Principles of Cardiac Arrest Management Richard Lake 10/2003

Background Information 40% of deaths under the age of 75yrs in Europe are due to cardiovascular disease One third of people who suffer a myocardial infarction die before reaching hospital Most die within an hour of the onset of acute symptoms The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)

The only treatment for VF/ pulseless VT is attempted defibrillation With each minute’s delay the chance of a successful outcome fall by 7-10% Once in hospital the incidence of VF after Myocardial Infraction is approximately 5% Most likely presentation of in hospital cardiac arrest is asystole or pulseless electrical activity (PEA).

The Chain of Survival

Early Access to emergency services or cardiac arrest team Out of hospital summon EMS by dialling 999/112 In hospital call cardiac arrest team ring 2222 (check number when on placement)

External chest compressions and ventilation will slow down the rate of deterioration of the brain and heart Basic Life Support should be performed immediately

Basic Life Support Danger Response Shout for Help Airway Breathing If no help arrived leave victim, go for help Circulation

Danger Check for danger to: Yourself Bystanders Victim Even clinical areas can have dangers, so ALWAYS CHECK

Response Check the victim for response Ask a question, ‘hello are you alright?’ Give a command, ‘open your eyes!’ Give a painful stimulus; pinch the shoulder If no response shout for help

Checking for response

Airway Check the airway Open the airway, place one hand on the victims forehead and gently tilt head back Remove any visible obstruction from the victims mouth, including dislodged dentures. Leave well fitting dentures in place DO NOT ATTEMPT ANY FINGER SWEEPS

Opening the airway

Jaw thrust technique may be needed if C-spine injury

If available use airway adjuncts

Nasopharyngeal airway insertion

Oropharyngeal airway insertion

Breathing Keeping the airway open: Look – for chest movements Listen – at the victims mouth for breath sounds Feel – for air on your cheek Look, listen and feel for no more than 10 seconds to determine if the victim is not breathing.

If not breathing and no help has arrived Leave the victim and go to summon help

Turn the victim onto his back if he is not already in that position Give 2 effective rescue breaths, each of which should make the chest rise and fall If you have difficulty achieving an effective breath: Recheck the victims mouth and remove any obstruction Recheck there is head tilt and chin lift Make up to 5 attempts to achieve 2 effective breaths Even if unsuccessful move onto check circulation

If available use a pocket mask

Bag valve mask device may be used

Circulation Look, listen and feel for normal breathing, coughing, swallowing, eye flickering, or any movement by the victim If you feel confident check for a carotid pulse You should take no more than 10 seconds to do this

Always check pulse same side as you

If no breathing but signs of circulation Continue rescue breaths at a rate of 10 breaths per minute After every 10 breaths (every 1 minute) recheck for signs of circulation This should take no longer than 10 seconds to check

If no breathing and no signs of circulation Commence CPR at a ratio of 15 Compressions to 2 ventilations

Ensure correct hand position

The Chain of Survival

Out of hospital the aim is to deliver a shock within 5 minutes of the EMS receiving a call In hospital the first healthcare responder should be trained and authorised to use a defibrillator immediately

Automated External Defibrillator

AED hands off pads

Automated External Defibrillators may be used

Manual Defibrillator

Manual Defibrillator Paddles

Defibrillation

Defibrillation should be performed promptly

Often defibrillation restores a perfusing heart rhythm, this is often inadequate to sustain circulation and further advanced life support is required to improve the chances of long term survival

Remember the chain of survival

The Universal Treatment Algorithm An important part of Advanced Cardiac Life Support

Objectives Recognise the four cardiac arrest rhythms Identify correctly the appropriate algorithm for each of the rhythms Discuss the potential reversible causes of cardiac arrest

Re-assess one minute after defibrillation BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm +/- Pulse Check VF / VT NON VF/VT DEFIB X 3 as necessary During CPR Correct reversible causes CPR 3 min Re-assess one minute after defibrillation CPR 1 MIN Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

? VF / VT Non VF / VT BLS Algorithm Precordial Thump if appropriate Precordial Thump if appropriate Attach Monitor/Defib Assess rhythm +/- Pulse Check ? VF / VT Non VF / VT

During CPR Correct reversible causes BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm +/- Pulse Check VF / VT During CPR Correct reversible causes DEFIB X 3 as necessary Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics CPR 1 MIN

During CPR Correct reversible causes BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm +/- Pulse Check NON VF/VT During CPR Correct reversible causes 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 Causes Hypoxia Hypovolemia Hyper/ Hypokalemia and metabolic disturbances Hypothermia Tension pneumothorax Tamponade Toxic/ therapeutic disturbances Thrombo-embolic/ mechanical obstruction

Re-assess one minute after defibrillation BLS Algorithm if appropriate Precordial Thump Attach Monitor/Defib Assess rhythm +/- Pulse Check VF / VT NON VF/VT DEFIB X 3 as necessary During CPR Correct reversible causes CPR 3 min Re-assess one minute after defibrillation CPR 1 MIN Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics

Drugs used commonly during resuscitation Epinephrine (Adrenaline) Atropine Amiodarone Magnesium Sulphate Lidocaine (Lignocaine) Sodium Bicarbonate Calcium

Epinephrine (Adrenaline) First line cardiac arrest drug, given after every 3 minutes of CPR Dose 1mg (10ml of 1 in 10,000) IV Causes vasoconstriction, increased systemic vascular resistance increasing cerebral and coronary perfusion Increases myocardial excitability, when the myocardium is hypoxic or ischaemic

Atropine Given for asystole or pulseless electrical activity with a rate less than 60 beats per minute 3mg is given as a single intravenous dose It blocks the activity of the vagus nerve on the SA and AV nodes, increasing sinus automaticity and facilitating AV node conduction

Amiodarone For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmias If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered. If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline) Should be given centrally but in an emergency can be given peripherally Increases the duration of the action potential in the atrial and ventricular myocardium

Magnesium Sulphate For refractory VF when hypomagnesaemia is possible; ventricular tachyarrhythmias when hypomagnesaemia is possible In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) peripherally over 1 to 2 minutes. Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutes

Lidocaine (Lignocaine) For Refractory VF/ pulseless VT (when Amiodarone is unavailable 100mg for VF/ pulseless VT that persists after three shocks. Another 50mg can be given if necessary

Sodium Bicarbonate Given for severe metabolic acidosis and Hyperkalaemia 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac arrest associated with Hyperkalaemia

Calcium Administered when pulseless electrical activity caused by: Hyperkalaemia Hypocalcaemia Overdose of Calcium channel blocking drugs Dose 10ml of 10% calcium chloride repeated according to blood results

Summary Cardiac arrest can have a variety of causes The chain of survival is essential to improve outcome from cardiac arrest

Awareness of the universal treatment algorithm is important A knowledge of the drugs used in cardiac arrest, their routes and dilution is also essential

Questions

References Resuscitation Council (UK). (2000) Advanced Life Support Provider Course Manual . 4th Edition. Resuscitation Council (UK).:London Resuscitation Council (UK). (2002) Immediate Life Support Course Manual . 1st Edition. Resuscitation Council (UK).:London