Adult Cardiac Arrest

Question 1

What are the Shockable Rhythm’s in Cardiac Arrest

Answer 1

pVT (pulseless Ventricular Tachycardia)
VF (Ventricular Fibrillation)

Question 2

What are the NON-shockable rhythms in Cardiac Arrest

Answer 2

Asystole
PEA (Pulseless Electrical Activity

Question 3

CPR stands for:

Answer 3

Cardiopulmonary Resuscitation

Question 4

Treatment for NON-shockable rhythms in cardiac arrest (ie, PEA or Asystole)

Answer 4

Chest compressions for 2 min, then a 10 sec & and rhythm check, then resume 2 min chest compressions
IV Epi 1mg q3-5min
Work up and treat Reversible Causes - 5 H’s and 5 T’s

Question 5

Name the 5 H’s and 5 T’s that you immediately start working up in your head and in practice with any ACLS or Code/Cardiac Arrest situation

Answer 5

5 H’s
1) Hemorrhage
2) Hypoxia
3) H+ excess (Acidosis)
4) Hyperkalemia, Hypokalemia, other electrolyte imbalance
5) Hypothermia

5 T’s
1) Thrombosis coronary - ACS
2) Thrombosis pulmonary - PE
3) Tension PTX
4) Tamponade (Pericardial)
5) Toxins

Question 6

VT - monomorphic. Link

Answer 6

https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/

Question 7

VT - polymorphic. Link

Answer 7

https://litfl.com/polymorphic-vt-and-torsades-de-pointes-tdp/

Question 8

What is the first thing to do after a patient becomes pulseless?

Answer 8

Pulselessness means CARDIAC ARREST.

FIRST thing to do is start CHEST COMPRESSIONS immediately.

Then start doing the other things:
- Call a “code” / call for help
- Call for crash cart
- Hook up pads, analyze rhythm to determine if shockable or not.
- Intubate if not already done so, and start getting all the access
- Think through 5 H’s and T’s: order all the labs, CXR probably, TTE and/or TEE, and other things

Question 9

What is the first thing to do after a patient becomes pulseless and you see that it IS a shockable rhythm?

Answer 9

Start CPR immediately, then give UNsynchronized SHOCK as soon as possible. The answer is to SHOCK first, but that obviously only works if you already had pads on.

Do all the other code things as quickly as possible too (covered on a different card) after you recognize pulselessness

Question 10

Duration of CPR between shocks in a shockable rhythm?

Answer 10

2 min. Same duration of chest compressions for NON-shockable rhythm (PEA/asystole)

Also, restart chest compressions IMMEDIATELY after a shock. Don’t like sit and watch for sinus rhythm and a pulse to return! Just start right back in on CPR

Question 11

How many shocks before giving first medication, and what medication?

Answer 11

2 shocks before give IV Epi 1mg push, and continue giving q 3-5min. Put it on its own timer.

Continue CPR for 2 min cycles on it’s own timer, and epi q3-5min on its own timer.

Question 12

How many shocks before giving the other medications (other than Epi) in a SHOCKABLE rhythm?

Answer 12

IV Amiodarone - give AFTER THIRD shock:
- first dose = 300mg IV push
- second dose = 150mg IV push
- then you’re done with amio

IV Lidocaine - other (it’s Amio “or” Lido, not like both simultaneously) option to give AFTER THIRD shock:
- first dose = 1.5mg/kg IV push (just give full 100mg vial)
- second dose = 0.5-0.75mg IV push
- then you’re done with lidocaine

Question 13

During Cardiac arrest, when do you do pulse checks?

Answer 13

Take 10 seconds for a pulse check after 2 min straight of CPR. During this 10 second pause, also analyze the rhythm and give a shock if indicated (ie, if it’s VF or pVT).

Question 14

CPR Quality Measurements:
a) Depth and rate of chest compressions:
b) Compression to breath ratio

Answer 14

a) 2 inches (5cm) deep at 100-120/min for adults
b) If no advanced airway, 30:2 compression-ventilation ratio, or 1 breath every 6 seconds (basically the same with an advanced airway - 10 breaths/min or 1 breath every 6 seconds)

Question 15

Define ROSC

Answer 15

Return of Spontaneous Circulation is achieved with the following:
- Pulse and blood pressure return
- Abrupt sustained increase in Petco2 (typically ≥40 mm Hg)
- Spontaneous arterial pressure waves with intra-arterial monitoring

Question 16

Hypoxia treatment - 5 H’s and 5 T’s

Answer 16

• 100% FiO2
• High flow
• confirm function, connections, and positioning of everything starting either from machine to patient, or from patient to machine:
  
  • including listening for bilateral breath sounds, and suctioning ETT and maybe flexible fiberoptic verification of correct placement
• CXR!

Question 17

Hypovolemia/Hemorrhage treatment - 5 H’s and 5 T’s

Answer 17

• Fluids wide open - whatever’s in line
• Give blood obviously if hemorrhage. T&C if haven’t already
• Consider RELATIVE hypovolemia: auto-PEEP (disconnect circuit), High spinal, or shock states such as DIC or Anaphylaxis

Question 18

H+ excess treatment - 5 H’s and 5 T’s

Answer 18

ABG and CMP immediately

Breath off some H+
Sodium Bicarb 1 amp (50 mEq) if profound

Question 19

Hypokalemia /Hyperkalemia or other electrolyte imbalance treatment - 5 H’s and 5 T’s

Answer 19

ABG and CMP immediately

HYPERkalemia:
- 4 drugs: Insulin 10U, D50 1 amp (25 grams dextrose), Calcium Chloride 1 gram, Sodium bicarb 1 amp (50 mEq)
Monitor serial ABG’s for K+ and Glucose levels

HYPOkalemia:
- Controlled K+ and Mag2+ infusion

Hypoglycemia:
- Fingerstick if ABG delay
- D50 1 amp (25g dextrose).
- Monitor glucose

Hypocalcemia:
- Calcium Chloride 1g IV

Hypomagnesemia, or Torsades + prolonged QT (Torsades is defined as polymorphic VT due to prolonged QT):
- Magnesium sulfate 2mg IV
- Would NOT give Amiodarone if had Torsades, since Torsades by definition has prolonged QT and Amio causes prolongation of the QT!
- Do NOT give amio if there is a prolonged QT (like > 600).
- If wanted to give an anti-arrhythmic in addition to magnesium during Torsades, just give LIDOCAINE 1.5mg/kg instead of Amio.

Question 20

Hypo- or Hyper- thermia treatment - 5 H’s and 5 T’s

Answer 20

Active warming with:
- forced air blanket
- warm IVF
- raise room temp
- Consider CPB with warm fluid

If MH, call for MH cart and give DANTROLENE immediately starting at 2.5 mg/kg

Question 21

Thrombosis, coronary (ACS) treatment - 5 H’s and 5 T’s

Answer 21

STEMI basically. A heart attack. Look for ST elevations OR depressions, unexplained tachy or brady-arrhythmias, or hypotension. Workup with TEE/TTE to look for wall motion abnormalities, new or worse MR. In awake patients assess for CHEST PAIN.

Treatment:
- Emergent CORONARY REVASCULARIZATION - so CALL CARDS

Detailed treatment:
1. 100% FiO2 if hypoxemic
2. order 12-lead EKG (and expand tele to 12 lead view) - to verify cardiac ischemia
3. Treat HYPO- or HYPER- tension as necessary -
4. Call for code card and apply pads - be ready for malignant arrhythmias
5. BETA BLOCKER to slow heart rate - HOLD for bradycardia or hypotension
6. Consult with Cardiology and Surgery:
- start ASA 160-325mg (PR, PO, or NG)?
- start HEPARIN +/- CLOPIDOGREL?
7. Narcotics for pain (fentanyl or morphine)
8. Consider NTG (nitroglycerin) infusion - HOLD until hypotension treated)
9. A-line and send Labs: ABG, CBC, Troponin
10. If Anemic, give blood!
11. TTE and/or TEE - monitor volume and WMA’s
12. Consider CENTRAL access
13. If hemodynamically UNstable, consider Intra-Aortic Balloon Pump

Question 22

Thrombosis, pulmonary (PE) treatment - 5 H’s and 5 T’s

Answer 22

TTE/TEE to evaluate RIGHT VENTRICLE

Consider Fibrinolytics (tPA) or Pulmonary Thrombectomy

Question 23

Tension PTX treatment - 5 H’s and 5 T’s

Answer 23

S/S:
- Unilateral breath sounds
- Deviated trachea
- Distended neck veins

CALL FOR CXR, but do NOT delay treatment

Treatment:
- Large bore (14 Ga) needle decompression of 2nd intercostal space at mid-clavicular line, THEN CHEST TUBE placement by TCV

Question 24

Tamponade, pericardial treatment - 5 H’s and 5 T’s

Answer 24

TTE and/or TEE to workup. Narrowed pulse pressure, pulsus paradoxis. See Onenote notes for proper anesthetic in pericardial tamponade - basically keep all hemodynamics full force.

Treatment = Pericardiocentesis. But actually call TCV or Interventional cardiology ASAP so they can do it.

Question 25

Toxins treatment - 5 H’s and 5 T’s

Answer 25

Consider MEDICATION ERRORS
Consider LAST ==> Intralipid
Turn OFF GAS and OFF INFUSIONS that could be killing BP

Question 26

Shock (UNsynchronized) Joules for shockable rhythms of cardiac arrest (VF/pVT)

Answer 26

Biphasic = Manufacturers recs, usually 120-200J. If unknown manufacturer’s recs, use MAX available. Second and subsequent doses should be equivalent, and higher doses may be considered.
Monophasic = 360J

Question 27

Treatment of Torsades + Prolonged QT, or HypoMg

Answer 27

Mag sulfate 2 grams SLOW IV PUSH - so NOT a fast bolus, but also NOT a 15 min infusion from a small hanging bag