Cardiac Arrest

Adenosine

When: Doses: **Not affective in V-tach**

Five Hs

**KNOW THESE** 1. Hypovolemia 2. Hypoxia 3. Hydrogen ions (acidosis) 4. Hypo-/hyperkalemia 5. Hypothermia

Five Ts

**KNOW THESE** 1. Tension pneumothorax 2. Tamponade (cardiac) 3. Toxins 4. Thrombosis (pulmonary) 5. Thrombosis (coronary)

Agonal Breathing/Gasps

**Not moving any air, they are not actually breathing. Resuscitation and CPR should continue even if agonal breathing is present. Agonal breathing is common after cardiac arrest.** • May be present in first few minutes after sudden cardiac arrest • It is NOT normal breathing! It is a sign of cardiac arrest! • The mouth may be open and the jaw, head, or neck may move with gasps. Can appear forceful or weak, usually at a slow rate. No air is moving!!

Components and indicators of high-quality CPR

1. Components: o Quality chest compressions o Limit interruptions in chest compressions to less than 10 seconds o Switch compressors about every 2 minutes or earlier if fatigued o Avoid excessive ventilation 2. Indicators: o Palpate pulse during compressions (femoral or coratid) o End tidal CO2 (Petco2) greater than 10, is a good measurement if we are doing high quality CPR normal PETCO2 is 30-40

Systemic Approach

1. Initial impression a. unconscious or conscious patient (appearance) o Unconscious patient- BLS assessment o Conscious patient- primary assessment and secondary assessment. **Scene safety first, then...initial impression. Provider visually checks while approaching pt.

Amiodarone

1. When patient has V-tach, stable and with a pulse

BLS Assessment

CAB o Check responsiveness o Shout for help, activate emergency response system, get AED (or send someone) o Assess for breathing and pulse o If no pulse, start CPR beginning with compressions Check for shockable rhythm as soon as AED/defibrillator arrives o If pulse but no breathing, start rescue breathing **In an unconscious patient, perform BLS assessment first**

Quality chest compressions

Compression rate of 100-120/min Compression depth of at least 2 inches (not more than 2.4 inches) 2 hands placed on lower half of sternum (breastbone) Allow full recoil of the chest after each compression o Minimize chest compression interruptions (we need to keep perfusing the heart and the brain) - shouldn't interrupted greater than 10. Only stop compressions for critical interventions such as: rhythm analysis, shock, intubation. Reducing interval between stopping compressions and shock delivery can increase success of shock

PEA Treatment

Immediate CPR and ACLS • Epinephrine immediately • Search for reversible causes (reversible causes are the 5 H's and the 5 T's)

Atropine

When: Doses:

Epinephrine

When: Doses:

Naloxone

When: Doses:

Norepinephrine

When: Doses:

Oxygen

When: Doses:

Avoid Excessive Ventilation

Why? Increases intrathoracic pressure (decreased venous return, decreased CO), pushing against the heart leaving the heart less room to fill Can cause gastric inflation (leads to regurgitation and aspiration) Hyperventilation with decreased CO2 can cause cerebral vasoconstriction, decreased cerebral blood flow Lung trauma/damage How: Ratio of 30:2 with compressions, or once very 6 sec with advanced airway Breath should take 1 sec to deliver Volume should be enough to see chest rise or approx. 500-600 mL for adult

Intraosseous (IO

goes into the bone marrow o IO can be used in all age groups o Can usually be established quickly o Any ACLS drug or fluid that is administered IV can be given IO o Contraindications: Fracture or crush injury near, or proximal to, insertion site Conditions in which bone are fragile (osteogenesis imperfecta) Previous attempts to establish access in same bone Presence of infection in overlying tissue

Defibrillation vs Cardioversion

synchronized- this patient has a pulse and is conscious...synchronizing to fall on the R wave (we do not want it during T wave- when the depolarization of ventricle is occurring)

Primary Assessment

• A: airway • B: breathing • C: circulation • D: disability • E: exposure, look for obvious signs of trauma, bleeding, burns, unusual markings, medical alert bracelets ** in a conscious patient, do primary assessment first. In unconscious patient- primary assessment follows BLS assessment/ interventions**

Aystole

• Absence of any ventricular electrical activity • Patient is unresponsive, pulseless, and apneic • Poor prognosis Causes: 5 H's and 5 T's **always confirm in more than 1 lead (could be a loose lead, low amplitude, could be fine V-fib - which is treated differently)**

Circulation

• Are chest compressions effective? • What is the cardiac rhythm? • Is defibrillation or cardioversion indicated? • Has IV/IO access been established? • Is ROSC present? (ROSC- return of spontaneous circulation) • Is the patient with a pulse unstable? • Are medications needed for rhythm or blood pressure? • Does the patient need volume/fluid for resuscitation?

Breathing

• Are ventilation and oxygenation adequate? • Are quantitative waveform capnography and oxyhemoglobin saturation monitored?

Waveform Capnography

• Capnography tracing displays the partial pressure of exhaled carbon dioxide (Petco2) • Can be measured with a variety of airways • Main determinate of Petco2 during CPR is blood delivery to lungs o Persistently low values less than 10 suggest return of spontaneous circulation (ROSC) is unlikely (normal 30-40) Try and improve chest compressions first!! o Abrupt increase to normal value or above may indicate ROSC

Disability

• Check for neurologic function • Quickly assess for responsiveness, level of consciousness, pupil dilation • AVPU (alert, responds to verbal stimuli, pain stimuli, unresponsive)

Effective Team Dynamics

• Clear role and responsibilities • Know your limitations • Constructive interventions • Knowledge sharing • Summarizing and reevaluating • Closed-loop communication • Clear messages • Mutual respect **calm, direct, confident tone, succinct language**

Team Leader

• Coordinates the efforts of the team • Monitors individual performance of team members • Models excellent team behavior • Facilitates understanding • Focuses on comprehensive patient care

Safety with defibrillation

• Designated team member in charge of defibrillator • Communicates clearly when charging and delivering shock • Ensures all team members are not in contact with patient or equipment (verbally and visually) • I'm clear...you're clear... we're all clear... • Face the patient and not machine when delivering shock • Ensure oxygen is not flowing across patient - can spark.

Family Presence

• Family members should be offered the opportunity to be present whenever possible • A designated team member, who is knowledgeable about resuscitation practices, needs to be assigned to the family **offer, don't wait for them to ask. Assess the appropriateness**

Priorities During Cardiac Arrest

• High quality CPR and early defibrillation • Advanced airway and drugs are secondary • Identifying and treating underlying cause in another priority after CPR/defib

Secondary Assessment

• History (SAMPLE) (situation and s/sx, allergies, medications, past medical history, last oral intake, events leading up to the present injury. • Identifying and treating underlying causes: Five Hs and Five Ts **The focus is on a differential diagnosis - why did this person have this cardiac arrest at this time?**

ROSC: Follow commands

• If patient does not follow commands, initiate Targeted Temperature Management (TTM) • Select and maintain a constant core temperature between 32 and 36 degrees Celsius (89.6 and 95.2F) for at least 24 hours

Aystole Treatment

• Immediate CPR and ACLS • Epinephrine immediately • Search for reversible causes (reversible causes are the 5 H's and the 5 T's) • Poor prognosis- unless special circumstances like drug overdose or hypothermia or potentially reversible cause is quickly identified. **Don't shock asystole** **Unless special resuscitation situation exists (such as hypothermia or drug overdose) consider stopping resuscitation efforts if ETCO2 is less than 10 after 20 min of CPR**

V-Fib with no pulse Tx

• Immediate initiation of CPR and ACLS • Defibrillation (as soon as it is available) • Drug therapy (see algorithm) ***v-fib and v-tach are shockable issues**

Synchronized cardioversion

• Indicated for patients with persistent, symptomatic tachycardia (see algorithm) • Delivers a shock in synch with the QRS complex • Pre-medicate (sedation) whenever possible ** • Have emergency equipment at bedside 1. We are not stopping the heart with synchronized cardioversion 2. Worst thing that can happen, is put patient into a cardiac arrest 3. After a shock, we need to check the defibrillator to make sure we sync back up again

Cardiac Arrest Tx

• Initial shock delivered as soon as shockable rhythm recognized • After each shock, resume CPR starting with compressions • Epi (1mg every 3-5 minutes) push fast given after second shock • Rhythm check after 2 minutes of CPR following shock - only assess for pulse if organized rhythm seen • Amiodarone (300mg) push fast is the anti-dysrhythmic drug used **In the first minutes after a successful defibrillation, any spontaneous rhythm is usually slow and may not create pulses or adequate perfusion - pt continues to need CPR. Additionally, not all shocks will lead to successful restoration of an organized rhythm (AHA, 2016)** **2 shocks before you start thinking about drugs or advanced airways per algorithm**

Ventricular tachycardia

• Irritable foci in ventricle generating rapid impulse • What two main factors determine how we treat this patient? **Ventricular Tachycardia with a pulse and stable- tx: amiodarone** **Ventricular Tachycardia and symptomatic and have a pulse- tx: synchronized cardioversion and consider sedation prior to giving the conversion** **Ventricular Tachycardia and No pulse: use cardiac arrest algorithm**

Airway

• Is the airway patent? • Is an advanced airway indicated? • Is proper placement of airway device confirmed? • Is tube secured and placement reconfirmed frequently?

ROSC: Optimize ventilation and oxygenation:

• Maintain oxygen saturation greater than or equal to 94% (or 94-99%) • Consider advanced airway and waveform capnography • Do not hyperventilate: start at RR 10/min and titrate to target Petco2 of 35 - 40 mm Hg. **use 100% O2 in cardiac or respiratory arrest - otherwise titrate to maintain sats 94-99%**

Advanced Airways

• May include: laryngeal mask airway, laryngeal tube (can be inserted blindly)- also called a king tube, esophageal-tracheal tube, ET (endotracheal) tube (laryngoscope used to visualize the vocal cords (glottis) and the tube passing through. • With the exception of the ET tube, these are known as supraglottic, or extraglottic airways, and can be placed "blindly" without visualization of the glottis/vocal cords. They are placed either above the glottis or into the esophagus

Return of Spontaneous Circulation (ROSC):

• Optimize ventilation and oxygenation • Treat hypotension (BP >90) think about fluid and vasopressors if below 90. • 12 lead ECG • Follow commands? NO = Induce hypothermia **1st, 2 priorities oxygenation and hypotension **

Pulseless Electrical Activity (PEA)

• Organized electrical activity is seen on the ECG but there is NO mechanical activity of the ventricles • **Patient is unresponsive, pulseless, and apneic** • Causes o H's and T's o **2 most common, potentially reversible causes are hypovolemia and hypoxia** • **EKG: Can be fast or slow and have narrow or wide QRS...** **FYI: narrow QRS and fast heart rate mostly caused by a non-cardiac etiology. Wide QRS, slow rate mostly caused by cardiac etiology. (AHA, 2016).**

V-Fib

• Rapid firing of multiple irritable foci in the ventricle • Results in the ventricles "quivering" with no effective contraction and therefore no cardiac output (Cardiac Arrest) • Patient is unresponsive, pulseless, and apneic o A lethal dysrhythmia. Erratic, rapid twitching, described as a bag of worms.

Advanced Airways in Resuscitation

• Rate of ventilation once advanced airway is in place is 1 every 6 seconds (continuous compression) • Waveform capnography should be used in addition to clinical assessment to confirm and monitor ET tube placement (most reliable method per AHA). (you can also auscultate lungs and stomach as well as look for chest movement). o Waveform capnography should be checked after each hand-off or transfer of patient to reduce the risk of unrecognized tube misplacement or displacement (AHA, 2016)

Timer/Recorder

• Records the time of interventions and medications • Announces when these are next due • Records the frequency and duration of interruptions in compressions - communicates these to team leader and rest of team

Exposure

• Remove clothing to perform a physical examination, looking for obvious signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets o Figure out why this happened. Possible cause of why the patient has gone into cardiac arrest.

ACLS Drugs

• Route: IV, IO (intraosseous), or ET o Establishing a peripheral IV line can be done without interruption of CPR • Peripheral IV (preferred IV route unless central line access already available) o Give the drug by bolus injection unless otherwise specified o Follow with a 20 mL bolus of IV fluid o Elevate the extremity for about 10-20 seconds to facilitate delivery to central circulation

ROSC: 12-lead ECG

• STEMI or high suspicion of acute myocardial infarction (AMI): send to cath lab for coronary reperfusion • Targeted temperature management does not prevent cath lab intervention

ACLS Interventions: Defibrillation

• Stuns the heart and briefly terminates all electrical activity - goal is for the SA node to resume pacemaker role • Can be placed right anterior chest/ left axillary position OR anterior/ posterior.

ROSC: Treat hypotension

• Treat SBP < 90 mm Hg • Fluid bolus (1-2 liters normal saline or lactated Ringer's) • Vasopressor infusion • Epinephrine, dopamine, or norepinephrine • Consider treatable causes

CODE Team

• Who is on the team? o Nurse, doctor, respiratory therapist, team leader, pharmacist. • What are the different roles? o Team leader - always ACLS certified, usually a physician of some kind o Pharmacist - can hand/prep meds - cannot administer o Recorder - should be someone with a license - often nursing/house supervisor (depending on setting) o Recorder - time/intervention/response o Role may be determined by several factors: one being when you arrive on scene