Principles of Cardiac Arrest Management Richard Lake 10/2003.
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Transcript of Principles of Cardiac Arrest Management Richard Lake 10/2003.
Principles of Principles of Cardiac Arrest Cardiac Arrest ManagementManagement
Richard Lake 10/2003Richard Lake 10/2003
Background InformationBackground Information
40% of deaths under the age of 75yrs in 40% of deaths under the age of 75yrs in Europe are due to cardiovascular diseaseEurope are due to cardiovascular disease
One third of people who suffer a myocardial One third of people who suffer a myocardial infarction die before reaching hospitalinfarction die before reaching hospital
Most die within an hour of the onset of acute Most die within an hour of the onset of acute symptomssymptoms
The majority of these deaths the presenting The majority of these deaths the presenting rhythm is Ventricular Fibrillation or pulseless rhythm is Ventricular Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)Ventricular Tachycardia, (VF/ pulseless VT)
The only treatment for VF/ pulseless The only treatment for VF/ pulseless VT is attempted defibrillationVT is attempted defibrillation
With each minute’s delay the chance With each minute’s delay the chance of a successful outcome fall by 7-of a successful outcome fall by 7-10%10%
Once in hospital the incidence of VF Once in hospital the incidence of VF after Myocardial Infraction is after Myocardial Infraction is approximately 5%approximately 5%
Most likely presentation of in hospital Most likely presentation of in hospital cardiac arrest is asystole or pulseless cardiac arrest is asystole or pulseless electrical activity (PEA).electrical activity (PEA).
The Chain of SurvivalThe Chain of Survival
Early Access to emergency services Early Access to emergency services or cardiac arrest teamor cardiac arrest team
Out of hospital summon EMSOut of hospital summon EMS
by dialling 999/112by dialling 999/112 In hospital call cardiac arrestIn hospital call cardiac arrest
team ring 2222 (check team ring 2222 (check
number when on placement)number when on placement)
External chest compressions and External chest compressions and
ventilation will slow down the ventilation will slow down the
rate of deterioration of the brain rate of deterioration of the brain
and heartand heart Basic Life Support should be Basic Life Support should be
performed immediatelyperformed immediately
Basic Life SupportBasic Life Support
DangerDanger ResponseResponse Shout for HelpShout for Help AirwayAirway BreathingBreathing If no help arrived leave victim, go for If no help arrived leave victim, go for
helphelp CirculationCirculation
DangerDanger
Check for danger to:Check for danger to: YourselfYourself BystandersBystanders VictimVictim Even clinical areas can have dangers, Even clinical areas can have dangers,
so so ALWAYS CHECKALWAYS CHECK
ResponseResponse Check the victim for Check the victim for
responseresponse Ask a question, ‘hello are you Ask a question, ‘hello are you
alright?’alright?’ Give a command, ‘open your Give a command, ‘open your
eyes!’eyes!’ Give a painful stimulus; pinch Give a painful stimulus; pinch
the shoulderthe shoulder If no response shout for helpIf no response shout for help
Checking for responseChecking for response
AirwayAirway
Check the airwayCheck the airway Open the airway, place one hand on Open the airway, place one hand on
the victims forehead and gently tilt the victims forehead and gently tilt head backhead back
Remove any visible obstruction from Remove any visible obstruction from the victims mouth, including dislodged the victims mouth, including dislodged dentures. Leave well fitting dentures in dentures. Leave well fitting dentures in placeplace
DO NOT ATTEMPT ANY FINGER SWEEPSDO NOT ATTEMPT ANY FINGER SWEEPS
Opening the airwayOpening the airway
Jaw thrust technique may be Jaw thrust technique may be needed if C-spine injuryneeded if C-spine injury
If available use airway If available use airway adjunctsadjuncts
Nasopharyngeal airway Nasopharyngeal airway insertioninsertion
Oropharyngeal airway Oropharyngeal airway insertioninsertion
BreathingBreathing
Keeping the airway open:Keeping the airway open: Look –Look – for chest movements for chest movements Listen – Listen – at the victims mouth for breath at the victims mouth for breath
soundssounds Feel – Feel – for air on your cheekfor air on your cheek Look, listen and feel for Look, listen and feel for no more than 10 no more than 10
secondsseconds to determine if the victim is not to determine if the victim is not breathing.breathing.
If not breathing If not breathing and no help has arrivedand no help has arrived
Leave the victim and go to summon helpLeave the victim and go to summon help
Turn the victim onto his back if he is not Turn the victim onto his back if he is not already in that positionalready in that position
Give 2 effective rescue breaths, each of which Give 2 effective rescue breaths, each of which should make the chest rise and fall should make the chest rise and fall
If you have difficulty achieving an effective If you have difficulty achieving an effective breath:breath:
Recheck the victims mouth and remove any Recheck the victims mouth and remove any obstructionobstruction
Recheck there is head tilt and chin lift Recheck there is head tilt and chin lift Make up to 5 attempts to achieve 2 effective Make up to 5 attempts to achieve 2 effective
breathsbreaths Even if unsuccessful move onto check Even if unsuccessful move onto check
circulationcirculation
If available use a pocket If available use a pocket maskmask
Bag valve mask device may be Bag valve mask device may be usedused
CirculationCirculation
Look, listen and feel for normal Look, listen and feel for normal breathing, coughing, swallowing, eye breathing, coughing, swallowing, eye flickering, or any movement by the flickering, or any movement by the victimvictim
If you feel confident check for a If you feel confident check for a carotid pulsecarotid pulse
You should take no more than 10 You should take no more than 10 seconds to do thisseconds to do this
Always check pulse same side Always check pulse same side as youas you
If no breathing If no breathing but signs of circulation but signs of circulation
Continue rescue breaths at a rate of Continue rescue breaths at a rate of 10 breaths per minute10 breaths per minute
After every 10 breaths (every 1 After every 10 breaths (every 1 minute) recheck for signs of minute) recheck for signs of circulationcirculation
This should take no longer than 10 This should take no longer than 10 seconds to checkseconds to check
If no breathing and If no breathing and no signs of circulationno signs of circulation
Commence CPR at a ratio ofCommence CPR at a ratio of
15 Compressions 15 Compressions
to 2 ventilationsto 2 ventilations
Ensure correct hand Ensure correct hand positionposition
The Chain of SurvivalThe Chain of Survival
Out of hospital the aim is toOut of hospital the aim is to
deliver a shock within deliver a shock within
5 minutes of the EMS receiving5 minutes of the EMS receiving
a calla call In hospital the first healthcare In hospital the first healthcare
responder should be trained andresponder should be trained and
authorised to use a defibrillatorauthorised to use a defibrillator
immediatelyimmediately
Automated External Automated External DefibrillatorDefibrillator
AED hands off padsAED hands off pads
Automated External Automated External Defibrillators Defibrillators may be usedmay be used
Manual DefibrillatorManual Defibrillator
Manual Defibrillator PaddlesManual Defibrillator Paddles
DefibrillationDefibrillation
Defibrillation should be Defibrillation should be performed promptlyperformed promptly
Often defibrillation restores a Often defibrillation restores a
perfusing heart rhythm, this isperfusing heart rhythm, this is
often inadequate to sustain often inadequate to sustain
circulation and further circulation and further
advanced life support is advanced life support is
required to improve the required to improve the
chances of long term survivalchances of long term survival
Remember the chain of Remember the chain of survivalsurvival
The Universal Treatment The Universal Treatment AlgorithmAlgorithm
An important part of An important part of
Advanced Cardiac Life Advanced Cardiac Life SupportSupport
ObjectivesObjectives
Recognise the four cardiac arrest Recognise the four cardiac arrest rhythmsrhythms
Identify correctly the appropriate Identify correctly the appropriate algorithm for each of the rhythmsalgorithm for each of the rhythms
Discuss the potential reversible Discuss the potential reversible causes of cardiac arrestcauses of cardiac arrest
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
During CPR Correct reversible causes
+/- Pulse Check
VF / VT NON VF/VT
DEFIB X 3 as necessary
CPR 1 MIN
CPR 3 min
Re-assess one minute after defibrillationCheck electrode / paddle positions
Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
BLS Algorithmif appropriate
Attach Monitor/Defib
Assess rhythm
+/- Pulse Check
VF / VT Non VF / VT
?
Precordial Thumpif appropriate
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
During CPR Correct reversible causes
+/- Pulse Check
VF / VT
DEFIB X 3 as necessary
CPR 1 MIN
Check electrode / paddle positions Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
During CPR Correct reversible causes
+/- Pulse Check
NON VF/VT
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 CausesPotentially Reversible Causes
HHypoxiaypoxia
HHypovolemiaypovolemia
HHyper/ Hypokalemia and metabolic yper/ Hypokalemia and metabolic disturbancesdisturbances
HHypothermiaypothermia
TTension pneumothoraxension pneumothorax
TTamponadeamponade
TToxic/ therapeutic disturbancesoxic/ therapeutic disturbances
TThrombo-embolic/ mechanical obstructionhrombo-embolic/ mechanical obstruction
BLS Algorithm
if appropriate
Precordial Thump
Attach Monitor/Defib
Assess rhythm
During CPR Correct reversible causes
+/- Pulse Check
VF / VT NON VF/VT
DEFIB X 3 as necessary
CPR 1 MIN
CPR 3 min
Re-assess one minute after defibrillationCheck electrode / paddle positions
Attempt/verify airway/02/IV access Give adrenaline every 3 mins ? buffers/atropine/ pacing/antiarrhythmics
Drugs used commonly Drugs used commonly during resuscitationduring resuscitation
Epinephrine (Adrenaline)Epinephrine (Adrenaline) AtropineAtropine AmiodaroneAmiodarone Magnesium SulphateMagnesium Sulphate Lidocaine (Lignocaine)Lidocaine (Lignocaine) Sodium BicarbonateSodium Bicarbonate CalciumCalcium
Epinephrine (Adrenaline)Epinephrine (Adrenaline)
First line cardiac arrest drug, given after First line cardiac arrest drug, given after every 3 minutes of CPRevery 3 minutes of CPR
Dose 1mg (10ml of 1 in 10,000) IVDose 1mg (10ml of 1 in 10,000) IV Causes vasoconstriction, increased Causes vasoconstriction, increased
systemic vascular resistance increasing systemic vascular resistance increasing cerebral and coronary perfusioncerebral and coronary perfusion
Increases myocardial excitability, when Increases myocardial excitability, when the myocardium is hypoxic or ischaemicthe myocardium is hypoxic or ischaemic
AtropineAtropine
Given for asystole or pulseless Given for asystole or pulseless electrical activity with a rate less electrical activity with a rate less than 60 beats per minutethan 60 beats per minute
3mg is given as a single intravenous 3mg is given as a single intravenous dosedose
It blocks the activity of the vagus It blocks the activity of the vagus nerve on the SA and AV nodes, nerve on the SA and AV nodes, increasing sinus automaticity and increasing sinus automaticity and facilitating AV node conductionfacilitating AV node conduction
AmiodaroneAmiodarone
For Refractory VF/VT; haemodynamically stable For Refractory VF/VT; haemodynamically stable VT and other resistant tachyarrhythmiasVT and other resistant tachyarrhythmias
If VF or pulseless VT persists after the first 3 If VF or pulseless VT persists after the first 3 shocks then Amiodarone 300mg is considered.shocks then Amiodarone 300mg is considered.
If not pre-diluted, must be diluted in 5% dextrose If not pre-diluted, must be diluted in 5% dextrose to 20ml. (Will crystallise is mixed with saline)to 20ml. (Will crystallise is mixed with saline)
Should be given centrally but in an emergency Should be given centrally but in an emergency can be given peripherallycan be given peripherally
Increases the duration of the action potential in Increases the duration of the action potential in the atrial and ventricular myocardiumthe atrial and ventricular myocardium
Magnesium SulphateMagnesium Sulphate
For refractory VF when For refractory VF when hypomagnesaemia is possible; hypomagnesaemia is possible; ventricular tachyarrhythmias when ventricular tachyarrhythmias when hypomagnesaemia is possiblehypomagnesaemia is possible
In refractory VF – 1 to 2g (2-4ml of In refractory VF – 1 to 2g (2-4ml of 50% magnesium sulphate) 50% magnesium sulphate) peripherally over 1 to 2 minutes. peripherally over 1 to 2 minutes.
Other circumstances 2.5g (5ml of 50% Other circumstances 2.5g (5ml of 50% magnesium sulphate) over 30 minutesmagnesium sulphate) over 30 minutes
Lidocaine (Lignocaine)Lidocaine (Lignocaine)
For Refractory VF/ pulseless VT For Refractory VF/ pulseless VT (when Amiodarone is unavailable(when Amiodarone is unavailable
100mg for VF/ pulseless VT that 100mg for VF/ pulseless VT that persists after three shocks. Another persists after three shocks. Another 50mg can be given if necessary50mg can be given if necessary
Sodium BicarbonateSodium Bicarbonate
Given for severe metabolic acidosis Given for severe metabolic acidosis and Hyperkalaemiaand Hyperkalaemia
50mmol (50ml of 8.4% solution), 50mmol (50ml of 8.4% solution), where there is an acidosis or cardiac where there is an acidosis or cardiac arrest associated with arrest associated with HyperkalaemiaHyperkalaemia
CalciumCalcium
Administered when pulseless electrical Administered when pulseless electrical activity caused by: activity caused by:
HyperkalaemiaHyperkalaemia HypocalcaemiaHypocalcaemia Overdose of Calcium channel blocking Overdose of Calcium channel blocking drugsdrugs Dose 10ml of 10% calcium chloride Dose 10ml of 10% calcium chloride
repeated according to blood resultsrepeated according to blood results
SummarySummary
Cardiac arrest can Cardiac arrest can have a variety of have a variety of causes causes
The chain of The chain of survival is essential survival is essential to improve to improve outcome from outcome from cardiac arrestcardiac arrest
Awareness of the universal treatment Awareness of the universal treatment algorithm is important algorithm is important
A knowledge of the drugs used in A knowledge of the drugs used in cardiac arrest, their routes and cardiac arrest, their routes and dilution is also essentialdilution is also essential
QuestionsQuestions
ReferencesReferences
Resuscitation Council (UK). (2000) Resuscitation Council (UK). (2000) Advanced Life Advanced Life Support Provider Course ManualSupport Provider Course Manual . 4 . 4thth Edition. Edition. Resuscitation Council (UK).:LondonResuscitation Council (UK).:London
Resuscitation Council (UK). (2002) Resuscitation Council (UK). (2002) Immediate Life Immediate Life Support Course ManualSupport Course Manual . 1 . 1stst Edition. Edition. Resuscitation Council (UK).:LondonResuscitation Council (UK).:London