Date post: | 03-Jun-2015 |
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• Cardiac arrest :
is an abrupt cessation of cardiac pump function that may be reversible but will progress to death without prompt intervention.
• The four rhythms that produce pulseless cardiac arrest are :
• ventricular fibrillation, • pulseless ventricular tachycardia • Asystole• Pulseless electrical activity
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Clinical features :
A patient who is :
1. unconscious,
2. apneic, and
3. pulseless
fulfills the cardiac arrest diagnosis criteria
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Clinical features :
• In ventricular fibrillation : • loss of consciousness occurs within 15 seconds, • but agonal gasping may persist for around 60 seconds following
collapse. • Brief seizure may occur, caused by cessation of cerebral blood
flow
•Cardiac arrest secondary to respiratory arrest causes :• loss of consciousness, bradycardia, and absent pulse within 5
minutes
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Clinical features :
Symptoms : ( may be present )
New or changing angina
Fatigue
Palpitations
Dyspnea
Chest pain
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often results from reversible causes that must be rapidly identified and treated.
5 Ts':
• Tamponade, cardiac
• Toxins
• Tension pneumothorax
• Thrombosis, pulmonary
• Thrombosis, coronary
'5 Hs :
• Hypovolemia
• Hypothermia
• Hypoxia
• Hypo- or hyperkalemia
• Hydrogen ion (acidosis)
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Coronary artery disease with myocardial infarction is the most common structural heart disease predisposing to cardiac arrest.
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physical examination factors :
• immediate CPR and rapid defibrillation take precedent over examination in the cardiac arrest victim.
• Ensure adequacy of airway. Note the presence of any blood, vomitus, or secretions
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• Absent respiratory effort
• presence of only agonal gasps are characteristic of cardiac arrest.
•Unilateral breath sounds may indicate:• tension pneumothorax or • aspiration.
•Wheezing and rales• underlying pulmonary edema or• aspiration
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• Heart tones may be heard in patients with :• pulmonary embolus, tension pneumothorax, or
hypovolemia
• Jugular venous distension may be noted in :• tension pneumothorax, cardiac tamponade, or pulmonary
embolus
• A distended, dull abdomen may be noted in patients with a
• ruptured abdominal aortic aneurysm or ruptured ectopic pregnancy
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Investigations:
• Rapid rhythm assessment
• End-tidal carbon dioxide partial pressure
• Central venous oxygen saturation
• Arterial relaxation pressure
• Echocardiogram
• Serum electrolytes
• 12-lead electrocardiogram
• Serum lactate
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Differential diagnosis :
• Supraventricular tachycardia with aberration
•Choking
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Choking• a person choking on a piece of food may be mistakenly thought to be
suffering acardiac arrest
• Choking commonly occurs during a meal, often when the person is talking or laughing
• Food lodges in the oropharynx, causing sudden cyanosis and collapse
• May cause primary respiratory arrest with absence of respiratory efforts or severe stridor with persistence of a pulse
• The Heimlich maneuver usually dislodges the piece of food, allowing immediate recovery
• Choking may progress to cardiac arrest if the piece of food or other foreign body is not dislodged
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Causes : • Respiratory causes :
• mechanical airway obstruction, submersion injury, and respiratory failure originating from asthma, pulmonary edema, or sedative overdose.
• Metabolic abnormalities :
• commonly hyperkalemia, which is most frequently seen in patients with renal failure.
• Less commonly, hypokalemia, hypermagnesemia, hypomagnesemia and hypercalcemia .
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Causes : • Toxins :
• overdose of prescription medications or • illicit drugs e.g. digitalis, β-blockers, cocaine, and heroin .
• Electrical currents of 100 mA to 1 A usually cause ventricular fibrillation; currents above 10 A can cause asystole
• Brugada syndrome:
• which is an inherited disorder affecting cardiac membrane channels that is associated with polymorphic ventricular tachycardia and ventricular fibrillation.
• ECG showing a right bundle branch block with ST segment elevation in leads V1 to V3
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Causes :
Long QT syndrome :
• characterized by prolonged QT interval (repolarization) on resting ECG .
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CPR :
• Initiate CPR with 30 chest compressions.
•For all adults:
provide cycles of 30 chest compressions
followed by 2 breaths.
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CPR :
• In the pediatric :
30 compressions:2 breaths for 1 rescuer CPR
15 compressions: 2 breaths for 2 or more rescuers.
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CPR :
• push hard, push fast (≥ 100 compressions/min) while allowing full recoil of the chest between compressions.
• Compressions should be delivered over the lower half of the sternum to a depth of 2 inches in adults and
• at least one-third of anterior-posterior diameter of the chest ininfants and children
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CPR :
• Immediately resume CPR after each defibrillation attempt and continue for 2 minutes before rechecking rhythm .
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Immediate action : • 1- Begin high-quality CPR & defibrillation .
• Perform rapid rhythm assessment with quick-look paddles, electrode pads, or limb leads
• Patients with ventricular tachycardia or ventricular fibrillation require immediate defibrillation
• Patients with PEA or asystole should have continued CPR while attempts are made to diagnose and treat the underlying cause
• 2- Administer supplemental oxygen as soon as it is available
• 3- Establish intravenous or intraosseous access as soon as possibleby : A.taskin ( [email protected] )
Immediate action : • After 2 minutes of CPR, reassess rhythm. If a shockable rhythm is
present, shock again
• Administer epinephrine 1 mg intravenously or intraosseously. • Repeat every 3 to 5 minutes.
• Administer amiodarone 300 mg intravenously or intraosseously. Repeat once at 150 mg in 3 to 5 minutes .
• A single dose of vasopressin 40 units intravenously or intraosseously may be substituted for the first or second dose of epinephrine
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Immediate action : • Magnesium sulfate
• 1 to 2 g intravenously or intraosseously may be considered for suspected hypomagnesemia or torsade de pointes associated with a long QT interval.
• It is not recommended for routine use in cardiac arrest
• sodium bicarbonate• Routine use of for the treatment of cardiac arrest is not
recommended.• May beneficial for tricyclic antidepressant overdose,
severe cocaine toxicity, hyperkalemia, and pre-existing acidosis . by : A.taskin ( [email protected] )
Immediate action : • Atropine is no longer recommended for routine use in the
management of asystole/PEA
• Electrical pacing is not recommended for the treatment of:• PEA or asystole
•Norepinephrine can be used as adjunctive treatment for patients with profound hypotension
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In a non-ventricular fibrillation/ventricular tachycardia pulseless rhythm:
•Continue with CPR
•Add epeniphrine
•Continue CPR for 2 minutes, then recheck rhythm.
• If shockable rhythm is present, defibrillate
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Bradycardia (heart rate < 50 beats/min):• If perfusion is inadequate and thought to be due to
bradycardia:• Administer a 0.5-mg intravenous bolus of atropine; repeat
every 3 to 5 minutes to a maximum of 3 mg• If atropine is inadequate :1. proceed to transcutaneous pacing or
administer dopamine 2 to 10 μg/kg/min or epinephrine 2 to 10 μg/min by intravenous infusion.
2. Intravenous infusion of chronotropic agents is an equally effective alternative to external pacing in this setting Consider transvenous pacing
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Tachycardia (heart rate typically greater than or equal to 150 beats/min):
• If there is no evidence of inadequate perfusion,
• obtain a 12-lead ECG to assess whether rhythm is
• wide-complex tachycardia (QRS ≥ 0.12 s) or• narrow-complex tachycardia (QRS < 0.12 s)
• If there is evidence of inadequate perfusion, perform immediate synchronized cardioversion
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In wide-complex tachycardia:( V-tach , (SVT) with aberrancy, pre-excitation tachycardia, and ventricular paced rhythms )
If the rhythm is regular with a monomorphic QRS waveform,
•adenosine can be used for diagnosis and treatment.
• Administer a 6-mg rapid intravenous push
• followed by a flush to deliver the drug as a rapid bolus.
• If there is no conversion, give a 12-mg rapid intravenous push of adenosine; the 12-mg dose may be given once more.
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Cont, complex tach :
Consider an antiarrythmic infusion of amiodarone.
• Administer 150 mg intravenously over 10 minutes.
• repeat as needed to a maximum dose of 1.1 g/24 h.
• Follow with a maintenance infusion of 1 mg/min for the first 6 hours. Alternatives include procainamide and sotalol
• Prepare for synchronized cardioversion
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For irregular rhythm:
• Consider atrial fibrillation with aberrancy and treat as for atrial fibrillation.
• If there is pre-excitation atrial fibrillation, such as Wolff-Parkinson-White syndrome, consider a consultation with a cardiologist.
• Avoid atrioventricular nodal blocking agents (adenosine, digoxin, diltiazem, verapamil), which may paradoxically increase ventricular rate. Consider amiodarone .
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In narrow-complex tachycardiafor regular rhythm:
• Attempt vagal maneuvers
• Administer a 6-mg rapid intravenous push of adenosine.
• If there is no conversion, give a 12-mg rapid intravenous push of adenosine. The 12-mg dose may be given once more
• If the rhythm converts, • it is likely to be re-entrant SVT; • consider diltiazem or β-blockers to prevent recurrence
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If rhythm does not convert :
• consider possible atrial flutter, ectopic atrial tachycardia, or junctional tachycardia.
• Consider expert consultation, and consider diltiazem or β-blockers to control rate
Implantable cardioverter-defibrillators (ICDs) are:
indicated for patients surviving cardiac arrest resulting from ventricular fibrillation or ventricular tachycardia
that is not due to a transient or reversible cause . by : A.taskin ( [email protected] )
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References :
• First consult .
•Oxford emergency medicine 4th e .
• (©2010 American Heart Association )
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