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Acute Coronary Syndromes: Cardiac Arrest and Return of Spontaneous Circulation

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.

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Acute Coronary Syndromes: Cardiac Arrest and Return of Spontaneous Circulation

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

  2. 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.

  3. 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 Heart Disease

  4. 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.

  5. 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

  6. 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

  7. 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

  8. 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

  9. 2010 AHA Guidelines

  10. Adult CPR • 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!

  11. 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

  12. 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

  13. Adult CPR • Open the airway with head tilt-chin lift • Place the mask on the patient’s face • Use the E-C clamp technique • Deliver each breath over 1 second

  14. ACLS Guidelines Adult Cardiac Arrest

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

  16. Region 6 Adult Cardiac Arrest ProtocolAsystole / PEA • Initiate CPR and attach monitor/defibrillator • Initiate vascular access; manage airway • Administer Epinephrine 1mg every 3-5 minutes • Consider possible causes and treatments • “H’s and T’s”

  17. Reversible Causes – H’s and T’s • 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)

  18. 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

  19. 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

  20. Immediate Post Arrest Care –Return of Spontaneous Circulation (ROSC) • Induced Hypothermia • If not following commands • Improved neurological recovery • 32º - 34º C for 12-24 hours • Coronary reperfusion • If STEMI • May do concurrently with hypothermia

  21. Ventricular Assist Devices • A ventricular assist device (VAD) is a mechanical pump that’s 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.

  22. 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 patient’s 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: • INITIAL MEDICAL CARE. • Call for intercept per INTERCEPT CRITERIA.

  23. Region 6 Protocol VAD (Ventricular Assist Device) ILS/ALS TREATMENT: • Continue FR / BLS TREATMENT. • If stable, follow appropriate ILS/ALS protocol. • Auscultate heart. Continuous whirling noise indicates VAD is working, but even a carotid pulse may not be palpable. • Monitor ECG. If there is a pulse, the rhythm may not correlate with it. • NS KVO or saline lock. • 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. • Obtain 12 lead ECG. Follow appropriate protocol if STEMI or dysrhythmia present. • Be sure patient brings back up power sources (batteries, charger, etc.), and hand pump (if applicable). • Strongly consider transporting a VAD knowledgeable family member with patient. • Inspect VAD control for model name and alarms. Use color code for atlas. Controller will usually be located at the waist. • For VAD alarms or VAD malfunction, please see VAD Emergency Care Guidelines.

  24. VAD (Ventricular Assist Device) Care Guideline VAD atlas:http://www.mylvad.com/assets/ems_docs/2013-field-guide.pdf SPECIFIC SITUATIONS: • If VAD is alarming, follow manufacturer’s instructions or look at VAD atlas. Attempt to contact VAD Specialist via manufacturer’s phone number (on machine or wallet card). • “Low flow alarm” states are usually improved by NORMAL SALINE IV 250ml bolus, up to 500ml. Monitor for signs of CHF. • 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. • CPR should NOT be performed on patients with Thoratec PVAD w/ TLC II. • If indicated, CPR may be performed on patients with: HeartWare HVAD, VentrAssist LVAD, HeartMate II, or Jarvik 2000 FlowMaker. • 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.

  25. 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.

  26. 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:

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

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

  29. Scenario 2 • 92 year old man in the nursing home. Found in cardiac arrest. No DNR present. The cardiac monitor shows this rhythm:

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

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

  32. According to the 2010 ACLS guidelines, what are the 4 components of Post Cardiac Arrest Care following return of spontaneous circulation? • True/False: All VAD’s may be left on during defibrillation. • True/False: CPR may be performed on any patient with a VAD regardless of the model.

  33. Answers • C • True • 450mg • A • 30:2 • Epinephrine 1:10,000

  34. Answers • Optimize ventilation and oxygenation, treat hypotension, consider induced hypothermia and coronary reperfusion • True • False

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