Cardiac arrest

Cardiac arrest
By: A. Taskin

by : A.taskin ( a_taskeen91@hotmail.com )

• Cardiac arrest :
is an abrupt cessation of cardiac pump function that may be reversible
but will progress to death without prompt intervention.
• The four rhythms that produce pulseless cardiac arrest are :

• ventricular fibrillation,
• pulseless ventricular tachycardia
• Asystole
• Pulseless electrical activity

Clinical features :
A patient who is :

1. unconscious,
2. apneic, and
3. pulseless

fulfills the cardiac arrest diagnosis criteria


Clinical features :
• In ventricular fibrillation :
• loss of consciousness occurs within 15 seconds,
• but agonal gasping may persist for around 60 seconds following
collapse.
• Brief seizure may occur, caused by cessation of cerebral blood
flow

• Cardiac arrest secondary to respiratory arrest causes :

• loss of consciousness, bradycardia, and absent pulse within 5
minutes

Clinical features :
Symptoms : ( may be present )
New or changing angina
Fatigue
Palpitations
Dyspnea
Chest pain


often results from reversible causes that
must be rapidly identified and treated.
5 Ts':

'5 Hs :
• Hypovolemia
• Hypothermia
• Hypoxia
• Hypo- or hyperkalemia
• Hydrogen ion (acidosis)

• Tamponade, cardiac
• Toxins
• Tension pneumothorax
• Thrombosis, pulmonary
• Thrombosis, coronary


Coronary artery disease with myocardial infarction is the most
common structural heart disease predisposing
to cardiac arrest.


physical examination factors :
• immediate CPR and rapid defibrillation take precedent over
examination in the cardiac arrest victim.
• Ensure adequacy of airway. Note the presence of any blood,
vomitus, or secretions


• Absent respiratory effort

• presence of only agonal gasps are characteristic
of cardiac arrest.
• Unilateral breath sounds may indicate:
• tension pneumothorax or
• aspiration.
• Wheezing and rales
• underlying pulmonary edema or
• aspiration

• Heart tones may be heard in patients with :
• pulmonary embolus, tension pneumothorax, or
hypovolemia
• Jugular venous distension may be noted in :
• tension pneumothorax, cardiac tamponade, or pulmonary
embolus
• A distended, dull abdomen may be noted in patients with a
• ruptured abdominal aortic aneurysm or ruptured ectopic
pregnancy

Investigations:
• Rapid rhythm assessment
• End-tidal carbon dioxide partial pressure
• Central venous oxygen saturation
• Arterial relaxation pressure
• Echocardiogram
• Serum electrolytes
• 12-lead electrocardiogram
• Serum lactate

Differential diagnosis :
• Supraventricular tachycardia with aberration
• Choking


Choking
• a person choking on a piece of food may be mistakenly thought to be
suffering acardiac arrest
• Choking commonly occurs during a meal, often when the person is
talking or laughing
• Food lodges in the oropharynx, causing sudden cyanosis and collapse
• May cause primary respiratory arrest with absence of respiratory
efforts or severe stridor with persistence of a pulse
• The Heimlich maneuver usually dislodges the piece of food, allowing
immediate recovery
• Choking may progress to cardiac arrest if the piece of food or other
foreign body is not dislodged

Causes :


Causes :
• Respiratory causes :

• mechanical airway obstruction, submersion injury, and
respiratory failure originating from asthma, pulmonary
edema, or sedative overdose.
• Metabolic abnormalities :

commonly hyperkalemia, which is most frequently seen
in patients with renal failure.
• Less commonly, hypokalemia, hypermagnesemia,
hypomagnesemia and hypercalcemia .
•


Causes :
• Toxins :
• overdose of prescription medications or
• illicit drugs e.g. digitalis, β-blockers, cocaine, and heroin .
• Electrical currents of 100 mA to 1 A usually cause ventricular fibrillation;
currents above 10 A can cause asystole
• Brugada syndrome:

which is an inherited disorder affecting cardiac membrane
channels that is associated with polymorphic ventricular
tachycardia and ventricular fibrillation.
• ECG showing a right bundle branch block with ST segment
elevation in leads V1 to V3
•


Causes :
Long QT syndrome :
• characterized by prolonged QT interval (repolarization) on
resting ECG .


Algorithms & management


CPR :
•Initiate CPR with 30 chest compressions.
•For all adults:
 provide cycles of 30 chest compressions
 followed by 2 breaths.


CPR :
•In the pediatric :
30 compressions:2 breaths for 1 rescuer CPR
 15 compressions: 2 breaths for 2 or more
rescuers.


CPR :
• push hard, push fast (≥ 100 compressions/min) while allowing
full recoil of the chest between compressions.
• Compressions should be delivered over the lower half of the
sternum to a depth of 2 inches in adults and

• at least one-third of anterior-posterior diameter of the chest in
infants and children

CPR :
• Immediately resume CPR after each defibrillation
attempt and continue for 2 minutes before rechecking
rhythm .


Immediate action :
• 1- Begin high-quality CPR & defibrillation .
• Perform rapid rhythm assessment with quick-look paddles, electrode
pads, or limb leads

• Patients with ventricular tachycardia or ventricular fibrillation require
immediate defibrillation
• Patients with PEA or asystole should have continued CPR while attempts
are made to diagnose and treat the underlying cause

• 2- Administer supplemental oxygen as soon as it is available
• 3- Establish intravenous or intraosseous access as soon as possible

Immediate action :
• After 2 minutes of CPR, reassess rhythm. If a shockable rhythm is
present, shock again
• Administer epinephrine 1 mg intravenously or intraosseously.
• Repeat every 3 to 5 minutes.
• Administer amiodarone 300 mg intravenously or

intraosseously. Repeat once at 150 mg in 3 to 5 minutes .
• A single dose of vasopressin 40 units intravenously or
intraosseously may be substituted for the first or second dose of
epinephrine

Immediate action :
• Magnesium sulfate
• 1 to 2 g intravenously or intraosseously may be considered for
suspected hypomagnesemia or torsade de pointes associated
with a long QT interval.
• It is not recommended for routine use in cardiac arrest
• sodium bicarbonate
• Routine use of for the treatment of cardiac arrest is not
recommended.
• May beneficial for tricyclic antidepressant overdose,
severe cocaine toxicity, hyperkalemia, and pre-existing
acidosis .

Immediate action :
• Atropine is no longer recommended for routine use in the
management of asystole/PEA
• Electrical pacing is not recommended for the treatment of:
• PEA or asystole

• Norepinephrine can be used as adjunctive treatment for
patients with profound hypotension


In a non-ventricular fibrillation/ventricular
tachycardia pulseless rhythm:
• Continue with CPR
• Add epeniphrine

• Continue CPR for 2 minutes, then recheck rhythm.
• If shockable rhythm is present, defibrillate

Bradycardia
(heart rate < 50 beats/min):
• If perfusion is inadequate and thought to be due to
bradycardia:
• Administer a 0.5-mg intravenous bolus of atropine; repeat
every 3 to 5 minutes to a maximum of 3 mg
• If atropine is inadequate :
1. proceed to transcutaneous pacing or
administer dopamine 2 to 10 μg/kg/min or epinephrine
2 to 10 μg/min by intravenous infusion.
2. Intravenous infusion of chronotropic agents is an equally
effective alternative to external pacing in this setting
Consider transvenous pacing

Tachycardia
(heart rate typically greater than or equal to 150 beats/min):
• If there is no evidence of inadequate perfusion,
• obtain a 12-lead ECG to assess whether rhythm is

• wide-complex tachycardia (QRS ≥ 0.12 s) or
• narrow-complex tachycardia (QRS < 0.12 s)
• If there is evidence of inadequate perfusion, perform immediate
synchronized cardioversion

In wide-complex tachycardia:
( V-tach , (SVT) with aberrancy, pre-excitation
tachycardia, and ventricular paced rhythms )
If the rhythm is regular with a monomorphic QRS
waveform,

• adenosine can be used for diagnosis and
treatment.
• Administer a 6-mg rapid intravenous push

• followed by a flush to deliver the drug as a rapid bolus.
• If there is no conversion, give a 12-mg rapid intravenous
push of adenosine; the 12-mg dose may be given once more.

Cont, complex tach :
Consider an antiarrythmic infusion of amiodarone.
• Administer 150 mg intravenously over 10 minutes.
• repeat as needed to a maximum dose of 1.1 g/24 h.
• Follow with a maintenance infusion of 1 mg/min for the first 6 hours.
Alternatives include procainamide and sotalol
• Prepare for synchronized cardioversion


For irregular rhythm:
• Consider atrial fibrillation with aberrancy and treat as for atrial
fibrillation.
• If there is pre-excitation atrial fibrillation, such as Wolff-ParkinsonWhite syndrome, consider a consultation with a cardiologist.

• Avoid atrioventricular nodal blocking agents (adenosine, digoxin,
diltiazem, verapamil), which may paradoxically increase ventricular
rate. Consider amiodarone .

In narrow-complex tachycardia
for regular rhythm:
• Attempt vagal maneuvers
• Administer a 6-mg rapid intravenous push of adenosine.
• If there is no conversion, give a 12-mg rapid intravenous
push of adenosine. The 12-mg dose may be given once more
• If the rhythm converts,
• it is likely to be re-entrant SVT;
• consider diltiazem or β-blockers to prevent recurrence

If rhythm does not convert :
• consider possible atrial flutter, ectopic atrial tachycardia, or
junctional tachycardia.
• Consider expert consultation, and consider diltiazem or βblockers to control rate
Implantable cardioverter-defibrillators (ICDs) are:

indicated for patients surviving cardiac arrest resulting from
ventricular fibrillation or ventricular tachycardia
that is not due to a transient or reversible cause .

Cardiac arrest

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