KCl over 30 minutesHypokalemia: 10mEq KCl over 30 minutes Hypothermia: rewarm body coreHypothermia: rewarm body core

AsystoleAsystole

Possible CausesPossible Causes Drug overdoseDrug overdose

Tricyclics: BicarbonateTricyclics: Bicarbonate Digitalis: Digibind (Digitalis Digitalis: Digibind (Digitalis

antibodies)antibodies) Beta-blockers: GlucagonBeta-blockers: Glucagon Ca-channel blockers: CalciumCa-channel blockers: Calcium

Asystole & PEA Differentials Asystole & PEA Differentials (The 5Hs & 5Ts)(The 5Hs & 5Ts) HypovolemiaHypovolemia HypoxiaHypoxia Hydrogen ions Hydrogen ions

(Acidosis)(Acidosis) Hyper/hypo-Hyper/hypo-

kalemiakalemia HypothermiaHypothermia

Tablets (Drug OD)Tablets (Drug OD) TamponadeTamponade Tension Tension

PneumothoraxPneumothorax Thrombosis, Thrombosis,

CoronaryCoronary Thrombosis, Thrombosis,

PulmonaryPulmonary

Asystole TreatmentAsystole Treatment Primary ABCDPrimary ABCD

Confirm Asystole in two leadsConfirm Asystole in two leads Reasons to NOT continue?Reasons to NOT continue?

Secondary ABCDSecondary ABCD ECG monitor/ET/IVECG monitor/ET/IV Differential Diagnosis (5Hs & 5Ts)Differential Diagnosis (5Hs & 5Ts) TCP (if early)TCP (if early) Epinephrine 1:10,000 1 mg IV q 3-5 min.Epinephrine 1:10,000 1 mg IV q 3-5 min. Atropine 1 mg IV q 3-5 min, max 0.04 mg/kgAtropine 1 mg IV q 3-5 min, max 0.04 mg/kg Consider TerminationConsider Termination


What are you going to do for this patient?

Case PresentationCase PresentationThe 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 dofor this patient?

PEAPEA PossibilitiesPossibilities

Massive pulmonary embolusMassive pulmonary embolus Massive myocardial infarctionMassive myocardial infarction Overdose:Overdose:

Tricyclics - BicarbonateTricyclics - Bicarbonate Digitalis - DigibindDigitalis - Digibind Beta-blockers - GlucagonBeta-blockers - Glucagon Ca-channel blockers - CalciumCa-channel blockers - Calcium

PEAPEA Identify, correct underlying cause if possibleIdentify, correct underlying cause if possible Possibilities:Possibilities:

Hypovolemia: volumeHypovolemia: volume Hypoxia: ventilateHypoxia: ventilate Tension pneumo: decompressTension pneumo: decompress Tamponade: pericardiocentesisTamponade: pericardiocentesis Acute MI: vasopressorAcute MI: vasopressor Hyperkalemia: Bicarbonate 1mEq/kgHyperkalemia: Bicarbonate 1mEq/kg Preexisting metabolic acidosis: Bicarbonate 1mEq/kgPreexisting metabolic acidosis: Bicarbonate 1mEq/kg Hypothermia: rewarm coreHypothermia: rewarm core

PEA TreatmentPEA Treatment ABCDsABCDs ETT/IV/ECG monitorETT/IV/ECG monitor Differential DiagnosisDifferential Diagnosis

Find the cause and treat if possibleFind the cause and treat if possible

Epinephrine 1:10,000 1 mg q 3-5 min. Epinephrine 1:10,000 1 mg q 3-5 min. If bradycardic,If bradycardic,

Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kgAtropine 1 mg IV q 3-5 min, Max 0.04 mg/kg TCPTCP

In many systems, consider termination of In many systems, consider termination of effortsefforts

Hypothermia-Initial TherapyHypothermia-Initial Therapy

Remove wet garmentsRemove wet garments Protect against heat loss & wind chillProtect against heat loss & wind chill Maintain horizontal positionMaintain horizontal position Avoid rough movement and excess Avoid rough movement and excess

activityactivity

Hypothermia – No PulseHypothermia – No Pulse CPRCPR Defibrillate X 3 if VF/VTDefibrillate X 3 if VF/VT ETT with warm, humidified O2ETT with warm, humidified O2 IV access with warm fluidsIV access with warm fluids Temp >30C/86F:Temp >30C/86F:

Continue as usual with longer intervalsContinue as usual with longer intervals Repeat defibrillation as temp risesRepeat defibrillation as temp rises

Temp <30C/86FTemp <30C/86F Continue CPRContinue CPR Withhold medications and further defibrillationWithhold medications and further defibrillation Transport for core warmingTransport for core warming

Hypothermia – No PulseHypothermia – No Pulse

Remember: A hypothermic patient is not dead until he is WARM & DEAD!!!

Managing Cardiac ArrestManaging Cardiac Arrest

Check pulse after any treatment or Check pulse after any treatment or rhythm changerhythm change

Post-resuscitation CarePost-resuscitation Care

If pulse present:If pulse present: Assess breathingAssess breathing

Present?Present? Air moving adequately?Air moving adequately? Equal breath sounds?Equal breath sounds? Possible flail chest?Possible flail chest?


If pulse present:If pulse present: Protect airwayProtect airway

Position to prevent aspirationPosition to prevent aspiration Consider intubationConsider intubation

100% Oxygen via BVM or NRB100% Oxygen via BVM or NRB Vascular accessVascular access


Assess perfusionAssess perfusion EvaluateEvaluate

PulsesPulses Skin colorSkin color Skin temperatureSkin temperature Capillary refillCapillary refill BPBP

Key is perfusion, not pressureKey is perfusion, not pressure


Management of Decreased PerfusionManagement of Decreased Perfusion Fluid challengeFluid challenge Catecholamine infusionCatecholamine infusion

Dopamine, orDopamine, or NorepinephrineNorepinephrine

Titrate to BP ~ 90 to 100 systolicTitrate to BP ~ 90 to 100 systolic

Post-resuscitation CarePost-resuscitation Care Suppression of ventricular Suppression of ventricular

irritabilityirritability If VT or VF converted before lidocaine If VT or VF converted before lidocaine

given, lidocaine bolus and dripgiven, lidocaine bolus and drip If lidocaine or bretylium worked, begin If lidocaine or bretylium worked, begin

infusioninfusion Suppress irritability before giving Suppress irritability before giving

vasopressorsvasopressors

cardiac arrest arrhythmias

Documents