SUDDEN CARDIAC DEATHSUDDEN CARDIAC DEATH PREVENTION AND PREVENTION AND

CARDIO-PULMONARY RESSUSSITATION CARDIO-PULMONARY RESSUSSITATION (CPR)(CPR)

Rasim ENAR; M.DRasim ENAR; M.DProfessor of CardiologyProfessor of Cardiology

İstanbul Universityİstanbul UniversityCerrahpaşa Medical FacultyCerrahpaşa Medical FacultyDepartment of CardiologyDepartment of Cardiology

SUDDEN CARDIAC DEATH (SCD)SUDDEN CARDIAC DEATH (SCD)

Definition:Definition:

““Natural Death due to cardiac causes Natural Death due to cardiac causes

(1)(1) Loss of consciousness within one hour Loss of consciousness within one hour after start of the symptomsafter start of the symptoms

(2)(2) Pre-existing heart disease may be present; Pre-existing heart disease may be present; but the cause or the timing of the death can but the cause or the timing of the death can

not be predictednot be predicted

Keys of Definition :Keys of Definition :

(a)(a) Non-taumatic nature Non-taumatic nature

(b)(b) Unexpected and sudden Unexpected and sudden

CARDIAC CARDIAC ARRESTARREST

Definition:Definition:Sudden cessation of cardiac pump functionSudden cessation of cardiac pump functionReversible with rapid and effective intervention;Reversible with rapid and effective intervention;otherwise cardiac death is unevitableotherwise cardiac death is unevitable

►►►►►► The common electrophysological mechanism The common electrophysological mechanism which cause cardiac arrest as a cause of SCD: which cause cardiac arrest as a cause of SCD:

(1(1)- )- Ventricular Tachyarrhytmias;Ventricular Tachyarrhytmias; Ventricular Fibrillation, Ventricular Fibrillation, Ventricular TachycardiaVentricular Tachycardia

(2)-(2)- Non-Tachyarrhytmic causes ;Non-Tachyarrhytmic causes ; Other important Other important causes of cardiac arrest; causes of cardiac arrest; Pulseless electrical activity (Electromachanical Pulseless electrical activity (Electromachanical Dissosiation);Dissosiation);Asistoly; Asistoly;

Bradiarrhythmias Bradiarrhythmias

ECG:Sınus arrestECG:Sınus arrest

No P waves.No P waves.

ECG: VFECG: VF

ECG: Polimorphic VT (Torsade de ECG: Polimorphic VT (Torsade de Pointes)Pointes)

ECG: Complete AV BlockECG: Complete AV Block

Dissociate P an QRS waves.Dissociate P an QRS waves.

ETY-1:ETY-1: SCD- CARDIOVASCULAR SCD- CARDIOVASCULAR DISEASES:.DISEASES:.

►►1-1- Coronary artery diseaseCoronary artery disease Acute coronary sydrome, Acute coronary sydrome, Chronic ischemic heart diseaseChronic ischemic heart disease

►►2-2- Dilated cardiomyopathyDilated cardiomyopathy**►► “The above two cinical states is responsible for “The above two cinical states is responsible for

>90% of SCD events”.>90% of SCD events”.

►►3- 3- Other cardiomyopathiesOther cardiomyopathies; ; (a) (a) hipertrophic cardiomyopathy, hipertrophic cardiomyopathy, (b) arrhythmogenic right ventricular cardiomyopathy(b) arrhythmogenic right ventricular cardiomyopathy

►►4-4- Primary “electrical” disturbances.Primary “electrical” disturbances.

►►5-5- Mechanical cardiovascular diseases.Mechanical cardiovascular diseases.

ETY -2:►ETY -2:► 4- Primary “electrical” 4- Primary “electrical” disturbances:disturbances:

(a)(a) Long QT syndrome Long QT syndrome

(b)(b) Brugada syndromeBrugada syndrome

(c)(c) Cathecholaminergic polimorphic VT. Cathecholaminergic polimorphic VT.

(d)(d) Wolf-Parkinson-White syndromeWolf-Parkinson-White syndrome (WPW). (WPW).

(e)(e) Sinus and AV node related conduction Sinus and AV node related conduction

disturbancesdisturbances

ETY-3 SCD ETY-3 SCD -- Mechanical Cardiyovascular Mechanical Cardiyovascular Diseases;Diseases;

a-a- Aortic stenosis. Aortic stenosis. b-b- Mitral valve prolapseMitral valve prolapsec- c- Myocardial bridgingMyocardial bridgingd-d- Anolomous coronary artery origin Anolomous coronary artery origin----------------------------------------------------------------------------------------------------------------------------------------

ETY-4ETY-4 ► SCD-► SCD- Other Causes:Other Causes:

(a)(a) Myocarditis Myocarditis (b)(b) Chest trauma Chest trauma(c)(c) Drug overdose - Torsade de Pointes Drug overdose - Torsade de Pointes(d)(d) Atheletes heart _ trained heart Atheletes heart _ trained heart(e)(e) SCD in normal heart (idiopathic VF). SCD in normal heart (idiopathic VF).

Prevention from SCD:Prevention from SCD:

►►Principal:Principal: Multi-factorial etiology and various Multi-factorial etiology and various treatment targets.treatment targets.

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►►Primary prophlaxis:Primary prophlaxis: Prevention of fatal Prevention of fatal arrhythmias in patients without prior sustainead arrhythmias in patients without prior sustainead VT and high risk for SCD VT and high risk for SCD

►►Secondary prophlaxis:Secondary prophlaxis: Prevention of fatal Prevention of fatal arrhythmias in patients who exprerienced arrhythmias in patients who exprerienced cardiac arrest and sustained ventricular cardiac arrest and sustained ventricular tachyarrhytmiastachyarrhytmias

PrimaryPrimary ProflaxisProflaxis::

3 different proflactic treatment 3 different proflactic treatment modalities:modalities:

1- 1- Drugs without electrophysiologic effectsDrugs without electrophysiologic effects

2- 2- Drugs with electrophysiologic effectsDrugs with electrophysiologic effects

3- ICD3- ICD(Implantable Cardiac Defibrillator)(Implantable Cardiac Defibrillator)

1- Drugs without electrophysiologic 1- Drugs without electrophysiologic effects :effects :

Importance of the treatment:Importance of the treatment: Both total mortality Both total mortality and SCDand SCD is reduced. is reduced.

------------------------------------------------------------------------------------------------------------------------3 different class drugs:3 different class drugs:1- ACE-I 1- ACE-I (angiootensin converting enzyme (angiootensin converting enzyme

inhibitors), inhibitors), ARBARB ( (+?+?))2- 2- Aldosterone receptor blockersAldosterone receptor blockers3-3- Poli-unsaturated fatty acids (omega-3)Poli-unsaturated fatty acids (omega-3) +-+- StatinsStatins

RESSUSİTATION.RESSUSİTATION.

Return of spontaneous circulation (ROS) can Return of spontaneous circulation (ROS) can be achived only 15% of cardiac arrest cases, be achived only 15% of cardiac arrest cases, and only 50% of those could be dischargedand only 50% of those could be discharged

As a result;As a result; There is only a 5-7% chance of There is only a 5-7% chance of survival in cardiac arrst victims.survival in cardiac arrst victims.

Survival from cardiac arrestSurvival from cardiac arrest::

(a)(a) Etiolgy of cardiac arrest (VF>EM-Diss), Etiolgy of cardiac arrest (VF>EM-Diss),

(b)(b) Pre- cardiac arrest status, Pre- cardiac arrest status,

(c)(c) Unwitnessed cardiac arrest Unwitnessed cardiac arrest

(d)(d) Emergency CPR and availability of Emergency CPR and availability of

automated external defibrilatorautomated external defibrilator

CHAIN OF SURVIVAL:CHAIN OF SURVIVAL:((ABLS: Adult Basic Life SupportABLS: Adult Basic Life Support))

“Call 112,“Call 112,+Chest compression ++Chest compression +DefibrilltorDefibrilltor+ IV Drug+ IV DrugTherapy”.Therapy”.

Electrical meaning of Electrical meaning of Ressussitation:Ressussitation:

VF is the most common cause of cardiac VF is the most common cause of cardiac arrestarrest

Spontaneous termination does not occurSpontaneous termination does not occur VF more than 3-4 minutes causes VF more than 3-4 minutes causes

irrversible organ damage.irrversible organ damage. Prevention of death secondary to cardiac Prevention of death secondary to cardiac

arrestarrest Immediate, rapid Defibrillation (DFB).Immediate, rapid Defibrillation (DFB).* * Every minute delay with DFB reduces life Every minute delay with DFB reduces life

expactancy by 7-10% according to direct expactancy by 7-10% according to direct CPR with chest compression or CPR with chest compression or entubationentubation

External Defibrillator.External Defibrillator.

Devices with automated rhythm analysis and Devices with automated rhythm analysis and shock delivery featuresshock delivery features

External defibrilator (EDFB); should be used only External defibrilator (EDFB); should be used only in patients who are unresponsive, not breathing in patients who are unresponsive, not breathing and without effective circulationand without effective circulation

DEFIBRILATOR(DFB): Manually operated; DEFIBRILATOR(DFB): Manually operated; Paddeles and Monitore.Paddeles and Monitore.

Eksternal Defibrilator- Localization Eksternal Defibrilator- Localization of Pedalsof Pedals

Return of NSR (“arrow sign”) after DFB Return of NSR (“arrow sign”) after DFB of VFof VF

CPR; Cardio-Pulmonary CPR; Cardio-Pulmonary RessussitationRessussitation

If immediate DFB is not possible, then CPR should If immediate DFB is not possible, then CPR should be started without delay.be started without delay.

Late-CPR and/or advanced cardiac life support Late-CPR and/or advanced cardiac life support (ACLS) should be discouraged.(ACLS) should be discouraged.

Only 10-20% of out-of hospital VF cases survive Only 10-20% of out-of hospital VF cases survive and 50% of those will have neurological and 50% of those will have neurological problems.problems.

As a result:As a result: If cardiac arrest is not diagnosed If cardiac arrest is not diagnosed within 4 minutes and CPR and DFB is not given within 4 minutes and CPR and DFB is not given within 8 minutes; ressussitation will be within 8 minutes; ressussitation will be unsuccessful.unsuccessful.

How to do CPR ?How to do CPR ?

BLSBLS (Basıc Life Support) Algorhthm: (Basıc Life Support) Algorhthm: ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1- 1- Check the responsiveness Check the responsiveness ; if unresponsive- start CPR:; if unresponsive- start CPR: 2-2- Open AirwayOpen Airway; “Head tilt-jaw trust” ; “Head tilt-jaw trust”

►► ►► 3- 3- Check the breathing- not breathingCheck the breathing- not breathing; Start mouth-to-mouth ; Start mouth-to-mouth breathingbreathing

4- 4- Give your breath ; Give your breath ; - Give 1-1,5 seconds break for breathing and - Give 1-1,5 seconds break for breathing and observe the patient after the first two full breathsobserve the patient after the first two full breaths

5- 5- Assess circulationAssess circulation;- Check pulse at carotide artery;- Check pulse at carotide artery ►► ►► 6- 6- If no sign of circulation (no pulse); start chest compressionIf no sign of circulation (no pulse); start chest compression ------------------------------------------------------------------------------------------------------------------------------------------ 1- 2 rescuer CPR :1- 2 rescuer CPR : 15 compression - 2 ventilation. 15 compression - 2 ventilation. Rate of compression : Rate of compression : 90- 100/min90- 100/min At the end of compression 2 full breaths should be given;At the end of compression 2 full breaths should be given; if endotracheal tube is inplace; 5 chest compression / 1 ventilationif endotracheal tube is inplace; 5 chest compression / 1 ventilation

ABC of CPRABC of CPR

Autamated External DFB.Autamated External DFB.

Copyright ©2005 American Heart Association

Estes, N.A. M. Circulation 2005;112:e349-e351

An AED is used on a victim of sudden cardiac arrest

CPR: “The moment every thing is over or started again CPR: “The moment every thing is over or started again “That moment”(“That moment”(?!??!?):):

First-aid ( First-aid ( Semi-autamated DFBSemi-autamated DFB).).

----VF,-DFB and -Sinüs rhythm.VF,-DFB and -Sinüs rhythm.-- “-- “Geçmiş olsunGeçmiş olsun”….”….