1. Cardiac arrest قل ان الموت الذي تفرون منه فانه ملاقيكم ثم تردون الى عالم الغيب والشهادة فينبئكم بما كنتم تعملون By Dr. Zuhair Al-Samarrae FRCS, FICS, CABS, DS, MBCHB

2. Cardiac arrest سهل سهل واضح واضح بسيط بسيط

3. Cardiac arrest rythmssss: 4 1. بازلاء 1. بازلاء 2.VF & 2.VF & 3.Pulseless VT 3.Pulseless VT 4.Asystole 4.Asystole What is common to all? What is common to all?

4. No cardiac output Thats why patient will lose conciosness. Thats why patient will lose conciosness. PEA (Pulseless Electric Activity) PEA (Pulseless Electric Activity) VF/ VT VF/ VT Asystole Asystole Approach is same, Approach is same,

5. BLS +ACLS 2 things contribute significantly to survival: Early CPR (bystander CPR) Early Defibrillation All of the above is BLS EVERY MINUTE COUNTS

6. Given the choice to take one course which one u prefer: BLS or ACLS? BLS BLS Early CPR & Effective D

7. BLS vs ACLS BLS vs ACLS Basic CPR&early DF--- PRIMARY IMPORTANCE Basic CPR&early DF--- PRIMARY IMPORTANCE DRUGS---------------secondary importance, where only few drugs are supported by strong evidence DRUGS---------------secondary importance, where only few drugs are supported by strong evidence ACLS therapies such as advaced airway insertion and drugs have not been shown to increase survival to hospital discharge!!!! ACLS therapies such as advaced airway insertion and drugs have not been shown to increase survival to hospital discharge!!!! Basically u need defibrillator& face mask i.e BLS Basically u need defibrillator& face mask i.e BLS

8. BLS is ABCD, which letter most important? D is more important than the A lmond B oard of C alifornia(ABC) D is more important than the A lmond B oard of C alifornia(ABC) So how can you get an EFFECTIVE DF? So how can you get an EFFECTIVE DF? How to increase chance of successful DF? How to increase chance of successful DF?

9. Energy reserve-determine success The more delay in DF—the more energy loss--- the less likely DF to be successful The more delay in DF—the more energy loss--- the less likely DF to be successful Witnessed arrest vs unwitnessed arrest. Witnessed arrest vs unwitnessed arrest. WITNESSED arrest--good reserve—more response to DF ---IMMEDIATELY DEFIBRILLATE WITNESSED arrest--good reserve—more response to DF ---IMMEDIATELY DEFIBRILLATE

10. Unwitnessed arrest---poor reserve what to do-how to increase reserve 2 min of a GOOD CPR – improve coronary perfusion-improve reserve-more response to DF. 2 min of a GOOD CPR – improve coronary perfusion-improve reserve-more response to DF. Do 2 min CPR after each defib.- EVEN if rhythm change to normal –many of whom Do 2 min CPR after each defib.- EVEN if rhythm change to normal –many of whom donot have a perfusing rhythm. donot have a perfusing rhythm.

11. Defibrillation 360 j سهل واضح بسيط Monophasic 360 j Monophasic 360 j Biphasic 120j Biphasic 120j If u donot know your machine :give 200j If u donot know your machine :give 200j

12. Concept of CPR سهل سهل واضح واضح بسيط بسيط Simply support your patient and give him what he needs----if not breathing –give him breathing - ---if no pulse—give him a pulse Simply support your patient and give him what he needs----if not breathing –give him breathing - ---if no pulse—give him a pulse

13. What is new in BLS? Early CPR before DF in unwitnessed arrest Early CPR before DF in unwitnessed arrest 30:2 cycles UNIVERSAL formula-for unintubated patients eg at the time of collapse 30:2 cycles UNIVERSAL formula-for unintubated patients eg at the time of collapse 2min CPR after each shock even if revert to sinus rythm,as this rhythm is often not perfusing 2min CPR after each shock even if revert to sinus rythm,as this rhythm is often not perfusing This formula applies for ALL AGES This formula applies for ALL AGES Emphasis on uninterrupted compressions Emphasis on uninterrupted compressions Avoid hyperventilation Avoid hyperventilation

14. Approach to cardiac arrest Act quickly Act quickly Support your patient ABCD Support your patient ABCD loooooooooooooooooook for the cause loooooooooooooooooook for the cause

15. Approach to the cardiac arrest- do not waste time Call first and fast Call first and fast Start CPR immediately Start CPR immediately New formula 30:2( 30 comp:2 vent)-cycles-this reduce interruption of cardiac compression New formula 30:2( 30 comp:2 vent)-cycles-this reduce interruption of cardiac compression Note 30:2 cycle only for unintubated, but once intubated –no more سيكل, i.e continuos compresssion(100/min) ventilation 8-10/min Note 30:2 cycle only for unintubated, but once intubated –no more سيكل, i.e continuos compresssion(100/min) ventilation 8-10/min It looks slow ventilation? It looks slow ventilation? No, avoid overventilation-it reduce venous return (as hyperventilation create +ve pressure in the chest) No, avoid overventilation-it reduce venous return (as hyperventilation create +ve pressure in the chest)

16. action sequence in cardiac arrest action sequence in cardiac arrest Check responsiveness Check responsiveness Call first( for AED) Call first( for AED) Start CPR cycle: 2 rescue breaths(each over 1 second to devote more time to compression (30)and then shock if it is VF. Start CPR cycle: 2 rescue breaths(each over 1 second to devote more time to compression (30)and then shock if it is VF. Once intubated : no more سيكل i.e no synchronization: uninterrupted compression100/min Once intubated : no more سيكل i.e no synchronization: uninterrupted compression100/min

17. What if you donot want to give mouth to mouse فارة الى فارة You can do chest compression only!!! You can do chest compression only!!! Remember : avoid hyperventilation Remember : avoid hyperventilation ---it is unnecessary(C.O is 25% -33% at best) ---it is unnecessary(C.O is 25% -33% at best) ---can create +ve pressure in the chest (further reducing C.O), ---can create +ve pressure in the chest (further reducing C.O), ---more gastric distension--may vomit and… ---more gastric distension--may vomit and…

18. Ventricular fibrillation-management Witnessed- (good energy reserve) Witnessed- (good energy reserve) so DF 360 فورا so DF 360 فورا Unwitnessed-(poor reserve) what to do ? -improve reserve(2min CPR) then DF 360, Where often they respond,what if no response?

19. VF—WHAT IF 1 ST SHOCK FAIL? CPR-shock-CPR-shock-CPR-SHOCK shock-2minCPR-shock-2min CPR-shock- 2min CPR NO MORE 3STACKED SHOCKS NO MORE 3STACKED SHOCKS i.e NO MORE SHOCK-SHOCK –SHOCK i.e NO MORE SHOCK-SHOCK –SHOCK If available: intubate, give vasopressors(epinephrine) early give vasopressors(epinephrine) early

20. So basically what are the new changes in VF management? 2 min CPR interposed among shock shock shock sequence… WHY? 2 min CPR interposed among shock shock shock sequence… WHY? To maximize chance of response to shock To maximize chance of response to shock 2min CPR even if revert to normal rhythm as this rhythm is often not perfusing-PEA 2min CPR even if revert to normal rhythm as this rhythm is often not perfusing-PEA Earlier use of ACLS therapies i.e intubation & medicines. Earlier use of ACLS therapies i.e intubation & medicines.

21. Management of cardiac arrest support the patient+treat the cause Support the patient:Epinephrine+_Atropine Epinephrine: in ALL 4 arrest rhythm(1 mg /3-5min) Atropine :in VF/VT No atropine in PEA only if بازلاء is slow in PEA only if بازلاء is slow in Asystole ALL patients in Asystole ALL patients Atropine dose: 1 mg every 3-5 min (max 3 doses)

22. Treat specific cause This applies to ALL cases of arrest rhythm This applies to ALL cases of arrest rhythm Not just PEA( pulseless electrical activity) Not just PEA( pulseless electrical activity) All the time consider 5 Hs &5 Ts in ANY arrest rhythm Unless you address the underlying cause….

23. Treat the cause e.g Unless u treat HypoMg of alcoholic…. Unless u treat HypoMg of alcoholic…. Unless treat arrythmia +the clot of MI…. Unless treat arrythmia +the clot of MI…. Unless treat eletrolyte imbalance in CRF… Unless treat eletrolyte imbalance in CRF…

24. Word of caution about Dx of PEA? A severely hypotensive patient may have no pulse+ sins rhyrhm A severely hypotensive patient may have no pulse+ sins rhyrhm Also PEA : no pulse+ sinus rhythm? Also PEA : no pulse+ sinus rhythm? How to differentiate? How to differentiate?

25. Post resuscitation support Remember many of these patients Remember many of these patients need hemodynamic support i.e hypotensive and need vasopressors e.g dopamine need hemodynamic support i.e hypotensive and need vasopressors e.g dopamine Keep searching for treatable causes

26. THANK YOU