Cardiovascular Emergencies Flashcards
What are reversible causes of CPR?
Hypoxia Hypovolaemia Hypo/hyperkalaemia Toxins Thrombosis (cardiac or pulmonary) Cardiac tamponade Tension pneumothorax
What are the first stages of action on discovering adult cardiac arrest, before an ECG establishes rhythm ?
- confirm cardiac arrest by monitoring pulse and breathing activity simultaneously
- call resus team (2222 at St. George’s)
- start CPR - uninterrupted chest compressions and apply defib pads - one under RIGHT clavicle and other in V6
- stop chest compressions to confirm rhythm on ECG
What are the 2 shockable rhythms?
VF / VT
What are the steps of action if VT/VF is confirmed?
- resume CPR while designated person selects shock energy
- charge defib and ensure all stand clear
- restart CPR using 30:2 ratio and continue for 2 mins then reassess rhythm - if organised electrical activity is seen, look for ROSC: central pulse, end-tidal CO2 trace - start post-resus care
- if still VT/VF, repeat shock and 2 mins CPR at 30:2, reassess and repeat if still VT/VF
- after 3rd shock resume CPR for 2 mins and give adrenaline 1mg IV and amiodarone 300mg IV
- continue 2 mins CPR - assess- shock sequence if still in VT/VF, giving further 1mg adrenaline IV after alternate shocks (every 3-5 mins)
- if asystole seen, switch to non-shockable course of action
What are the 2 non-shockable rhythms?
Asystole and PEA
What is PEA?
Pulseless electrical activity - no palpable pulse even though there is electrical rhythm expected to produce cardiac output - survival is unlikely unless a reversible cause is found
What is the course of action if PEA is discovered?
- CPR 30:2 and 1mg adrenaline IV as soon as access is achieved
- achieve secure airway and do continuous chest compressions
- look for and correct reversible causes
- reassess after 2 mins - if still no pulse or chance in ECG, continue CPR and recheck after 2 mins, giving 1mg adrenaline in alternate cycles
- if rhythm becomes VT/VF, switch to shockable protocol
- if pulse detected, start post-resus care
What is the course of action for asystole?
• CPR 30:2 and adrenaline 1mg IV as soon as you have access
• secure airway and continue uninterrupted chest compressions
• look for and correct reversible causes
(ARE THERE P WAVES? May respond to pacing)
• reassess after 2 mins and continue CPR if still PEA or asystole, giving adrenaline 1mg IV at alternate cycles
• if VT/VF, change to shockable rhythm plan
When does hypertension require hospital admission?
- when there is evidence of a rapid rise in blood pressure
- when BP is significantly raised, eg to a systolic BP >220mmHg and/or diastolic BP >120mmHg
- if there is evidence of severe or life-threatening end organ damage (eg hypertensive encephalopathy, intra-cranial haemorrhage, aortic dissection, acute coronary syndromes, acute LV failure with pulmonary oedema, pre-eclampsia/eclampsia)
What is malignant hypertension?
Syndrome characterised by severely elevated BP with retinopathy (retinal haemorrhages, exudates or papilloedema), visual impairment, nephropathy AKI +/- hypertensive encephalopathy and microangiopathic haemolytic anaemia
• send patient to HDU or ITU and seek advice from blood pressure unit
What is the aim of treatment of a hypertensive emergency?
To lower blood pressure in a rapid (2-4 hours) but controlled manner to safe levels of 160mmHg systolic 100mmHg diastolic (NOT ‘normal’ levels) - maximum initial BP drop should not exceed 25% of starting value - too rapid a fall could cause stroke/MI or acute renal failure
What is the drug of choice for most hypertensive emergencies?
SNP - sodium nitroprusside - arteriolar and venous dilator with immediate onset and short duration of action - beware associated with cyanide toxicity (clinical deterioration, altered mental status and lactic acidosis) - caution use in pre-eclampsia - only give in HDU/ITU with continuous intra-arterial blood pressure monitoring
When is labetalol used?
It is a combined alpha and beta blocker which can be used in most hypertensive emergencies or urgencies - logical for use in patients with IHD, aortic dissection or stroke (plus high BP in pregnancy as it is safe) - give by slow IV injection or infusion - beware postural hypotension
When might GTN be used?
GTN is a venodilator (slight arteriolar dilator) with quick onset of action but tolerance builds quickly - used in acute LV failure, acute pulmonary oedema, and ACS - beware BP response to GTN is not as predictable as with SNP
What else could be used in hypertensive emergencies in pregnancy?
Hydralazine- arteriolar dilator - given by slow IV injection or infusion - not to be given to pts with IHD or aortic dissection