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Management of Cardiac arrest

The chain of survival :
- It's interrelated series of interventions that must be in place to maximize functional survival from sudden cardiac
death. Any failure to implement a single link in the chain will lead to a decrease in survival.
- American Heart Association (AHA) describes four links in the chain of survival:
1-Rapid access to medical care,
2-Basic life support (BLS),
4-Adult advanced life support (ALS).

5-This chain has been expended to include early prevention which involves: both primary prevention,
including lifestyle modification (exercise and smoking cessation), & secondary prevention, including medical therapy.

1- Rapid access to medical care :

Upon finding the unresponsive patient, rescuer should immediately activate the EMS followed by adequate CPR system and if
available obtain an automated external defibrillator (AED).
Where a patient in cardiac arrest is being brought to hospital by ambulance, the members of the cardiac arrest team (either A&E
staff, the hospital team, or a combination of both) should already be present with all equipment ready to receive the patient.

2- Basic life support (BLS) : Provide BLS until further help arrives.

1- Airway Assessment :
- The first step of BLS is opening the patient's airway by either the head tilt -chin lift or the jaw-thrust method if suspects C-spine injury.
- Remove any visible obstructions from the mouth

2- Breating Assessment : (After opening the patient's airway, breathing is assessed)

- Perform: Look , listen & feel. This should take no more than 10 seconds
Look down at the chest for any rise or fall of breathing.
Listen for breathing while you ear near the patient's mouth,
Feel the flow of air over the cheek.

- In the absence of adequate breathing, perform :

1- mouth-to-mouth,
2- mouth-to-mask,
3- bag-mask ventilation.
Mouth to Mouth
Pinch the patient's nose shut. Seal your lips around the patient's mouth. Give two slow breaths over 2 seconds initially. There should be
good chest rise and fall.

If there is still no movement of air, presume that the patient has a foreign body airway obstruction (FBAO) and attempt to clear it .

Mouth to Mask

A clear mask with or without a one-way valve (often called a pocket-mask) .

Bag-Mask Ventilation

Cricoid Pressure Application (done only in the unconscious patient)

- Cricoid pressure ( Sellick maneuver ) is the posterior displacement of the cricoid cartilage to close off the esophagus.
- This minimizes gastric insufflation associated with ventilation, as well as preventing reflux of gastric contents into the
upper airway and lungs.

3- Circulation :

Circulation is assessed by palpation of the carotid pulse. (For no more than 10 seconds )

- If a pulse is present, rescue breathing can continue with one breath every 5 - 6 seconds.
- If a pulse is absent, start chest compressions. This is essential for providing blood flow during CPR

To perform chest compressions,

- Place the heel of one hand over the lower half of the patient's sternum
- The heel of the hand should be in this position, and place the second hand over the first so that they are overlapped
and parallel.

- Compressions should depress the sternum 4 -5 cm then allowing the chest to return to normal position.

- Chest recoil allows venous return to the heart.

- Compressions are given at 100 per minute.

- The compression ventilation ratio in adults should be 30:2.

3- Defibrillation :
- Defibrillation is the intervention for the heart in pulseless VT and VF.
- When a critical level of energy reaches the myocardium, the ventricles become depolarized providing an opportunity for the
sinoatrial node an organized rhythm.

Defibrillation Waveforms: ( reading only )

- Waveforms indicate the flow of energy between the two paddles.
- A monophasic waveform travels in one direction, whereas a biphasic waveform travels initially in one direction & then
reverses flow.

Automated External Defibrillation ( AED ) : ( reading only)

- VF & pulseless VT are the most common dysrythmias seen in cardiac arrest and may be successfully converted with
- However, in minutes  this rhythm may degenerate into asystole, which is usually refractory to further interventions.
It is thus important to deliver defibrillation as rapidly as possible.
- In an effort to improve the time of arrest till shock, AED is a computerized device which itself analyzes the patient's
rhythm & determines if a shock is required.
- If the patient has no pulse, an AED should be brought to the patient's side.The AED requires the rescuer to power on
the device, apply the self-adhesive pads to the patient's chest, press the Analyze button, and, if an electrical shock is
indicated, press the Shock button.

4- Adult Advance Life Support (ALS) :

Adult ALS algorithm

Indications :
- If a patient does not respond to initial CPR & defibrillation, further interventions are required.
- And in cases where initial interventions are successful in restoring a perfusing rhythm, the patient may still require
ALS (i.e., airway, medications, and further evaluation) to optimize outcome .

Shockable :
1) Ventricular Fibrillation or Pulseless Ventricular Tachycardia
- In an unwitnessed arrest, it is now recommended that five cycles (2 minutes) of CPR be performed prior to
defibrillation. It is felt that this will increase myocardial oxygen and energy substrates, increasing the likelihood of a restoration of spontaneous circulation
(ROSC) to the myocardium following defibrillation.
- If the arrest was witnessed and a defibrillator is present, deliver the first shock immediately.
- CPR is immediately resumed after the first shock.

- Vasopressors (i.e., epinephrine) may be given before or after the first shock ( Epinephrine is given at 0.5 - 1.0 mg IV
every 3 - 5 min.)
The pulse should only be checked if there is an organized rhythm on the monitor.
- Following the five cycles of CPR, a second shock should be performed if indicated.

- If VF or pulseless VT persists after 2-3 shocks, an antiarrhythmic (amiodarone or lidocaine) should be administered.

- The cycle of CPR, defibrillation, and vasopressors is continued until :

1- there is ROSC,
2- change in rhythm,
3- the resuscitation efforts are deemed futile.

Non-shockable : Dr.Ahmados
1) Pulseless Electrical Activity ( PEA) :
- Definition: It's condition where there is an organized rhythm on the monitor in the absence of cardiac output.
- Underlying cause: The key to successful resuscitation is identifying and treating the underlying cause by :
1- history,
2- vital signs including temperature,
3- electrocardiogram (ECG),
4- blood gas analysis,
5- electrolytes,
6- and a focused physical examination.
- Interventions :
1- Initial interventions to address hypoxemia and hypovolemia.
2- Effective CPR + epinephrine (1 mg IV every 3 - 5 minutes) is given.
3- If the patient is bradycardic, atropine (1 mg IV).
2) Asystole
- Definition: Asystole is usually a preterminal rhythm.
- Underlying cause: As with PEA, the underlying causes must be addressed.

- Interventions:
1- Transcutaneous pacing may be considered early on, but it should be used only if the patient was witnessed entering asystole
from a perfusing rhythm.
2- Epinephrine (1 mg IV every 3 - 5 minutes) & atropine (1 mg IV every 3 - 5 minutes with a maximum of three doses) are
- If an asystolic patient does not respond to ALS interventions in the field, resuscitation efforts may be terminated in
the field without urgent transport.

Postresuscitation Stabilization

Following successful ROSC after cardiac arrest, mortality is often associated with refractory cardiac damage, CNS injury, and sepsis.

There are four objectives of postresuscitation stabilization after the patient has been transported to the emergency department:
(1) optimize cardiopulmonary function and systemic perfusion,
(2) identify the precipitating cause of the arrest,
(3) prevent recurrence, and
(4) begin measures to improve long-term survival and neurologic function.

- Evaluate the patient's status by physical examination, laboratories, radiologic studies, and continuous hemodynamic
monitoring. Routine postresuscitation studies include complete blood count, electrolytes (including glucose and
magnesium), cardiac enzymes, toxicology, arterial blood gas, and a portable chest X-ray. Additional studies might include
bedside echocardiography, pulmonary artery catheterization, heart catheterization, and computed tomography.
- Direct initial interventions are toward maintaining stable hemodynamic parameters, with the primary goal to
restore adequate perfusion. Attach full monitoring equipment, if not done previously.

- Place a Foley catheter to monitor urine output.

Postresuscitation hypotension:

 Initially treated with small-volume (250 - 500 cc) boluses of crystalloid solution.
 Pulmonary artery catheterization or central venous pressure monitoring may aid in determining the patient's fluid

 Consider other causes of hypotension, such as pneumothorax and pericardial tamponade.

 If bolus fluid therapy fails, add vasoactive agents (e.g., norepinephrine).

- Hyperthermia increases the cerebral metabolic rate, which creates an imbalance between oxygen delivered and
demanded This can lead to anoxic cell death & initiate a subsequent systemic inflammatory response.

- Hypothermia, in contrast, can be beneficial to the patient.

- Hyperglycemia is associated with worsening prognosis following global ischemia from cardiac arrest. Tight
glucose control is felt to increase survival and reduce the incidence of developing infectious complications in the postresuscitation

Sources :
1- Current Emergency Diagnosis & Treatment - 6th