Cardiac arrest

By
ORAS ABD AL-RAHMAN
Emergency specialist
Cardiac arrest

Unresponsive patient with no palpable central pulse

Cardiac rhythms in cardiac arrest

Shockable :
1. VF
2. Pulseless VT
Non-shockable :
1. Asystole
2. PEA
ACLS survey
THE ACLS SURVEY (A-B-C-D)
AIRWAY
Monitor and maintain an open airway at all times.
The provider must decide if the benefit of adding an
advanced airway outweighs the risk of pausing
CPR.
If the individual’s chest is rising without using an
advanced airway, continue giving CPR without
pausing.
However, if you are in a hospital or near trained
professionals who can efficiently insert and use the
airway, consider pausing CPR.
AIRWAY MANAGEMENT

BASIC AIRWAY ADJUNCTS

OROPHARYNGEAL AIRWAY (OPA)
NASOPHARYNGEAL AIRWAY (NPA)

ADVANCED AIRWAY ADJUNCTS

ENDOTRACHEAL TUBE (ETT)
LARYNGEAL MASK AIRWAY (LMA)
LARYNGEAL TUBE
ESOPHAGEAL-TRACHEAL TUBE (combitube)
THE ACLS SURVEY (A-B-C-D)
BREATHING
In cardiac arrest, administer 100% oxygen.
Keep blood O2 saturation (SPO2) greater than or
equal to 94% as measured by a pulse oximeter.
Use quantitative waveform capnography when
possible.
Normal partial pressure of CO2 is between 35 to 40
mmHg.
High-quality CPR should produce a ETCO2
between 10 to 20 mmHg.
If the ETCO2 reading is less than 10 mmHg after 20
minutes of CPR for an intubated individual, then you
may consider stopping resuscitation attempts.
THE ACLS SURVEY (A-B-C-D)
CIRCULATION
Obtain intravenous (IV) access, when possible;
intraosseous access (IO) is also acceptable.
Monitor blood pressure with a blood pressure cuff or
intra-arterial line if available.
Monitor the heart rhythm using pads and a cardiac
monitor.
When using an AED, follow the directions (i.e.,
shock a shockable rhythm).
Give fluids when appropriate. Use cardiovascular
medications when indicated.
THE ACLS SURVEY (A-B-C-D)
DIFFERENTIAL DIAGNOSIS
Start with the most likely cause of the arrest and
then assess for less likely causes.
Treat reversible causes and continue CPR as you
create a differential diagnosis.
Stop only briefly to confirm a diagnosis or to treat
reversible causes.
Minimizing interruptions in perfusion is key.
Potential Etiology of Maternal Cardiac
Arrest
A = Anesthetic complications
B = Bleeding
C = Cardiovascular
D = Drugs
E = Embolic
F = Fever
G = General nonobstetric causes of
cardiac arrest (H’s and T’s)
H = Hypertension
• Team planning should be done in collaboration with the
obstetric, neonatal, emergency, anesthesiology, intensive
care, and cardiac arrest services.
• Priorities for pregnant women in cardiac arrest should
include provision of high-quality CPR and relief of aortocaval
compression with lateral uterine displacement.
• The goal of perimortem cesarean delivery is to improve
maternal and fetal outcomes.
• Ideally, perform perimortem cesarean delivery in 5
minutes, depending on provider resources and sets
End of CPR
If the end-tidal CO2 is less than 10 mmHg during
CPR, consider adding a vasopressor and
improve chest compressions.
However, after 20 minutes of CPR for an
intubated individual, you may consider stopping
resuscitation attempts.
Case:
80 y.o.female brought to the ED by EMS , she is
unconscious , she has 2 IV lines , and hooked to a
defibrillator
Her vitals : HR=42 / RR=25 / BP=80/60 /temp.=37
ECG trace was found as follow:
What is the finding?
a. Normal sinus rhythm
b. Premature junctional rhythm
c. Idioventricular rhythm
d. Sinus bradycardia
Answer :
D ,, sinus bradycardia : P-wave for every QRS with
a rate < 60
What to do next?
a. Amiodarone 150 mg infusion over 10 min.
b. Atropine 1 mg iv
c. Defibrillate
d. Adenosine 6 mg iv with 20 cc normal saline flush
Answr
B , atropine iv bolus 1 mg
After your initial management , you checked her vitals and
you found that there is no pulse , blood pressure can not
be detected , without spontaneous breathing
You checked the ECG trace and found the following

What is this ECG

a. AF
b. VT
c. Idioventricular rhythm
d. VF
Answer
D , VF : rapid , no P-waves nor QRS complexes ,
bizare shape
 What is next most appropriate
action?
a. High quality CPR for 2 min. with adrenalin 1 mg iv bolus
with 20 cc flush.
b. Apply advanced airway with waveform capnography
c. Defibrillate
d. Atropine 0.5 mg iv bolus
Answer is
C , defibrillate : according to AHA , once you
document VF , you should defibrillate
What is next most appropriate action?
a. High quality CPR for 2 min.
b. Advanced airway with waveform capnography
c. repeat defibrillation
d. Atropine 0.5 mg iv bolus
Answer
A , after defibrillating you should start CPR for 2 min.
After CPR for 2 min. you notice the
following rhythm:
What is your next step

a. Defibrillate
b. Give atropin 0.5 mg IV bolus
c. Transcutaneous pacing
d. Check vital signs
answer

D , you should check vitals after each cycle to know

the best action you should do
After checking vitals , there is no palpable pulse
and no spontaneous breathing , you check the
monitor you find this trace
What is your assessment?

a. Agonal rhythm
b. Premature atrial beat
c. PEA
d. Idioventricular rhythm
answer
C , its PEA
What is your next most appropriate action?

a. CPR for 2 min. followed by adrenalin 1 mg every 3-5

min. iv bolus
b. Atropine 0.5 mg iv bolus
c. Defibrillate
d. Transcutaneous pacing
answer
A , PEA is not a shockable rhythm , so you should
continue CPR for 2 min. with adrenalin every 3 -5
min . And reassess after each step(cycle).
You continue CPR for 2 min. with adrenalin 1 mg
iv bolus but there is no change in patient
condition .What should you consider now?

a. Declare death and halt your effort

b. Seek expert help immediately
c. Defibrillate
d. Continue CPR , apply advanced airway with
waveform capnography , with adrenalin iv bolus
answer
D , it’s the best action now according to AHA
guidelines since this is only the second round of
CPR
1 round of CPR = 5 cycles = 2 min.
After your CPR cycle you checked the
monitor and found the following trace
What is your next appropriate action

a. Continue CPR for 2 min. with adrenalin 1 mg iv

every 3-5 min.
b. Synchronized cardioversion
c. Defibrillate
d. Give Lidocaine iv
answer
C , defibrillate since its VF which is a shockable
rhythm , and energy should be the same or higher
than previous shock.
Remember to begin CPR for 2 min. immediately
after giving a shock.
You check the patient vitals and found
pulse , the monitor showed the
following trace
What is your next appropriate
action?

a. Defibrillate
b. Seek expert help
c. Check vital signs
d. Give atropine o.5 mg iv bolus
answer
C , check vital signs , you should always check the
patient vital signs after each step of algorithm
 Checked the vitals and found :
HR: 140 b/min , RR : 12 b/min ,
BP : 80/60 , temp. : 36
What had you achieved
(according to AHA guidelies) ?

a. Successful resuscitation
b. Return of spontaneous circulation ( ROSC)
c. Cardiac revival
d. Resumption of sustained cardiac function
answer
B
Accordig to AHA guidelines , ROSC means when
cardiac arrest patient regained a pulse and BP and if
waveform capnography measured a sustained
increase in ETPCO2 of 40 mmHg or greater.
Shockable Rhythm
VF and PULSELESS VT
Non-Shockable Rhythm
PULSELESS ELECTRICAL ACTIVITY (PEA)
AND
ASYSTOLE
Shock Energy for Defibrillation in pediatric :

• First shock: 2 Joules per kilogram

• Second shock: 4 Joules per kilogram
• Subsequent shocks: at least 4 Joules per kilogram, up to
a maximum of 10 Joules per kilogram or adult dose
Drug Therapy in pediatric
• Epinephrine IV or IO dose: 0.01 milligrams per kilogram
(0.1 milliliter per kilogram of the 0.1 milligram per milliliter
concentration). Maximum dose: 1 milligram. Repeat every 3
to 5 minutes. If no IV or IO access, may give endotracheal
dose of 0.1 milligrams per kilogram (0.1 milliliter per
kilogram of the 1 milligram per milliliter concentration)
• Amiodarone IV or IO dose: 5 milligrams per kilogram
bolus during cardiac arrest. May repeat up to 3 total doses
for refractory VF or pulseless VT or Lidocaine IV or IO
dose: Initial: 1 milligram per kilogram loading dose
Thank you