Cardiopulmonary Arrest Flashcards
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
Asystole: Absence of detectable ventricular activity (flat line).
Pulseless Electrical Activity (PEA):
Cardiopulmonary Arrest
Organized electrical rhythm, but absence of
mechanical ventricular activity sufficient to generate pulse.
Pulseless Electrical Activity (PEA):
(1) Any of the 4 rhythms plus clinical correlation (pulseless) are indicative of cardiopulmonary arrest.
(2) If patient is awake and responsive, check leads.
(3) Perform rapid assessment (look, listen, feel, ABC’s).
(4) If no pulse, then start CPR immediately and call for AED or Defibrillator to assess rhythm.
(5) Determine if the rhythm is Shockable or Non-Shockable.
(6) When the only available defibrillator is an AED, ensure CPR continues until the AED is analyzing. Compressions will continue during placement and charging of the AED.
(7) Should chest compressions be interrupted, the goal is to not exceed more than 10 seconds in-between pauses.
(8) SHOCKABLE is either pulseless VT or pulseless VF.
Initial Actions and principals: Cardiopulmonary Arrest
SHOCKABLE
is either pulseless VT or pulseless VF.
(a) Continue CPR until defibrillator available, attached and charged.
(b) Deliver shock as soon as possible at the highest energy available (use maximum available J for both biphasic and monophasic defibrillators).
(c) Provide CPR for 2 minutes and obtain vascular access.
(d) After 2 minutes of CPR then check pulse and rhythm for less than 10 seconds, switch chest compressors.
(e) If rhythm is still shockable then resume CPR and charge the defibrillator again to deliver another shock at maximum energy.
(f) Provide CPR for 2 minutes, administer Epinephrine 1mg IV push, consider advanced airway and capnography.
(g) After 2 minutes of CPR then check pulse and rhythm for less than 10 seconds, switch chest compressors.
(h) If rhythm is still shockable then resume CPR and charge the defibrillator again to deliver another shock at maximum voltage.
(i) Provide CPR for 2 minutes, administer Amiodarone 300 mg IV push or Lidocaine 1-1.5 mg/kg IV push.
(j) After 2 minutes of CPR then check pulse and rhythm for less than 10 seconds, switch chest compressors.
(k) If rhythm is still shockable then resume CPR and charge the defibrillator again to deliver another shock at maximum voltage.
(l) Repeat cycles of 2 minutes of CPR, rhythm check, shock and
medications as appropriate until the rhythm check reveals a nonshockable rhythm (go to the non-shockable rhythm pathway (see below)), Return of Spontaneous Circulation (ROSC) is achieved or resuscitation is terminated.
(n) If ROSC obtained, then go to that pathway (see below).
ACLS Procedure SHOCKABLE
1) Hypovolemia
2) Hypoxemia
3) Hydrogen ion excess (acidosis)
4) Hyper-/hypokalemia
5) Hypothermia
6) Hyper-/hypoglycemia
7) Tamponade
8) Tension Pneumothorax
9) Thrombosis (pulmonary embolism)
10) Thrombosis (myocardial infarction)
11) Toxins
H’s and T’s.
(a) Provide CPR for 2 minutes,
1) Obtain vascular access,
2) Administer Epinephrine 1 mg IV push (may repeat dose every
3-5 minutes).
3) Consider advanced airway, capnography.
(b) After 2 minutes of CPR then check pulse and rhythm for less than 10 seconds, switch chest compressors.
(c) If the rhythm becomes a shockable rhythm, then go to that algorithm (see above).
(d) If rhythm is still non-shockable then resume CPR and evaluate is the rhythm an organized rhythm? If it is an organized rhythm then check again for a pulse, if not then continue CPR.
(e) Repeat cycles of 2 minutes of CPR, epinephrine and rhythm check until the rhythm check reveals a shockable rhythm (go to the appropriate step in shockable (VF/pVT) pathway), ROSC is achieved (see below), or resuscitation is terminated.
NONSHOCKABLE rhythms is either Pulseless Electrical Activity
(PEA) and Asystole.
Return of spontaneous circulation
ROSC
1) If not breathing, hypoxemia, or cyanosis then will need
advanced airway.
2) Head tilt-chin lift.
3) Oral pharyngeal airway (OPA), or nasal pharyngeal airway
(NPA).
4) Use advanced airway if needed.
a) Laryngeal mask airway (LMA).
b) Supraglottic airway
c) Endotracheal tube (ET).
(b) Do not interrupt CPR to place advanced airway unless you cannot get any air in through bag-mask ventilation.
(c) Do not interrupt chest compressions for more than 10 seconds.
(d) Confirm airway placement by:
1) Physical examination: Auscultation of lungs and abdomen.
2) Quantitative wave form capnography.
3) Qualitative CO2 detector.
Advanced Airway during Cardiopulmonary Arrest
(a) With bag-mask ventilation with OPA or no airway adjunct
then you give 2 ventilation after every 30 compressions.
(b) IF you have an advanced airway then you ventilate 1 breath
every 6-8 seconds and maintain continuous CPR for 2 minutes.
(c) Make sure you avoid hyperventilation.
(d) Support ventilations starting at a rate of 10 breaths per
minute and adjusting as necessary to keep carbon dioxide levels
in physiologic range (ETCO2 between 35-40 mmHg and
PaCO2 between 40-45).
1) Continuously monitor with capnography and pulse
oximetry.
Ventilation during CPR
(a) Conduct primary assessment and perform initial interventions.
1) Establish (if not already done) cardiac monitoring, pulse
oximetry, capnography, and noninvasive blood pressure
monitoring or arterial pressure monitoring.
2) Obtain 12 lead ECG and blood samples for laboratory
testing expediently (CBC, CMP, ABG, Troponin, Lactic
Acid).
(b) Optimize ventilation and oxygenation.
(c) Manage hemodynamics.
Post-Cardiac Arrest Care: Return of Spontaneous Circulation
(ROSC)
1) Monitor with noninvasive blood pressure monitoring or
arterial pressure monitoring.
2) Goal is to maintain SBP > 90 mmHg.
3) If SBP is < 90 mmHg or MAP < 60 mmHg then
a) Administer an IV fluid bolus (1-2 liters of NS or LR solution).
b) Initiate a vasopressor infusion.
(1 Norepinephrine infusion at 0.1-0.5 mcg/kg/min IV/IO OR
(2 Epinephrine infusion at 0.1-0.5 mcg/kg/min IV/IO OR
(3 Dopamine infusion at 5-10 mcg/kg/min IV/IO.
Manage hemodynamics:
Post-Cardiac Arrest Care: Return of Spontaneous Circulation
(ROSC)
If YES (based on history of 12 lead EKG revealing a STEMI)
then:
a) Initiate coronary reperfusion therapy AND
b) Assess if the patient is able to follow commands.
(1 If YES then admit to critical care unit for ongoing care and
monitoring.
(2 If NO then initiate Targeted Temperature Management
(TTM).
c) Maintain core body temperature 32-36 degrees Celsius for 24
hours.
d) Methods to cool the patient include: Ice-cold IV fluid bolus (30
ml/kg); Endovascular catheters; Surface-cooling strategies (e.g. cooling blankets, ice packs).
e) Continuously monitor core temperature via esophageal
thermometer, bladder catheter, or pulmonary artery catheter.
If NO then check if the patient is able to follow commands.
a) If YES then admit to critical care unit for ongoing care and monitoring.
b) If NO then initiate Targeted Temperature Management (TTM).
(1 Maintain core body temperature 32-36 degrees Celsius for 24
hours.
(2 Methods to cool the patient include: Ice-cold IV fluid bolus (30
ml/kg); Endovascular catheters; Surface-cooling strategies (e.g.
cooling blankets, ice packs).
(3 Continuously monitor core temperature via esophageal
thermometer, bladder catheter, or pulmonary artery catheter.
Clinical Suspicion of STEMI or suspected myocardial infarction.
(1) MEDEVAC
Disposition: Clinical Suspicion of STEMI or suspected myocardial infarction.
