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Emergency Medicine_Cardiac Arrest 2.pdf
1.
Adult Cardiac Arrest
Part II: Advanced Life Support General Emergency Medicine Topics With Julianna Jung, MD Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
2.
Learning Objectives • You
will be able to identify the three major cardiac arrest rhythms (ventricular fibrillation/tachycardia, pulseless electrical activity, and asystole). • You will be able to list the differential diagnoses and describe the underlying physiology for each arrest type. • You will be able to identify key similarities and differences between the treatment algorithms for each arrest type. • You will be able to describe the pathophysiologic and evidentiary rationale for major interventions within each algorithm. Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
3.
Three Major Cardiac
Arrest Rhythms Absence of electrical activity in the heart Definition Ventricular fibrillation/ Pulseless ventricular tachycardia Asystole Absence of clinically detectable pulse despite the presence of organized electrical activity in the heart Abnormal and accelerated electrical activity originating in the ventricles and leading to loss of effective circulation Pulseless electrical activity Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
4.
Usually caused by
primary cardiac disease, most commonly ischemia Less commonly caused by systemic conditions (electrolyte disturbances, toxins, autoimmunity) Can also be caused by structural heart disease or channelopathies Ventricular Fibrillation/Tachycardia Etiology Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
5.
Ventricular Fibrillation Jafary FH
- The "incidental" episode of ventricular fibrillation: a case report., cropped and resized https://openi.nlm.nih.gov/detailedresult.php ?img=PMC2000884_1752-1947-1-72-1&query=ventricular+fibrillation&it=xg&lic=by&req=4&npos=5, CC BY 2.0 Diagnosis No mechanical contraction = no pulse! Incompatible with life Randomly fluctuating, no pattern, no QRS complexes Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
6.
Ventricular Tachycardia ps://openi.nlm. nih.gov/detailedresult.php?img=PMC4320716_pjms-30-1281-g003&query=ventricular+tachycardia&it=xg&lic=by&req=4&npos=27, CC
BY 2.0 Diagnosis Wide, bizarre QRS complexes, but organized and regular May be pulseless, stable, or unstable Rapid rate (> 100 by definition; usually > 150) 150 100 Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
7.
Ventricular Fibrillation/Tachycardia Management What
is the single most important intervention for these arrest types? Defibrillate! Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
8.
Ventricular Fibrillation/Pulseless Ventricular
Tachycardia - Algorithm Management Call for help, start CPR Defibrillate Rhythm check/defib Epinephrine If rhythm is not restored, 5 cycles 30:2 CPR (or 2 min) Rhythm check/defib Consider amiodarone If rhythm is not restored, 5 cycles 30:2 CPR (or 2 min) Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
9.
Nonselective adrenergic agonist Very little
supporting evidence Increases systemic vascular resistance, increasing perfusion to heart and brain Epinephrine Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
10.
Only one randomized
controlled trial: Epinephrine Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143. Management Outcome Placebo (n = 262) Adrenaline (n = 272) OR (95 % CI) P value ROSC achieved pre-hospital 22 (8.4 %) 64 (23.5 %) 3.4 (2.0 5.6) < 0.001 Admitted to hospital 34 (13.0 %) 69 (25.4 %) 2.2 (1.4 3.6) < 0.001 Survived to hospital discharge 5 (1.9 %) 11 (4.0 %) 2.2 (0.7 6.3) 0.15 CPC 1 or 2 5 (100 %) 9 (81.8 %) - 0.31 Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
11.
• Stimulates α
receptors to increase vascular tone • Optimizes perfusion of the heart and brain • Improves short-term survival, which is a prerequisite for long-term survival • Stimulates β receptors, which increase myocardial oxygen demand • Reduces perfusion to all other organs • Effect on long-term survival may be negligible or deleterious Epinephrine Pros Cons Complications Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
12.
Epinephrine Bottom Line Epi
is mandatory in current arrest algorithms. Give 1 mg (10 mL of 1:10,000 solution) IV/IO every 3 5 minutes. Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
13.
• Class III
antiarrhythmic indicated for shock- refractory VF/VT • lidocaine not mandatory • Two studies show improved short-term survival with amiodarone vs. placebo • No evidence of superiority of amiodarone over lidocaine • No evidence of benefit for long-term survival Amiodarone Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
14.
Amiodarone Bottom Line Amio
is commonly used for refractory VF/VT. Give 300 mg IV/IO loading dose; consider infusion after ROSC. Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
15.
Ventricular Fibrillation/Tachycardia Algorithm
Management Call for help, start CPR Defibrillate If rhythm is not restored, 5 cycles 30:2 CPR (or 2 min) Rhythm check/defib Epinephrine Rhythm check/defib Consider amiodarone or lidocaine If rhythm is not restored, 5 cycles 30:2 CPR (or 2 min) Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
16.
Pulseless Electrical Activity Mugmon
M - J PubMed, Is it really sinus tachycardia?, resized, https://openi.nlm.nih.gov/detailedresul t.php?img=PMC3714029_JCHIMP-1-7241-g001&query=sinus+tachycardia&lic=by&req=4&npos=1, CC BY 2.0 Diagnosis Electrical activity on the monitor + no pulse on exam = PEA Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
17.
Pulseless Electrical Activity What
is the single most important intervention for this arrest type? Identify and reverse the underlying pathology! Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
18.
Mechanisms of PEA Electromechanical
dissociation Electrical conduction in the heart is normal. Electrical conduction in the heart is normal. Caused by hypovolemia or extracardiac obstruction to filling (e.g., tamponade, tension pneumothorax). Caused by systemic derangements that impair energy metabolism or directly impair myocyte function in the heart. Contraction occurs but is ineffective because the heart does not fill. Action potentials yield little or no cardiac myocyte contraction. Etiology Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
19.
High-yield Differential Diagnosis of
PEA H s and T s Diagnosis Hypovolemia Hypoxia Hydrogen ion (acidosis) Hyper/hypokalemia Hypothermia Tension pneumothorax Tamponade, pericardial Toxins Thrombosis, coronary Thrombosis, pulmonary Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
20.
PEA Identifying the
Underlying Cause Diagnosis History Physical exam Bedside ultrasound Circumstances surrounding the arrest, past medical/surgical history Signs of trauma, pregnancy, presence of dialysis catheter/fistula, temperature, cyanosis, breath sounds, jugular venous distension Pericardial effusion/tamponade, absence of lung sliding, cardiac ejection fraction, IVC size Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
21.
Ultrasound in PEA
Cardiac Tamponade -5 B, Saunders (Elsevier) Diagnosis RV RA C PE Pericardial effusion Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
22.
Ultrasound in PEA
IVC Collapse Bedside emergency cardiac ultrasound in children, Doniger SJ - J Emerg Trauma Shock (2010), cropped and resized, https://openi.nlm.nih. gov/detailedresult.php?img=PMC2938495_JETS-3-282-g012&query=IVC+Collapse&it=u&lic=by&req=4&npos=4, CC BY 2.0 Diagnosis IVC size (cm) Resp. Change CVP < 1.5 Total 0 5 1.5 2.5 > 50 % 6 10 1.5 2.5 < 50 % 11 15 > 2.5 < 50 % 16 20 > 2.5 None > 20 Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
23.
Clinical pearl Important to
Note while Treating Cardiac Arrest Clinical pearl Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
24.
Empiric Treatments for
PEA Management Suspected diagnosis Management Hypovolemia/hemorrhage IV fluids, blood Hypoxia Supplemental O2, intubate Acidosis Bicarbonate, correct cause Hyperkalemia Calcium, insulin/glucose, albuterol, bicarbonate Hypothermia Rewarming Tension pneumothorax Needle decompression Cardiac tamponade Pericardiocentesis Toxins Antidotes Myocardial infarction PCI or thrombolysis Pulmonary embolism Thrombolysis Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
25.
High-quality CPR Rhythm
checks every 2 minutes Epinephrine 1 mg every 3 5 minutes Continue searching for the underlying cause and attempt to reverse it Other Interventions for PEA Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
26.
Pulseless Electrical Activity
Algorithm Management Call for help, start CPR Obtain IV access, search for underlying cause Epinephrine, treat underlying cause Continue CPR, check rhythm every 2 min Repeat epi every 3 5 min Continue to search for and treat cause Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
27.
Asystole Glenlarson, PD Diagnosis Sbonakaliso Gumede,
sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
28.
Management is the same
as for PEA: CPR, epinephrine, search for and treat cause. Differential diagnosis is also the same as PEA. Pay particular attention to oxygenation and ventilation. Verify asystole in at least two leads. Asystole Management 90 95 Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
29.
Asystole Asystole is more
commonly a confirmation of death rather than a disease to be treated. Terminate resuscitation when appropriate. Clinical pearl Management Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
30.
Perform high-quality CPR
for all arrests. Cardiac rhythm dictates appropriate management. Defibrillate VF/VT, and give epi/amiodarone or lidocaine. Reverse cause of PEA/asystole, and give epi. Conclusion Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
31.
• Ensure appropriate
oxygen levels with pulse oximetry monitoring. • If the patient is hypotensive, treat with IV fluids and vasopressers (e.g. levophed, norepinephrine, dopamine). • If the patient has a pulse but is unarousable, induce hypothermia at 32-36 °C. • If the patient follows commands, get an ECG and treat accordingly. • Continue evaluating H's and T's. The H's are: hypovolemia, hypoxia, hydrogen ion (acidosis), hyper/hypokalemia, and hypothermia. The T's are: toxins, tamponade (cardiac), tension pneumothorax, trauma, and thrombosis. Post-arrest Care Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
32.
Learning Outcomes ✓ You
are now able to perform advanced cardiac life support for all three arrest rhythms. ✓ You are able to approach the differential diagnosis of PEA. ✓ You are able to incorporate ultrasound into patient assessment during cardiac arrest. Sbonakaliso Gumede, sbonakalisogumede037@gmail.com © www.lecturio.com | This document is protected by copyright. Powered by TCPDF (www.tcpdf.org)
33.
This document is
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