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Acute Coronary

Syndromes: Cardiac
Arrest and Return of
Spontaneous Circulation
Presence Regional EMS
February 2014 ALS CE

Objectives

Describe the relationship of the chain of survival


to successful resuscitation of the cardiac arrest
patient.
Review AHA BLS guidelines.
Demonstrate cardiac arrest management
following ACLS guidelines.
Discuss the interventions required to ensure good
outcomes with Return of Spontaneous Circulation.
Outline the current technology for Left Ventricular
Assist Devices and the role that EMS plays with
patients who have these devices.

Heart Disease

Cardiovascular disease is the number one


cause of death in the U.S., and many times
the first indication of this disease is an
acute coronary event

Cardiac arrest is the most severe


manifestation of an acute coronary
syndrome, and with rapid intervention EMS
providers can make the difference between
life and death

American Heart Association


Facts

7 to 8 million people a year seek


treatment for chest pain.
Of these, 2 million will actually have a
cardiac condition that affects the
coronary arteries.
About 1.5 million will suffer a heart
attack.
500,000 of these heart attack patients
will die.
250,000 of these patients will die within
the first hour of symptom onset.

Cardiac Arrest

Few cardiac arrest patients survive outside


a hospital without a rapid sequence of
events.
Chain of survival:
Early recognition and activation of EMS
Immediate bystander CPR
Early defibrillation
Early advanced cardiac life support
Integrated post-arrest care

Early CPR

Why is CPR Important


Studies have shown that the general population
will start CPR only 1/3 of the time and only 15% of
that total is done correctly
Chest Compressions can be started within 18
seconds of arriving at the patient, whereas airway
management first can delay compressions by 1-2
minutes or more
CPR prolongs the period during which
defibrillation can be effective

Rationale for Early


Defibrillation

Ventricular fibrillation is the most frequent


rhythm found in cardiac arrest

Defibrillation is the most effective


treatment for VF

Probability of successful defibrillation


diminishes with time

VF will lead to asystole quickly without


proper treatment

Early Defibrillation

Hearts and Brains


are going to die
Peter Safar MD

EMS has the most


opportunity to
perform CPR, so we
should be good at
performing good,
quality CPR

2010

AHA Guidelines

Adult CPR
1.
2.
3.
4.

Make sure the scene is SAFE!


Check responsiveness and breathing
If alone call 9-1-1 and get an AED
Check for a pulse and if no pulse present
begin CPR
Always start CPR with Compressions First!

Chest Compressions
Always start CPR with Compressions
First!
Push hard and fast
Rate should be at least 100 per minute
Provide 30 compressions then 2 breaths
Make sure the chest is allowed to re-expand
completely at the end of each compression

CPR

Chest compressions and breaths are the


same for adults, child, and infant if you are
alone
Adult age starts at the onset of puberty
(12-14 years of age)
Child is age 1year to the onset of puberty
Infant is anyone under the age of 1year

Adult CPR
5.
6.
7.
8.

Open the airway with head tilt-chin lift


Place the mask on the patients face
Use the E-C clamp technique
Deliver each breath over 1 second

ACLS Guidelines
Adult Cardiac Arrest

Region 6 Adult Cardiac Arrest


Protocol V-Fib / Pulseless V-Tach
1. Initiate CPR and attach monitor/defibrillator
2. Defibrillate at 360j or equivalent biphasic shock
3. Resume CPR immediately following defibrillation
and continue for 2 minutes
4. Initiate vascular access; manage airway
5. Reevaluate rhythm; defibrillate if needed; resume
CPR
6. Administer Epinephrine 1mg every 3-5 minutes
7. Defibrillate if needed; resume CPR
8. Administer Amiodarone 300mg; may repeat at
150 mg IV/IO in 5 minutes if needed.
9. Continue cycles of CPR and defibrillation as
needed

Region 6 Adult Cardiac Arrest


Protocol
Asystole / PEA
1. Initiate CPR and attach
monitor/defibrillator
2. Initiate vascular access; manage airway
3. Administer Epinephrine 1mg every 3-5
minutes
4. Consider possible causes and treatments
Hs and Ts

Reversible Causes Hs
and Ts

Hypovolemia (Volume infusion)


Hypoxia (Ventilation and oxygenation)
Massive Myocardial Infarction (Volume infusion)
Tension Pneumothorax (Needle decompression)
Acidosis/Hyperkalemia (Hyperventilation)
Drug Overdose (Refer to appropriate protocol)
Hypothermia (Refer to appropriate protocol)
Pericardial Tamponade (Rapid transport)
Massive Pulmonary Embolism (Ventilation, Volume
infusion)

Immediate Post Arrest Care


Return of Spontaneous Circulation
(ROSC)

Optimize ventilation and oxygenation


O2 Saturation > 94%
Advanced Airway
10-12 per minute
PETCO2 35-40 mm/Hg
Do not hyperventilate
< cerebral perfusion
Oxygen toxic

Immediate Post Arrest Care


Return of Spontaneous Circulation
(ROSC)
Treat hypotension (SBP <90 mm Hg)
Fluid Bolus 1-2 liters
Vasopressors
Epinephrine 0.1-0.5 mcg/kg/minute
Dopamine 5-10 mcg/kg/minute

Immediate Post Arrest Care


Return of Spontaneous Circulation
(ROSC)
Induced Hypothermia
If not following commands
Improved neurological recovery
32 - 34 C for 12-24 hours
Coronary reperfusion
If STEMI
May do concurrently with hypothermia

Ventricular Assist Devices


A ventricular assist device
(VAD) is a mechanical
pump thats used to
support the heart
The device takes blood
from a lower chamber of
the heart and helps pump
it to the body and vital
organs, just as a healthy
heart would.

Region 6 Protocol
VAD (Ventricular Assist Device)
NOTE: Pulse may not be palpable, manual blood pressure often cannot be measured, and
pulse oximetry may be unreliable. The patients automated blood pressure will usually be
hypotensive and pulse pressure will be narrow.

CRITERIA:
Presence of a left, right, or bilateral ventricular assist device
Serious signs or symptoms, including:
Respiratory difficulty
Pulmonary edema
Chest pain
Signs or symptoms of shock
Potentially lethal dysrhythmia
Altered LOC/ syncope
FR/BLS TREATMENT:
1. INITIAL MEDICAL CARE.
2.
Call for intercept per INTERCEPT CRITERIA.

Region 6 Protocol
VAD (Ventricular Assist Device)
ILS/ALS TREATMENT:
1. Continue FR / BLS TREATMENT.
2. If stable, follow appropriate ILS/ALS protocol.
3. Auscultate heart. Continuous whirling noise indicates VAD is working,
but even a carotid pulse may not be palpable.
4. Monitor ECG. If there is a pulse, the rhythm may not correlate with it.
5. NS KVO or saline lock.
6. If patient is dehydrated and lungs are clear administer 250 ml fluid
bolus over 10 minutes. May repeat once, up to a total of 500ml or until
MAP > 65 mmHg.
7. Obtain 12 lead ECG. Follow appropriate protocol if STEMI or
dysrhythmia present.
8. Be sure patient brings back up power sources (batteries, charger, etc.),
and hand pump (if applicable).
9. Strongly consider transporting a VAD knowledgeable family member
with patient.
10.Inspect VAD control for model name and alarms. Use color code for
atlas. Controller will usually be located at the waist.
11.For VAD alarms or VAD malfunction, please see VAD Emergency Care
Guidelines.

VAD (Ventricular Assist Device)


Care Guideline
VAD atlas: http://
www.mylvad.com/assets/ems_docs/2013-field-guide.pdf
SPECIFIC SITUATIONS:
1. If VAD is alarming, follow manufacturers instructions or look at VAD atlas. Attempt
to contact VAD Specialist via manufacturers phone number (on machine or wallet
card).
2. Low flow alarm states are usually improved by NORMAL SALINE IV 250ml bolus,
up to 500ml. Monitor for signs of CHF.
3. If there is a potentially lethal dysrhythmia, follow appropriate ILS/ALS protocol. Do
not detach or power off VAD. All VADs can be left on for defibrillation, cardioversion,
and external pacing.

For HeartMate XVE, keep current < 40 mA.


For Thoratec PVAD w/ TLC II the need to pace is very rare since it is a BiVAD.

4. CPR should NOT be performed on patients with Thoratec PVAD w/ TLC II.
5. If indicated, CPR may be performed on patients with: HeartWare HVAD, VentrAssist
LVAD, HeartMate II, or Jarvik 2000 FlowMaker.
6. If a VAD that features a hand pump (HeartMate XVE, or Thoratec PVAD w/ TLC II)
loses power or the motor fails and there is no flow on meter and no normal machine
sound over the precordium, hand pumping is indicated. The hand pumping rate
should be 60 to 90/minute. Foot pumping is acceptable.

Review

Answer the following questions as a group.


IDPH site code: Use site code assigned to your
agency for 2014.
If doing this CE individually, please e-mail your
answers to:
Shelley.Peelman@presencehealth.org
Use February 2014 ALS CE in subject box.
You will receive an e-mail confirmation. Print this
confirmation for your records, and document the CE
in your PREMSS CE record book.

Scenario 1

44 year old male at a local golf course


sitting in the club house complaining of
chest pain. As you begin your assessment,
he loses consciousness and becomes
pulseless and apneic. The cardiac monitor
shows this rhythm:

Scenario 1
1. According to the Region 6 protocols, what
is the appropriate next step in treating this
patient?
A. Provide 2 minutes of CPR prior to
defibrillation.
B. Initiate CPR, secure the airway and
establish vascular access
C. Immediately defibrillate at 360j or
equivalent biphasic shock
D. Deliver a synchronized shock at 200j

Scenario1
2. True/False: After defibrillation you should
immediately resume CPR and continue for
2 minutes.
3. According to the Region 6 protocols, what
is the maximum dose of amiodarone that
may be given to this patient?

Scenario 2

92 year old man in the nursing home.


Found in cardiac arrest. No DNR present.
The cardiac monitor shows this rhythm:

Scenario 2
4. According to the Region 6 protocols, what
is the appropriate next step in treating this
patient?
A. Begin CPR, initiate vascular access and manage
the airway
B. Immediately defibrillate and then resume CPR
C. Begin CPR and prepare to pace the rhythm
D. Do not start resuscitation

Scenario 2
5. What is the appropriate ratio of
compressions to breaths in adult CPR with
2 rescuers?
6. What medication(s) would be appropriate
for treating this rhythm?

7. According to the 2010 ACLS guidelines,


what are the 4 components of Post Cardiac
Arrest Care following return of
spontaneous circulation?
8. True/False: All VADs may be left on during
defibrillation.
9. True/False: CPR may be performed on any
patient with a VAD regardless of the
model.

Answers
1.
2.
3.
4.
5.
6.

C
True
450mg
A
30:2
Epinephrine 1:10,000

Answers
7. Optimize ventilation and oxygenation,
treat hypotension, consider induced
hypothermia and coronary reperfusion
8. True
9. False

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