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Y1 Cardiology > Cardiac Arrest (AMI) > Flashcards

Cardiac Arrest (AMI) Flashcards

1
Q

Cardiac Arrest (def.)

A

A clinical diagnosis that means effective cessation of the heart.
No circulation means no oxygen delivery.

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2
Q

ABC of patient with cardiac arrest.

A

Unresponsive patient
Not breathing properly
No pulse

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3
Q

OHCA vs. IHCA presenting rhythm

A

Presenting rhythm in OHCA is usually VF/VT aka shockable. Most IHCA non-VF/VT aka non-shockable.

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4
Q

What is the main problem with cardiac arrest?

+survival rates

A

Poor outcomes despite treatment.
Survival to leave hospital:
OHCA- 8%
IHCA- 18.4%

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5
Q

DO2 =

A

SaO2 x [Hb] x O2cc x CO (HR x SV)

[O2cc = oxygen carrying capacity of haemoglobin, approx 1.36ml O2/g Hb]

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6
Q

Overview of route of oxygen delivery.

A 
Inhalation by nostrils 
Nasopharynx 
Oral pharynx 
Glottis 
Trachea 
Bronchus (right and left) 
Bronchioles 
Alveoli 
Blood 
Heart 
Systemic Circulation
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7
Q

Why are most cardiac arrests predictable?

A

Prior deterioration in 50-80% of cases- hypoxia and hypotension common.

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8
Q

Core Standards in all settings

A
  1. Deterioration recognised early with effective help system to prevent arrest
  2. Arrest recognised early and CPR started immediately
  3. Help summoned as soon as arrest is recognised (if not already)
  4. Defibrillation, if appropriate, within three minutes of arrest where achievable
  5. Appropriate post-arrest care is resuscitated, including safe transfer
  6. Standards measured continually and identified problems dealt with
  7. At least annual training and updates in CPR
  8. Appropriate equipment available for resuscitation
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9
Q

Early recognition prevents…

A

Cardiac arrests and resulting deaths
Admissions to ICU
Inappropriate resuscitation attempts.

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10
Q

What is the “golden hour”?

A

concept of urgency, one hour after a trauma/event is the best time to treat.

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11
Q

Cardiorespiratory Arrest (def.)

A

No pulse, no breathing.

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12
Q

How can oxygen delivery factors be improved?

A

SaO2 - ↑FiO2, clear airway, adequate breathing
[Hb] - transfusion trigger, treat anaemia - Gp&S / X-match, IV access, (Fe etc)
Heart Rate - atropine or β-stimulant (e.g. ephedrine) for bradycardia
BP - preload (IV fluids, raise legs), contractility (treat cause e.g. PCI for MI), afterload.
(remember- golden hour concept)

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13
Q

6 Physiological Parameters of NEWS

A 
Respiratory Rate 
Oxygen Saturations
Temperature 
Systolic BP 
Pulse Rate 
Level of consciousness
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14
Q

How are oxygen delivery factors assessed?

A

SaO2 - clinical (not reliable), pulse oximetry, arterial blood gas (gold standard)
[Hb] - clinical (not reliable), part of full blood count, bedside (e.g. hemocue)
Heart rate - pulse, pulse oximetry, ECG monitor (with sound), arterial BP monitor
BP - use equation BP = CO x TPR. Once HR accounted for, BP determined by SV and/or TPR. SV depends of preload, contractility and afterload. BP always due to HR, preload, contractility or afterload change. Use clinical info to determine which).

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15
Q

Causes of airway obstruction

A

CNS depression- tongue
Lumen blocked- blood, vomit, foreign body
Swelling- traume, infection, inflammation
Muscle- laryngospasm, bronchospasm

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16
Q

How would you recognise airway obstruction?

A

Talking
Difficulty breathing, distressed or choking
SOC
Noisy breathing- stridor, wheeze, gurgling
Seesaw respiratory pattern, accessory muscles

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17
Q

How would you treat airway obstruction?

A
  1. Airway opening- head tilt, chin lift, jaw thrust, suction
  2. Simple adjuncts
    Advanced techniques e.g. LMA, tracheal tube
  3. Oxygen (increase FiO2)
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18
Q

Causes of breathing problems

A

Airway problems
Decreased resp drive (CNS depression)
Decreased resp effort (muscle weakness, nerve damage restrictive chest defect, pain from fracture ribs)
Lung disorders (pneumothorax, haemothorax, infection, COPD, asthma, PE, ARDS

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19
Q

How would you recognise a breathing problem?

A

LOOK- resp distress, accessory muscles, cyanosis, RR, chest deformity, consciousness.
LISTEN- noisy breathing, breathing sounds
FEEL- expansion, percussion, tracheal deviation

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20
Q

How would you treat breathing issue?

A
  1. Airway
  2. Oxygen
  3. Treat underlying cause e.g. drain pneumothorax
  4. Support breathing if inadequate
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21
Q

Causes of circulation problems (primary and secondary)

A 
Primary: 
ACS
Dysrhythmias 
Hypertensive heart diseases
Valve disease 
Drugs 
Hereditary cardiac diseases 
Electrolyte/acid base abnormalities 
Electrocution 
Secondary 
Asphysxia 
Hypoxaemia 
Blood loss 
Hypothermia 
Septic shock
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22
Q

How would you recognise a circulatory problem?

A

General examination- distress, pallor, etc.
Pulse- tachy/brady
BP
Peripheral perfusion- capillary refill time
Indicators of organ perfusion- chest pain, mental state, urine output
Bleeding, fluid losses

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23
Q

How would you treat a circulatory problem?

A
  1. Ensure airway, breathing and oxygen
  2. Cannula for taking blood, plus IV/IO access
  3. Treat the cause- fluid challenge, inotropes/vasopressors, MONAC for ACS
  4. Haemodynamic monitoring
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24
Q

How would you recognise/assess ‘disability’?

A

AVPU or GCS (+pupils)

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25
Q

How would you treat ‘disability’?

A

Treat underlying cause.
Check blood glucose- if < 3 mmol/l, give glucose
Consider lateral recovery position
Check drug chart

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26
Q

E = Exposure. How is this dealt with?

A

Remove clothing to enable thorough examination, to avoid missing the causes or problems, e.g. injury, bleeding, rashes. However, it is important to avoid heat loss and maintain patient dignity.

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27
Q

DNAR/DNACPR (def.)

A

Do not attempt resuscitation/CPR

ABCDE approach is still used but CPR is avoided.

28
Q

RCUK DNAR guidelines

A
  1. More advance care planning in hospital, decisions about CRP where approaching end of life.
  2. Effective and timely communication with patients and those close to them (where appropriate)
  3. Clear documentation of all decisions and reasons
  4. Clear documentation of discussion or why whis was not possible/appropriate
29
Q

Diagnosis of Cardiac Arrest

A
  1. Safe to approach?
  2. Check if responsive
  3. Shout for help if unresponsive- give aid if responsive

A
B
C

SEE TABLE FOR DIAGNOSIS

30
Q

What are the four subgroups that assessment will divide patients into?

A
  1. Responsive
  2. Unconscious
  3. Respiratory Arrest
  4. Cardiac Arrest
31
Q

How would you react to the four categories resulting from assessment?

A
  1. Responsive - aid/get help if required
  2. Unconscious - recovery position/help
  3. Respiratory arrest - help/ventilation
  4. Cardiac Arrest - help/CPR
32
Q

Compressions:Breaths

A

30:2

33
Q

Shockable vs. Non-shockable diagnosis

A 
Shockable = VF/VT 
Non-shockable = Asystole/PEA
34
Q

Ventricular Fibrillation (def)

A 
Bizarre, irregular waveform 
No recognisable QRS complexes 
Random frequency and amplitude 
Uncoordinated electrical activity 
Coarse/fine

Note- exclude artifact e.g. movement, electrical interference. May require to pause CPR to diagnose.

35
Q

Ventricular Tachycardia

A

Monomorphic- broad complex rhythm, rapid rate, constant QRS morphology.
Polymorphic- torsade de pointes

36
Q

Use of Precordial Thump

A

De-emphasised
Rarely effective
Should not delay defibrillation
Only used if defibrillator not immediately available in witnessed and monitored VF/VT cardiac arrest

37
Q

Tracheal Tube insertion - problems?

A

Problems if fail – delays (interferes with CPR/defib), incorrect placement.

Confirm clinically and with capnography.

38
Q

Defibrillation

A

Use of electrical current to reset the heart’s electrical rhythm, with the hope that regular rhythm will recur.

39
Q

Why is self adhesive defibrillation preferred to manual?

A 
Can (and should) apply during CPR
Analyse then CPR while charging
Shock delivered more rapidly
Similar transthoracic impedance/efficacy
Operator defibrillates from safe distance
Minimise interruptions!!!!
40
Q

Method of Manual Defibrillation

A
  1. Diagnose VF/VT from ECG and signs of cardiac arrest
  2. Select correct energy level
  3. Charge paddles on patient
  4. Shout “stand clear/O2 away”
  5. Visual check of area
  6. Check monitor
  7. “Stand clear” to CPR provider
  8. Deliver shock
  9. Resume CPR immediately
41
Q

After first shock and further two minutes of CPR, VF/VT still persists. What next?

A

Deliver second shock
CPR for a further 2 mins
Deliver third shock
CPR again, if VF/VT persists administer Adrenaline 1mg IV and 300 mg Amiodarone after third shock.

42
Q

When should adrenaline be administered during resuscitation attempt?

A

1 mg after third shock (if shockable) then every three to five mins/every 2 cycles.

43
Q

When should amiodarone be given during resuscitation attempt?

A

300 mg after third shock (if shockable)

44
Q

Organised electrical activity appears… what next?

A

If ROSC = post resuscitation care
If no ROSC = non VF/VT algorithm
If asystole = non VF/VT algorithm

45
Q

Asystole

A

NON-SHOCKABLE
Absent ventricular QRS activity (check the electrodes)
Atrial activity (P waves) may persist
Rarely a straight line trace

46
Q

How to treat Asystole

A

Adrenaline 1mg IV should be given as soon as possible, and every 3-5 mins thereafter (every 2 cycles).

47
Q

PEA (def)

A

Pulseless Electrical Activity
NON-SHOCKABLE
Clinical features of cardiac arrest, ECG normally associated with an output.

48
Q

How to treat PEA

A

Exclude and treat reversible underlying causes.

Adrenaline 1mg IV should be administered ASAP, then every 2 cycles thereafter.

49
Q

During CPR (ALS algorithm)

A

Ensure High quality CPR: rate, depth, recoil
Minimise interruptions to compressions
Give oxygen
Use waveform capnography
Continuous CPR when advanced airway in place
Vascular access (intravenous or intraosseous)
Give adrenaline every 3-5 min
Give amiodarone after 3 shocks
Treat reversible causes

IMPORTANT TO ADHERE TO AS NON-SHOCKABLE ASSOCIATED WITH POOR OUTCOMES

50
Q

Drugs used in resuscitation

A

Adrenaline and amiodarone should be administered using Min-I-Jets.
Adrenaline 1mg IV every 3-5 minutes/every 2 cycles.
-α vasoconstriction
-β inotropic
Amiodarone 300mg.

51
Q

Reversible Causes (4Hs 4Ts)

A 
Hypoxia 
Hypovolaemia 
Hypo-/Hyperkalaemia/metabolic 
Hypothermia 
Thrombosis - coronary or pulmonary 
Tension pneumothorax 
Tamponade (cardiac) 
Toxins
52
Q

How to treat Hypoxia

A

Airway and Ventilation- secure airway.

Once secured, do not interrupt chest compressions for ventilation. Avoid hyperventilation.

53
Q

Methods of Ventilation

A

Mouth to Mask
Self Inflating Bag
Supraglottic Airway Device (SAD), for example Laryngeal Mask Airway (LMA)

see notes for advantages and disadvantages.

54
Q

When to cease CPR

A

ROSC

When it seems useless- time, diagnosis, pre-arrest condition, DNAR order.

55
Q

Goal(s) of Post Resuscitation Care

A

Restore the patient’s QOL;
Normal cerebral perfusion
Normal organ perfusion/function
Stable cardiac rhythm

56
Q

4 parts of Post Cardiac Arrest Syndrome

A

Post cardiac arrest brain injury
Post cardiac arrest myocardial dysfunction
Systemic ischaemia/reperfusion response
Persistent precipitating pathology

57
Q

Immediate treatment of airway and breathing (in post resus care)

A 
Target SpO2 94-98% 
Advanced airway 
Endotracheal tube ay be required 
Ventilate to normocapnia 
Waveform capnography
58
Q

Immediate treatment of circulation (in post resus care)

A 
12 lead ECG 
Reliable IV access 
Intra-arterial BP monitor 
Target SBP > 100 mmHg 
Fluid (crystalloid) - normovolaemia
Consider inotrope/vasopressor
59
Q

If cause of Cardiac Arrest appears to be something other than cardiac, what would you do?

A

Consider CT brain or CTPA

60
Q

Who is considered for “Disability Management”?

A

subgroup of patients who remain unconscious after resus. They may have special requirements or brain may need time to recover.

61
Q

What is “Targeted Temperature Management”?

A

therapeutic hypothermia for unconscious adults with ROSC after arrest. Patients are cooled to 32-36 degrees c for 12-24 hours.

62
Q

Why may a patient also be administered a sedative alongside targeted temperature management?

A

shiver prevention

63
Q

Aim of patient transfer.

A

to facilitate a safe transfer of the patient between the site of resuscitation and an appropriate place of definitive care (critical care area).

64
Q

Important things to secure during patient transfer

A

cannulae, drains and tubes.

Also with patient must go the patient notes and monitoring. They should be reassessed before leaving.

65
Q

What are the next steps if a patient is rewarmed but remains comatose?

A

Investigations must be undergone to find out why this is- are they treatable or is it something more severe?

Y1 Cardiology (9 decks)

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