Cardiac arrestCardiac arrest

تفرون الذي الموت ان تفرون قل الذي الموت ان قلمالقيكم فانه مالقيكم منه فانه منه

الغيب عالم الى تردون الغيب ثم عالم الى تردون ثموالشهادةوالشهادة

تعملون كنتم بما تعملون فينبئكم كنتم بما فينبئكمByBy

Dr. Zuhair Al-SamarraeDr. Zuhair Al-SamarraeFRCS, FICS, CABS, DS, FRCS, FICS, CABS, DS,

MBCHBMBCHB

Cardiac arrestCardiac arrest

• سهلسهل

• واضحواضح

• بسيطبسيط

Cardiac arrest rythmCardiac arrest rythmssss: ssss: 44

• بازالءبازالء.1.1

• 22.VF & .VF &

• 3.Pulseless VT3.Pulseless VT

• 4.Asystole4.Asystole

• What is common to all?What is common to all?

No cardiac outputNo cardiac output

• Thats why patient will lose Thats why patient will lose conciosness.conciosness.

• PEA (Pulseless Electric Activity)PEA (Pulseless Electric Activity)

• VF/ VTVF/ VT

• AsystoleAsystole

• Approach is same , Approach is same ,

BLSBLS +ACLS +ACLS

2 things contribute significantly to survival:2 things contribute significantly to survival:

Early CPR (bystander CPR)Early CPR (bystander CPR)

Early DefibrillationEarly Defibrillation

All of the above is All of the above is BLSBLS

EVERY MINUTE COUNTS EVERY MINUTE COUNTS

Given the choice to take one Given the choice to take one coursecoursewhich one u prefer: BLS or which one u prefer: BLS or ACLS?ACLS?

BLSBLSEarly CPR & Early CPR & EffectiveEffective D D

BLS BLS vsvs ACLSACLS• Basic CPR&early DF--- PRIMARY IMPORTANCEBasic CPR&early DF--- PRIMARY IMPORTANCE

• DRUGS---------------secondary importance, where DRUGS---------------secondary importance, where only few drugs are supported by strong evidenceonly few drugs are supported by strong evidence

• ACLS therapies such as advaced airway insertion ACLS therapies such as advaced airway insertion and drugs have and drugs have not not been shown to increase been shown to increase survival to hospital discharge!!!!survival to hospital discharge!!!!

• Basically u need defibrillator& face mask i.e BLSBasically u need defibrillator& face mask i.e BLS

BLS is ABCD, which letter most BLS is ABCD, which letter most important?important?

•DD is more important than the is more important than the AAlmond lmond BBoard of oard of CCalifornia(ABC)alifornia(ABC)

•So how can you get So how can you get an an EFFECTIVEEFFECTIVE DF?DF?

How to increase chance of How to increase chance of successful DF?successful DF?

Energy reserve-determine Energy reserve-determine successsuccess

• The more delay in DF—the more energy The more delay in DF—the more energy loss--- the less likely DF to be successfulloss--- the less likely DF to be successful

• Witnessed arrest vs unwitnessed arrest.Witnessed arrest vs unwitnessed arrest.

• WITNESSED arrest--good reserve—more WITNESSED arrest--good reserve—more response to DF ---IMMEDIATELY response to DF ---IMMEDIATELY DEFIBRILLATEDEFIBRILLATE

Unwitnessed arrest---poor Unwitnessed arrest---poor reserve what to do-how to reserve what to do-how to increase reserveincrease reserve• 2 min of a 2 min of a GOODGOOD CPR – improve CPR – improve

coronary perfusion-improve reserve-coronary perfusion-improve reserve-more response to DF.more response to DF.

• Do 2 min CPR after each defib.- EVEN Do 2 min CPR after each defib.- EVEN if rhythm change to normal –many of if rhythm change to normal –many of whom whom

donot have a perfusing rhythm.donot have a perfusing rhythm.

Defibrillation Defibrillation 360360 j j

بسيط واضح بسيط سهل واضح سهل• Monophasic Monophasic 360360jj

• Biphasic 120jBiphasic 120j

• If u donot know your machine :give If u donot know your machine :give 200j200j

Concept of CPRConcept of CPR

• سهلسهل

•واضحواضح

•

• بسيطبسيط

• Simply support your patient and give him Simply support your patient and give him what he needs----if not breathing –give him what he needs----if not breathing –give him breathing - ---if no pulsebreathing - ---if no pulse—give him a pulse—give him a pulse

What is new in BLS?What is new in BLS?

• EEarlyarly CPRCPR before before DFDF in in unwitnessedunwitnessed arrest arrest• 30:2 30:2 cycles cycles UNIVERSALUNIVERSAL formula-for unintubated formula-for unintubated

patients eg at the time of collapsepatients eg at the time of collapse• 2min CPR after each shock even if revert to sinus 2min CPR after each shock even if revert to sinus

rythmrythm,as this rhythm is often not perfusing,as this rhythm is often not perfusing

• This formula applies This formula applies forfor ALL AGESALL AGES

• Emphasis on uninterrupted compressionsEmphasis on uninterrupted compressions

• Avoid hyperventilationAvoid hyperventilation

Approach to cardiac arrestApproach to cardiac arrest

• Act quicklyAct quickly

• Support your patient ABCD Support your patient ABCD

• loooooooooooooooooook for the loooooooooooooooooook for the causecause

Approach to the cardiac arrest- Approach to the cardiac arrest- do not waste time do not waste time

• Call first and fastCall first and fast• Start CPR Start CPR immediatelyimmediately

• New formula 30:2( 30 comp:2 vent)-cycles-New formula 30:2( 30 comp:2 vent)-cycles-this reduce interruption of cardiac compressionthis reduce interruption of cardiac compression

• Note 30:2 cycle only for unintubated , but once Note 30:2 cycle only for unintubated , but once intubated –no more intubated –no more سيكلسيكل , i.e continuos , i.e continuos compresssion(100/min) ventilation 8-10/mincompresssion(100/min) ventilation 8-10/min

• It looks slow ventilation? It looks slow ventilation? • No , avoid overventilation-it reduce venous return No , avoid overventilation-it reduce venous return

(as hyperventilation create +ve pressure in the (as hyperventilation create +ve pressure in the chest)chest)

action sequence in cardiac action sequence in cardiac arrestarrest

• Check responsivenessCheck responsiveness• Call first( for AED)Call first( for AED)• Start CPR Start CPR cyclecycle: 2 rescue breaths(each : 2 rescue breaths(each

over 1 second to devote more time to over 1 second to devote more time to compression (30)and then shock if it is VF.compression (30)and then shock if it is VF.

• Once intubated : no more Once intubated : no more سيكلسيكل i.e no synchronization: uninterrupted i.e no synchronization: uninterrupted compression100/min compression100/min

What if you donot want to give What if you donot want to give mouth to mouse mouth to mouse فارة الى فارة 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 ---can create +ve pressure in the chest (further reducing C.O) , reducing C.O) ,

• ---more gastric distension--may vomit and… ---more gastric distension--may vomit and…

Ventricular fibrillation-Ventricular fibrillation-managementmanagement

• Witnessed- (good energy reserve)Witnessed- (good energy reserve)

so so DF 360 DF 360 فورافورا

Unwitnessed-(poor reserve) what to do ?Unwitnessed-(poor reserve) what to do ?

-improve reserve(2min CPR) then -improve reserve(2min CPR) then DF DF 360,360,

Where often they respond,what if no Where often they respond,what if no response?response?

VF—WHAT IF 1VF—WHAT IF 1STST SHOCK FAIL? SHOCK FAIL? CPR-shock-CPR-shock-CPR- CPR-shock-CPR-shock-CPR-SHOCKSHOCK

shock-2minCPR-shock-2min CPR-shock- 2min CPRshock-2minCPR-shock-2min CPR-shock- 2min CPR

• NO MORE 3STACKED SHOCKSNO MORE 3STACKED SHOCKS

i.e NO MORE SHOCK-SHOCK –SHOCK i.e NO MORE SHOCK-SHOCK –SHOCK

If available: intubate , If available: intubate ,

give vasopressors(epinephrine) early give vasopressors(epinephrine) early

So basically what are the new So basically what are the new changes in VF management?changes in VF management?• 2 min CPR2 min CPR interposed among shock shock interposed among shock shock

shock sequence… shock sequence… WHY?WHY?• To maximize chance of response to shockTo maximize chance of response to shock

• 2min CPR even if revert to normal 2min CPR even if revert to normal rhythm rhythm as this as this rhythm is often not perfusing-PEArhythm is often not perfusing-PEA

• EarlierEarlier use of ACLS therapies i.e use of ACLS therapies i.e intubation & medicines.intubation & medicines.

Management of cardiac arrestManagement of cardiac arrestsupport the patient+treat the support the patient+treat the cause cause Support the patient:Epinephrine+_AtropineSupport the patient:Epinephrine+_Atropine

Epinephrine: in ALL 4 arrest rhythm(1 mg /3-Epinephrine: in ALL 4 arrest rhythm(1 mg /3-5min)5min)

Atropine :in VF/VT No atropineAtropine :in VF/VT No atropine

in PEA only ifin PEA only ifبازالءبازالء is slow is slow

in Asystole ALL patientsin Asystole ALL patients

Atropine dose: 1 mg every 3-5 min (max 3 doses)Atropine dose: 1 mg every 3-5 min (max 3 doses)

Treat specific causeTreat specific cause

• This applies to ALL cases of arrest rhythmThis 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 All the time consider 5 Hs &5 Ts in ANYANY arrest rhythm arrest rhythm

Unless you address the underlying cause…. Unless you address the underlying cause….

Treat the cause e.gTreat the cause e.g

• Unless u treat HypoMg of alcoholic….Unless u treat HypoMg of alcoholic….

• Unless treat arrythmia +the clot of Unless treat arrythmia +the clot of MI….MI….

• Unless treat eletrolyte imbalance in Unless treat eletrolyte imbalance in CRF…CRF…

Word of caution about Dx of Word of caution about Dx of PEA?PEA?

• A severely hypotensive patient may A severely hypotensive patient may have no pulse+ sins rhyrhmhave no pulse+ sins rhyrhm

• Also PEA : no pulse+ sinus rhythm?Also PEA : no pulse+ sinus rhythm?

• How to differentiate?How to differentiate?

Post resuscitation supportPost resuscitation support

• Remember many of these patientsRemember many of these patients

need hemodynamic support i.e need hemodynamic support i.e hypotensive and need vasopressors hypotensive and need vasopressors e.g dopaminee.g dopamine

Keep searching for treatable causesKeep searching for treatable causes

THANK YOUTHANK YOU