Transcript No Slide Title

Cardiac Arrest Arrhythmias
Terry White, RN
Cardiac Arrest
Mechanisms
 Ventricular
Fibrillation
 Pulseless Ventricular Tachycardia
 Asystole
 Pulseless Electrical Activity (PEA)
A condition; Not an ECG rhythm
Cardiac Arrest
Most
common rhythms
 Adults:
ventricular fibrillation
 Children: Asystole, Bradycardic PEA
 Pediatric V-fib suggests:
Drug toxicity
Electrolyte imbalance
Congenital heart disease
Cardiac Arrest
 ABCs
come first!
- unobstructed?  manually open
 Breathing - no or inadequate  ventilate
 Circulation - no pulse in 5 sec  chest
compressions
 Airway
 Do
NOT wait on equipment
 Assure effective BLS before going to ALS
 Rise
and fall of chest
 Air movement in lung fields
 Pulse with compressions
Cardiac Arrest
First ALS
 Only
priority is defibrillation
cure for v-fib is defib
 The quicker the better
Probability of resuscitation decreases
7-10% with each passing minute
Cardiac Arrest
 Vascular access
 Antecubital
space
Arm, EJ, Foot (last resort)
IO in peds < 6 y/o
 14 or 16 gauge
 LR or NS
 30 sec - 60 sec of CPR to circulate drug
Cardiac Arrest
Intubation
 Less
as time allows
emphasis today as compared to
past
 Epi, atropine, lidocaine may be
administered down tube
2x IV dose
IV is preferred
Analyze the Rhythm
Ventricular Fibrillation (VF)
 Characteristics
 Chaotic,
irregular, ventricular rhythm
 Wide, variable, bizarre complexes
 Fast rate of activity
 Multiple ventricular foci
 No cardiac output
 Terminal rhythm if not corrected quickly
 Most common rhythm causing sudden
cardiac death in adults
Ventricular Fibrillation (VF)
Treatment
 ABC’s
 Witnessed

arrest: Precordial thump
Little demonstrated value but worth a try
 CPR
until defibrillator available
 Quick Look for VF or pulseless VT

Treat pulseless VT as if it were VF
 Defibrillate
200 J, 300 J, 360 J
 Quickly and in rapid succession

 Identify
cause if possible
Ventricular Fibrillation
Treatment
 If
still in VF/VT arrest, continue CPR for 1
minute
 Establish IV access and Intubate
If sufficient personnel, attempt both simultaneously
 If not, quick attempt at IV access then attempt ETT

 Vasopressor

Medication
Epinephrine
1 mg 1:10,000 IVP
 Repeat every 3-5 mins as long as arrest persists


Vasopressin (alternative to Epinephrine)

40 units IVP one time only
Ventricular Fibrillation
Treatment

Shock @ 360 J after each medication given as
long as VF/VT arrest persists


Alternate epi-shock & antidysrhythmic-shock sequence
Antidysrhythmic Medication
amiodarone 300 mg IVP single dose
 lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total
 procainamide 100 mg IV, q 5 min, max 17 mg/kg total
 magnesium 10% 1-2 g IV
 if hypomagnesemic or prolonged QT

Ventricular Fibrillation
Treatment

Consider NaHCO3 if prolonged


Only after effective ventilations
In many EMS systems, consider terminating
resuscitation efforts in consult with med control
Ventricular Fibrillation
The
ultimate unstable tachycardia
Shock early-Shock often
Sequence is drug-shock-drug-shock
 Sequence
of drugs is epiantiarrhythmic-epi-antiarrhythmic
Analyze the Rhythm
Asystole
Characteristics
 The
ultimate unstable bradycardia
 A terminal rhythm
poor prognosis for resuscitation
best hope if ID & treat cause
 No significant positive or negative
deflections
Asystole
Possible
Causes
 Hypoxia:
ventilate
 Preexisting metabolic acidosis:
Bicarbonate 1 mEq/kg
 Hyperkalemia: Bicarbonate 1 mEq/kg,
Calcium 1 g IV
 Hypokalemia: 10mEq KCl over 30
minutes
 Hypothermia: rewarm body core
Asystole
Possible
 Drug
Causes
overdose
Tricyclics: Bicarbonate
Digitalis: Digibind (Digitalis
antibodies)
Beta-blockers: Glucagon
Ca-channel blockers: Calcium
Asystole & PEA Differentials
(The 5Hs & 5Ts)
 Hypovolemia
 Hypoxia
 Hydrogen
ions
(Acidosis)
 Hyper/hypokalemia
 Hypothermia
 Tablets
(Drug OD)
 Tamponade
 Tension
Pneumothorax
 Thrombosis,
Coronary
 Thrombosis,
Pulmonary
Asystole Treatment
 Primary ABCD
 Confirm Asystole
in two leads
 Reasons to NOT continue?
 Secondary ABCD
 ECG
monitor/ET/IV
 Differential Diagnosis (5Hs & 5Ts)
 TCP (if early)
 Epinephrine 1:10,000 1 mg IV q 3-5 min.
 Atropine 1 mg IV q 3-5 min, max 0.04 mg/kg
 Consider Termination
Analyze the Rhythm
What are you going to do for this patient?
Case Presentation
The 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 do
for this patient?
PEA
Possibilities
 Massive
pulmonary embolus
 Massive myocardial infarction
 Overdose:
Tricyclics - Bicarbonate
Digitalis - Digibind
Beta-blockers - Glucagon
Ca-channel blockers - Calcium
PEA
 Identify,
correct underlying cause if possible
 Possibilities:
Hypovolemia: volume
 Hypoxia: ventilate
 Tension pneumo: decompress
 Tamponade: pericardiocentesis
 Acute MI: vasopressor
 Hyperkalemia: Bicarbonate 1mEq/kg
 Preexisting metabolic acidosis: Bicarbonate
1mEq/kg
 Hypothermia: rewarm core

PEA Treatment
 ABCDs
 ETT/IV/ECG
monitor
 Differential Diagnosis

Find the cause and treat if possible
 Epinephrine
1:10,000 1 mg q 3-5 min.
 If bradycardic,
Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg
 TCP

 In
many systems, consider termination of
efforts
Hypothermia-Initial Therapy
Remove
wet garments
Protect against heat loss & wind chill
Maintain horizontal position
Avoid rough movement and excess
activity
Hypothermia – No Pulse
 CPR
 Defibrillate
X 3 if VF/VT
 ETT with warm, humidified O2
 IV access with warm fluids
 Temp >30C/86F:
Continue as usual with longer intervals
 Repeat defibrillation as temp rises

 Temp
<30C/86F
Continue CPR
 Withhold medications and further defibrillation
 Transport for core warming

Hypothermia – No Pulse
Remember: A hypothermic patient is
not dead until he is WARM & DEAD!!!
Managing Cardiac Arrest
Check pulse after any treatment or
rhythm change
Post-resuscitation Care
 If
pulse present:
 Assess breathing
Present?
Air moving adequately?
Equal breath sounds?
Possible flail chest?
Post-resuscitation Care
If
pulse present:
 Protect
airway
Position to prevent aspiration
Consider intubation
 100% Oxygen via BVM or NRB
 Vascular access
Post-resuscitation Care
Assess
perfusion
 Evaluate
Pulses
Skin
color
Skin temperature
Capillary refill
BP
 Key is perfusion, not pressure
Post-resuscitation Care
Management
 Fluid
of Decreased Perfusion
challenge
 Catecholamine infusion
Dopamine, or
Norepinephrine
 Titrate to BP ~ 90 to 100 systolic
Post-resuscitation Care
Suppression
of ventricular
irritability
 If
VT or VF converted before lidocaine
given, lidocaine bolus and drip
 If lidocaine or bretylium worked, begin
infusion
 Suppress irritability before giving
vasopressors