Cardiac Arrest

Question 1

What are the 2 different algorithm paths used to treat Adult Cardiac Arrest?

Answer 1

-VF/pVT
-Asystole/PEA

Question 2

Because many pts will sudden cardiac arrest demonastrate VF at some point in their arrests, most ACLS providers will often follow the VF/pVT algorithm—Why is this the best approach?

Answer 2

Rapidly treating VT according to this sequence is the best approach to restoring spontaneous circulation.

Question 3

VF/pVT will require CPR until a defibrillator is available to deliver high-energy Unsynchronized shocks.

Question 4

What are atonal gasps a S/O cardiac arrest?

Answer 4

-Agonal gasps are not normal breathing
-A pt who gasps usually appears to be drawing air in very quickly
-The mouth may be open and the jaw, head or neck may move w/ gasps
-Gasps may appear to be forceful or weak, usually a slow rate
-The gasp may sound like a snort, snore or groan
-Gasping is a S/O cardiac arrest.

Question 5

Describe the shock energy for VF/pFVT for a biphasic defibrillator:

Answer 5

-Manufacturer recommendation (Zoll—120/150/200)
-If unknown, recommended shock energy use maximum available; second and subsequent shock doses should be equivalent & higher doses may be considered.

Question 6

What is the shock energy dose for VF/pVT for a Monophysite defibrillator?

Answer 6

-360 J

Question 7

What is the drub therapy for VF/pVT?

Answer 7

-Epinephrine 1 mg Q3-5 minutes IV/IO
-Amiodarone 300 mg IV/IO first dose; 150 mg IV/IO second dose
OR
-Lidocaine 1-1.5 mg/kg IV/IO first dose; 0.5-0.75 mg/kg IV/IO second dose

Question 8

Coronary perfusion pressure (CPP) is Aortic Relaxation (diastolic) pressure minus Right Atrial relaxation (diastolic) pressure. During CPR, PCC correlates w/ both may cardiac blood flow & ROSC. In 1 human study, ROSC did not occur unless a CPP 15 mg Hg or higher was achieved during CPR. What can providers do to achieve the best CPP possible?

Answer 8

-Provide good chest compressions w/ minimal interruptions.

Question 9

In adult cardiac arrest but do VF/pVT, the heart is quivering & not effectively pumping blood to vital organs. What can be done so that these pts have a much higher survival rate?

Answer 9

-Immediate chest compressions and CPR

Question 10

The first 4-6 minutes after cardiac arrest, referred to as ‘Clinical Death’, no damage occurs to the brain. In 6-10 minute period, ‘biological death’ after cardiac arrest, damage is likely to occur to the brain. Brain damage is usually irreversible, except in special circumstances such as accidental hypothermia or cold water drowning.

Question 11

Why is the interval from collapse (cardiac arrest) to defibrillation one of the most important determinants of survival from cardiac arrest?

Answer 11

-A common initial rhythm in out-of-hospital witnessed cardiac arrest is VF.
-pVT rapidly deteriorates to VF and then the heart is quivering & does not pump blood
-Electrical defibrillation is the most effective way to treat VF (delivery of shock to stop the VF) & pVT.
-The probability of successful defibrillation decreases over time.
-VF deteriorates to Asystole if not treated.

Question 12

When VF is present, CPR can provider a small amount of blood flow to the heart & brain but cannot restore an organized rhythm. Why is early defibrillation important?

Answer 12

-The earlier defibrillation occurs, the higher the survival rate.
-Restoring a perfusing rhythm is more likely w/ immediate CPR & defibrillation within a few minutes after the initial arrest.

Question 13

What should be done after defibrillation?

Answer 13

-Immediately resume CPR beginning w/ compressions. Do not perform a rhythm check at this point unless the pt is showing S/O life, such as ROSC.

Question 14

What is the effect of Epinephrine of the body and how does it help w/ cardiac arrest?

Answer 14

-Epinephrine causes vasoconstriction which will increase cerebral & coronary blood flow during CPR by increasing mean arterial pressure and aortic diastolic pressure.

Question 15

When is Magnesium Sulfate given?

Answer 15

-for Torsades de Pointes
-Loading Dose 1-2 g IV/IO over 20 minutes.

Question 16

For the intubated pt, what is the best way to monitor CPR quality, optimize chest compressions & detect ROSC.

Answer 16

-Quantitative waveform caphography

Question 17

How is ROSC determined by observing PETCO2?

Answer 17

-ROSC is evident from the abrupt increase in PETCO2 to >50 mm Hg
-PTCO2 >50 mm Hg is consistent w/ a substantial improvement in blood flow.

Question 18

What is the main determinant of ERCO2 during CPR?

Answer 18

-Blood delivery to the lungs

Question 19

How can ERCO2 reading be improved?

Answer 19

-Improve chest compressions
-Vasopressor therapy

Question 20

When drugs are given via peripheral IV route during CPR how long does it take to reach the central circulation?

Answer 20

-1-2 minutes—> follow drug w/ a 20 ml bolus of IVF and elevate extremity for about 10-20 seconds to help deliver drug to central circulation

Question 21

What is the preferred route of administration for drugs during CPR?

Answer 21

-IV or IO route
-ET is not preferred if IV/IO are available.

Question 22

Studies demonstrate that the circulation system absorbs epinephrine, vasopressin & Lidocaine after administration via ER route. When giving via ET route, dilute drug in 10-15 ml SWI or NSS & inject directly into the ETT.

Question 23

A post cardiac arrest reasonable B/P is a MAP of 65 or greater. Adjust fluid administration or vasoactive or IO tropic agents as needed to aptitude cardiac output and systemic perfusion.

Question 24

Ultrasound may be applied to pts receiving CPR to help assess myocardial contractility & identify potentially treatable causes of cardiac arrest. What are some causes of cardiac arrest that can be determined by U/S?

Answer 24

-Hypovolemia
-Pneumothorax
-Pulmonary Thromboembolism
-Pericardial Tamponade

Question 25

What are the rhythms for PEA?

Answer 25

-Rate—>too fast or too slow
-Width of QRS—>wide vs narrow

Question 26

What drugs are used for PEA & Asystole?

Answer 26

-Epinephrine
-Other medications, depending on the cause of PEA or Asystole arrest.

Question 27

What is PEA?

Answer 27

-Any organized rhythm w/o a pulse

Question 28

What is the definition of an organized rhythm?

Answer 28

-QRS complexes that are similar in appearance from beat-to-beat
-QRS may b e narrow or wide
-QRS complexes may occur at rapid or slow rate, regular or irregular

Question 29

What are examples of rhythm for PEA

Answer 29

-Sinus Rhythm
-A Fib/Flutter
-BBB
-Idioventrilcular & ventricular escape rhythm

Question 30

What rhythm is the most common present after successful defibrillation?

Answer 30

-PEA due to cardiac function being too weak to produce a pulse or cardiac output

Question 31

If good PCR produces a strong pulse, relatively high ETCO2 or B/P it is more likely that the L ventricle is full and the cause of PEA is a poorly contractile L ventricle.

Question 32

If good CPR does not produce evidence of good cardiac output, what is a likely cause that the L ventricle is empty.

Answer 32

-Consider H’s and T’s
-Hypovolemia

Question 33

When is Asystole most often seen?

Answer 33

-As a terminal rhythm ini a resuscitation attempt that started w/ another rhythm.
-As the first rhythm identified in a pt w/ unwitnessed or prolonged.
-Persistent Asystole represents extensive myocardial ischemia & damage from prolonged periods of inadequate coronary perfusion.

Question 34

News the 5 H’s

Answer 34

-Hypovolemia
-Hypoxia
-Hydrogen Ion (Acidosis)
-Hyper/Hypokalemia
-Hypothermia

Question 35

Name the 5 T’s

Answer 35

-Tension Pneumothorax
-Tamponade (cardiac)
-Toxins
-Thrombosis (pulmonary)
-Thrombosis (coronary)

Question 36

Special resuscitation interventions (such as Extracorporeal CPR or ECMO (Extracorporeal Membrane Oxygenation)) & prolonged resuscitative efforts may be indicated for [pts w/ hypothermia, drug OD, or other potentially reversible causes of arrest.

Question 37

What temp is considered “severe hypothermia”?

Answer 37

<30 C or 86 F

Question 38

Is it appropriate to defibrillate a pt w/ severe hypothermia?

Answer 38

Yes

Question 39

Is it reasonable to attempt additional defibrillation attempts (after Initial)?

Answer 39

Yes—while active rewarding is taking place

Question 40

When hypothermic, pts have a reduced drug metabolism & drugs may accumulate to toxic levels. What drug is considered safe to give according to standard ACLS protocol?

Answer 40

Vasopressin

Question 41

What is considered “mild” hypothermia?

Answer 41

30-34 C (86-93.2 F)

Question 42

What should be done for pts w/ mild hypothermia?

Answer 42

Start CPR, attempt defibrillation, give meds according to local protocols & (if in hospital) provide active core rewarding.