Management of Cardiac Arrest

Dr. Michael J. Baffsky

Intensive Care Registrar
Concord ICU
Concord Hospital
23rd February 2004

Definition of Cardiac Arrest

Abrupt cessation of cardiac pump function
which may be reversible by a prompt
intervention but will lead to death in its
absence
Sudden Cardiac Death is the most common
cause of sudden natural death

Definition of Cardiac Arrest

Out Of Hospital
In Hospital

Incidence
1 in 100,000 per year in young adults

1 in 1000 per year in aged 45-75

Causes Of Cardiac Arrest

Coronary heart disease (most
common)

Sympathetic nervous system

disorders

Myocardial hypertrophy

Proarrhythmic toxic exposures

Cardiac inflammatory diseases

Electrocution

Cardiac valvular disease

Tension pneumothorax

Electrophysiologic
Abnormalities (e.g. WPW)

Trauma

Electrolyte disturbances

Pulmonary embolism

Abnormal metabolic states

Drowning

Causes Of Cardiac Arrest

Coronary heart disease (most
common)

Sympathetic nervous system

disorders

Myocardial hypertrophy

Proarrhythmic toxic exposures

Cardiac inflammatory diseases

Electrocution

Cardiac valvular disease

Tension pneumothorax

Electrophysiologic
Abnormalities (e.g. WPW)

Trauma

Electrolyte disturbances

Pulmonary embolism

Abnormal metabolic states

Drowning

Causes Of Cardiac Arrest

Coronary heart disease (most
common)

Sympathetic nervous system

disorders

Myocardial hypertrophy

Proarrhythmic toxic exposures

Cardiac inflammatory diseases

Electrocution

Cardiac valvular disease

Tension pneumothorax

Electrophysiologic
Abnormalities (e.g. WPW)

Trauma

Electrolyte disturbances

Pulmonary embolism

Abnormal metabolic states

Drowning

Are Arrests Predictable?

Genetic
general
specific
Congenital long QT interval syndromes
Right ventricular dysplasia
Brugada Syndrome (RBBB with non-ischemic STsegment elevations

Survival Of A Cardiac Arrest

<5% of people survive an out of hospital
arrest
Statistics vary on in hospital arrests

The 'chain of survival' concept

To improve survival in an arrest: Recognition of the cardiac arrest
Early activation of emergency services
Early basic life support
Early defibrillation
Early advanced life support

How Does An Arrest Present?

Patient found, usually unconscious
most often by a nurse

An arrest is called
(Do YOU know the emergency number?)

BLS should commence immediately

The nature of the arrest identified quickly
Appropriate action should be taken

How Does An Arrest Present?

Ventricular Fibrillation/Flutter (60%-80%)
Ventricular Tachycardia
Conscious and Unconscious (Pulseless)

Supraventricular Tachycardia
Pulseless Electrical Activity (EMD) (~10%)
Cardiac Standstill (Asystole) (20%-40%)
More difficult to treat with worse prognosis

Ventricular Fibrillation (VF)

Survivability decreases by 10% per minute
until normal rhythm restored
Coarse or fine
Fine may looks like asystole
Could be equipment gain
If any doubt, shock

Ventricular Fibrillation

Ventricular Tachycardia (VT)

Conscious
Treat pharmacologically

Unconscious
Treat as for VF

AF with WPW

Causes of Pulseless Activity

PE
Hypovolaemia
Acidosis

Tension PTx
Cardiac Tamponade
Hypoxaemia

Treat the cause

Asystole
Impaired automaticity of SA node
Problems with conduction pathways
usually due to ischaemia/hypoxea

Sympathetic reflex failure

Acidotic and Ischaemic Environment
may affect the efficacy of adrenalin

Will My Efforts Be Successful?

The probability of achieving successful
resuscitation from cardiac arrest is related to
the interval from onset to institution of
resuscitative efforts, the setting in which the
event occurs, the mechanism (VF, VT, PEA,
asystole) and the clinical status of the
patient prior to the cardiac arrest

Point To Note
VF or asystole without CPR within the first
4 to 6 min has a poor outcome, and there
are few survivors among patients who had
no life support activities for the first 8 min
after onset

General Management

Defibrillate (if indicated)

AIRWAY
BREATHING
CIRCULATION
ALS Measures

In A WITNESSED Arrest
A praecordial thump delivered to the
junction of the middle and lower third of the
sternum may occasionally revert VT or VF
It may convert VT to VF
Works by delivering a 4J shock

BLS vs ALS
BLS = EAR + ECC = CPR
(A,B,C)

ALS = BLS +
Advanced Airway Management
IV meds
Defibrillation
Fluids

Defibrillation
When?
VF/pulseless VT
Torsades
? Asystole / fine VF (often post adrenalin)

How much?
200/200/360 (mono)
120-150 (biphasic) can max to 200
Biphasic may have less post-resus myocardial dysfunction (less
energy/thermal effects)

When to sync?

Defibrillation

Paddle position
Where should they be?

Expired Air Resuscitation (EAR)

Mouth to Mouth
Bag mask.Aim 6-7 ml/kg TV
Usually 100% O2 (EAR a misnomer here)
LOS tone less more TV increases risk of
gastric inflation
Difficult to be accurate

If you cant intubate, dont waste time trying

External Cardiac Compression

(ECC)
Current ratio is 15:2 with one OR two
operators
Compression rate 100/min
Improves Coronary Perfusion Pressure
Improves success of defibrillation

EAR + ECC = CPR

Rate of respiration = 12-15/min
otherwise may cause positive pressure in the chest
and impair the venous return generated

Must allow chest to recoil fully during ECC

to gain full benefit of negative pressure

ECC deliver about 1/3 normal SV

Start without delay
Dont wait for the defibrillator

IV Access
Central line best
direct access to heart

Often peripheral access only one available

Best is antecubital fossa or EJV

Avoid veins below the diaphragm and distal

to the antecubital fossa
Lots of flushes

Most Commonly Used Drugs

Adrenaline
Atropine
Amiodarone
Adenosine
Lignocaine
Sotalol
NaHCO3

CaCl2
Hypocalcaemia
Hyperkalaemia
Ca++ channel blocker
OD

MgSO4
Torsades
Refractory VF

Adrenalin

Mainstay of drug therapy

Naturally occurring inotropic agent
Both and effects
Positive inotrope
Increases SVR (and afterload)
Short acting
Can be given via ETT if no IV access

Adrenalin
Increasing doses (cumulatively) may
produce poor neurological outcomes post
VF arrest
May be as low as 6mg
If given 3-5 minutely, may be a time factor

Atropine

Anticholingeric
Increases heart rate
Useful in bradycardia
May be of use in asystole (after adrenalin)
Give enough
at LEAST 300 mcg (usually 500mcg to 1mg)
Otherwise may get paradoxical effects

Can be given via ETT if not IV access

Amiodarone
Anti Arrhythmic
Useful in refractory VF or Pulseless VT
Give 300mg as bolus
Then an infusion

Adenosine

Useful in SVT
May be helpful in obtaining the diagnosis
Ultra short acting
Must be followed by large bolus flush

Lignocaine
Local anaesthetic
Membrane stabilizing properties
Dose 1mg/kg
for refractory VF/VT

Vasopressin

Potent endogenous vasoconstrictor

Unsure of its value
Levels found to be higher in patients in whom CPR effective
(rather than died)
Improves Coronary Perfusion Pressure
(Diastolic aortic pressure - diastolic RAP)

Improves Cerebral O2 delivery

May have better neurological recovery
May be of use in catecholamine resistance
Its use is still under investigation

Goals In A Cardiac Arrest

Restore spontaneous pulse

Restore BP
Aim for no neurological deficit
Know when to STOP