Cardiac Arrest Arrhythmias

1. Cardiac Arrest Arrhythmias EMS Professions Temple College

2. Cardiac Arrest • Mechanisms • Ventricular Fibrillation • Pulseless Ventricular Tachycardia • Asystole • Pulseless Electrical Activity (PEA) • A condition; Not an ECG rhythm

3. Cardiac Arrest • Most common rhythms • Adults: ventricular fibrillation • Children: Asystole, Bradycardic PEA • Pediatric V-fib suggests: • Drug toxicity • Electrolyte imbalance • Congenital heart disease

4. Cardiac Arrest • ABCs come first! • Airway - unobstructed?  manually open • Breathing - no or inadequate  ventilate • Circulation - no pulse in 5 sec  chest compressions • Do NOT wait on equipment • Assure effective BLS before going to ALS • Rise and fall of chest • Air movement in lung fields • Pulse with compressions

5. Cardiac Arrest • First ALS priority is defibrillation • Only cure for v-fib is defib • The quicker the better • Probability of resuscitation decreases 7-10% with each passing minute

6. Cardiac Arrest • Vascular access • Antecubital space • Arm, EJ, Foot (last resort) • IO in peds < 6 y/o • 14 or 16 gauge • LR or NS • 30 sec - 60 sec of CPR to circulate drug

7. Cardiac Arrest • Intubation as time allows • Less emphasis today as compared to past • Epi, atropine, lidocaine may be administered down tube • 2x IV dose • IV is preferred

8. Analyze the Rhythm

9. Ventricular Fibrillation (VF) • Characteristics • Chaotic, irregular, ventricular rhythm • Wide, variable, bizarre complexes • Fast rate of activity • Multiple ventricular foci • No cardiac output • Terminal rhythm if not corrected quickly • Most common rhythm causing sudden cardiac death in adults

10. Ventricular Fibrillation (VF) Treatment • ABC’s • Witnessed arrest: Precordial thump • Little demonstrated value but worth a try • CPR until defibrillator available • Quick Look for VF or pulseless VT • Treat pulseless VT as if it were VF • Defibrillate • 200 J, 300 J, 360 J • Quickly and in rapid succession • Identify cause if possible

11. Ventricular Fibrillation Treatment • If still in VF/VT arrest, continue CPR for 1 minute • Establish IV access and Intubate • If sufficient personnel, attempt both simultaneously • If not, quick attempt at IV access then attempt ETT • Vasopressor Medication • Epinephrine • 1 mg 1:10,000 IVP • Repeat every 3-5 mins as long as arrest persists • Vasopressin (alternative to Epinephrine) • 40 units IVP one time only

12. Ventricular Fibrillation Treatment • Shock @ 360 J after each medication given as long as VF/VT arrest persists • Alternate epi-shock & antidysrhythmic-shock sequence • Antidysrhythmic Medication • amiodarone 300 mg IVP single dose • lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total • procainamide 100 mg IV, q 5 min, max 17 mg/kg total • magnesium 10% 1-2 g IV • if hypomagnesemic or prolonged QT

13. Ventricular Fibrillation Treatment • Consider NaHCO3 if prolonged • Only after effective ventilations • In many EMS systems, consider terminating resuscitation efforts in consult with med control

14. Ventricular Fibrillation • The ultimate unstable tachycardia • Shock early-Shock often • Sequence is drug-shock-drug-shock • Sequence of drugs is epi-antiarrhythmic-epi-antiarrhythmic

15. Analyze the Rhythm

16. Asystole • Characteristics • The ultimate unstable bradycardia • A terminal rhythm • poor prognosis for resuscitation • best hope if ID & treat cause • No significant positive or negative deflections

17. Asystole • Possible Causes • Hypoxia: ventilate • Preexisting metabolic acidosis: Bicarbonate 1 mEq/kg • Hyperkalemia: Bicarbonate 1 mEq/kg, Calcium 1 g IV • Hypokalemia: 10mEq KCl over 30 minutes • Hypothermia: rewarm body core

18. Asystole • Possible Causes • Drug overdose • Tricyclics: Bicarbonate • Digitalis: Digibind (Digitalis antibodies) • Beta-blockers: Glucagon • Ca-channel blockers: Calcium

19. Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hyper/hypo-kalemia Hypothermia Tablets (Drug OD) Tamponade Tension Pneumothorax Thrombosis, Coronary Thrombosis, Pulmonary Asystole & PEA Differentials (The 5Hs & 5Ts)

20. Asystole Treatment • Primary ABCD • Confirm Asystole in two leads • Reasons to NOT continue? • Secondary ABCD • ECG monitor/ET/IV • Differential Diagnosis (5Hs & 5Ts) • TCP (if early) • Epinephrine 1:10,000 1 mg IV q 3-5 min. • Atropine 1 mg IV q 3-5 min, max 0.04 mg/kg • Consider Termination

21. Analyze the Rhythm What are you going to do for this patient?

22. Case Presentation The patient is a 16-year-old male who was stabbed in the left lateral chest with a butcher knife. He responds only to pain. His respirations are rapid, shallow, and labored. Central cyanosis is present. Breath sounds are absent on the left side. The neck veins are distended. The trachea deviates to the right. Radial pulses are absent. Carotids are rapid and weak. Now, what are you going to dofor this patient?

23. PEA • Possibilities • Massive pulmonary embolus • Massive myocardial infarction • Overdose: • Tricyclics - Bicarbonate • Digitalis - Digibind • Beta-blockers - Glucagon • Ca-channel blockers - Calcium

24. PEA • Identify, correct underlying cause if possible • Possibilities: • Hypovolemia: volume • Hypoxia: ventilate • Tension pneumo: decompress • Tamponade: pericardiocentesis • Acute MI: vasopressor • Hyperkalemia: Bicarbonate 1mEq/kg • Preexisting metabolic acidosis: Bicarbonate 1mEq/kg • Hypothermia: rewarm core

25. PEA Treatment • ABCDs • ETT/IV/ECG monitor • Differential Diagnosis • Find the cause and treat if possible • Epinephrine 1:10,000 1 mg q 3-5 min. • If bradycardic, • Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg • TCP • In many systems, consider termination of efforts

26. Hypothermia-Initial Therapy • Remove wet garments • Protect against heat loss & wind chill • Maintain horizontal position • Avoid rough movement and excess activity

27. Hypothermia – No Pulse • CPR • Defibrillate X 3 if VF/VT • ETT with warm, humidified O2 • IV access with warm fluids • Temp >30C/86F: • Continue as usual with longer intervals • Repeat defibrillation as temp rises • Temp <30C/86F • Continue CPR • Withhold medications and further defibrillation • Transport for core warming

28. Hypothermia – No Pulse Remember: A hypothermic patient is not dead until he is WARM & DEAD!!!

29. Managing Cardiac Arrest Check pulse after any treatment or rhythm change

30. Post-resuscitation Care • If pulse present: • Assess breathing • Present? • Air moving adequately? • Equal breath sounds? • Possible flail chest?

31. Post-resuscitation Care • If pulse present: • Protect airway • Position to prevent aspiration • Consider intubation • 100% Oxygen via BVM or NRB • Vascular access

32. Post-resuscitation Care • Assess perfusion • Evaluate • Pulses • Skin color • Skin temperature • Capillary refill • BP • Key is perfusion, not pressure

33. Post-resuscitation Care • Management of Decreased Perfusion • Fluid challenge • Catecholamine infusion • Dopamine, or • Norepinephrine • Titrate to BP ~ 90 to 100 systolic

34. Post-resuscitation Care • Suppression of ventricular irritability • If VT or VF converted before lidocaine given, lidocaine bolus and drip • If lidocaine or bretylium worked, begin infusion • Suppress irritability before giving vasopressors