Management of Cardiac Arrest Flashcards
When has cardiac arrest occured?
When there is no effective cardiac output.
What are the non-shockable and shockable rhythms?
How do you distinguish between them?
CARDIAC ARREST RHYTHMS
Dinstinguish with ECG
- NON-shockable (A’a)
- Asystole
- PEA (Pulseless Electrical Activity)
- SHOCKABLE (V’s - Very Shockable)
- VF
- pulseless VT
What is the most common arrest rhythm in children and why?
Asystole.
Because the response of the young heart to prolonged hypoxia is:
- Acidosis
- Progressive bradycardia –>
- Asystole
Describe the appearance of asystole on ECG. What needs to be checked when you see this appearance?
ASYSTOLE
ECG
- almost straight line
- +/- P-waves occasionally
CHECK:
- ARTEFACT e.g. loose wire, disconnected electrode
- Turn up the GAIN on ECG monitor
What is PEA?
PEA
Pulseless Electrical Activity
- ECG monitor - recognisable complexes that NORMALLY produce perfusion
- BUT
- NO signs of life
- NO pulse
- Often a pre-asystolic state
- Treated in the same way as asystole (Non-shockable rhythm pathway)
What causes PEA (Pulseless Electrical Activity)? In what types of patients/ what situations may it occur?
PEA
Pulseless Electrical Activity
Causes
4 H’s & 4 T’s
May be due to an identifiable and reversible cause
- Hypoxia - most common
- Hypovolaemia - “
- Hypocalcaemia e.g. calcium channel blocker overdose (& hypo- hyper- K+)
- Hypothermia
- Trauma incl. cardiac tamponade
- Tension PTX
- Thromboembolism (massive PE - rarely)
- (Toxins)
Describe the APLS cardiac arrest algorithm, including Mx for shockable and non-shockable rhythms.
APLS
CARDIAC ARREST
START WITH SSS –> ABC
- SAFETY (to approach, free from danger)
- STIMULATE
- Are you alright?
- hold head in place + shake arm
- NEVER shake an infant
- NB pre-verbal/ scared children will not reply meaninfully (may make sound or open eyes)
- SHOUT for HELP!
- A
- airway opening manoeuvres - tongue may fall back and obstruct pharynx
- HEAD TILT CHIN LIFT (may need to part lips gently, do not press chin too hard)
- infant: NEUTRAL
- child: sniffing the morning air)
- JAW THRUST (C-spine injury suspected)
- NB rest elbows on same surface as child’s head
- can add head tilt if no C-spine issue
- even in trauma A takes priority - MILS by an assistant + increasing head tilt applied by 1st rescuer
- HEAD TILT CHIN LIFT (may need to part lips gently, do not press chin too hard)
- SUCTION if trache
- NB let child adopt any position they like if conscious - best at maintaining own airway
- assess success of airway opening manoeuvres w/ look/ listen/ feel
- airway opening manoeuvres - tongue may fall back and obstruct pharynx
- B
- LOOK - movement of chest and abdo
- LISTEN - for breath
- FEEL - for breath
- LISTEN - for breath
- 5 RESCUE BREATHS (BVM or mouth to mouth + 100% High flow O2)
- whilst maintaining head tilt chin lift
- pinch nose shut in children
- slow exhalation 1 second
- not too vigorous - gastric inflation –> regurgitation –> aspiration
- check that the chest rises
- failure? –> readjust head tilt chin lift –> try jaw thrust –> consider foreign body
- note any GAG/ COUGH response (signs of life)
- INTUBATE ASAP! + monitor ETCO2
- –> Continuous compressions
- –> ventilation rate 10-12 breaths per min
- person during compressions must assess adequacy of ventilation (feel for chest rise)
- LOOK - movement of chest and abdo
- C – not > 10 secs
- Check for SIGNS of LIFE
- NORMAL BREATHING (following on from B) - ineffective, gasping, obstructed, agonal breathing, do NOT count!
- COUGHING/ GAGGING (in response to rescue breaths)
- MOVEMENT (spontaneous)
- Check PULSE
- Child: neck (carotid), groin (femoral)
- Infant: antecubital fossa (brachial), groin (femoral)
- IV / IO access (IO when unable to cannulate w/i 1 min)
- Check for SIGNS of LIFE
- YES signs of life –> RECOVERY position
- NO - CPR 15 chest compressions: 2 ventilations – IF:
- NO signs of life
- NO/ ? pulse (central)
- PULSE < 60 bpm (+ no signs of life)
- NB ‘unnecessary’ chest compressions are almost NEVER damaging
- If in doubt, start compressions
- pulse present but apnoeic –> continue exhaled air resuscitation but no compressions
- Continue for 2 min
- [[Call emergency services]] <– OOH (if alone - NB take child with you to a phone! OR ask another bystander to call LAS whilst you start CPR)
- ASSESS RHYTHM - attach cardiac monitor/ defibrillator pads ASAP - hands off during rhythm assessment :
-
NON-SHOCKABLE = Asystole + PEA
-
ADRENALINE
- immediately –> every 4 mins (every 2 cycles of CPR)
- 10 mcg/kg IV/IO
- 0.1 ml/ kg of 1 : 10,000
- Saline flush 2-5 ml
- Consider 4 H’s + 4 T’s
- Check RHYTHM every 2 MINS or if SIGNS OF LIFE
- Asystole –> Check electrode position + contacts –> Cont. CPR
- Organised /Perfusable rhythm? –> Check SIGNS of LIFE & PULSE
- ROSC? –> post cardiac arrest Tx
- Increase ventilation rate 12-24 (age)
-
ADRENALINE
-
SHOCKABLE = VF + Pulseless VT
- DC shock 4 J/kg
- asynchronous
- use adhesive defib pads / manual paddles (or AED OOH)
- Resistance to defib
- diff. paddle positions
- different defibrillatpr
- infant - lager paddles
- 2 min CPR (immediately, do NOT reassess rhythm or check for pulse)
- Consider 4 H’s & 4 T’s
- Assess RHYTHM
- after every 2 MINS of CPR
- if SIGNS OF LIFE:
- normal breathing (regular resp effort)
- cough/ gag
- movement
- eye opening
- sudden increase in ETCO2
- VF/ pVT –> continue
- asystole/ PEA OR –> non-shockable algorithm
- organised electrical activity –> check for SIGNS of LIFE + PULSE
- (NO PULSE or bpm < 60) + NO SIGNS OF LIFE –> cont asystole/ PEA algorithm
- ROSC –> Post cardiac arrest Tx
- Ongoing shockable rhythm –> Repeat until 3rd shock given
-
ADRENALINE
- 10 mcg/ kg IV/IO
- after 3rd shock –>
- every alternate DC shock (every 4 mins)
-
AMIODARONE
- 5 mg/ kg IV/ IO
- after 3rd + 5th shock ONLY
- only give 2 boluses total (but continue to cycle through rest of algorithm if rhythm corrects then deteriorates again)
- Infusion if more necessary
- 300 mcg/ kg/ hr
- max 1.5 mg/ kg/ hr
- max 1.2 g in 24 hrs
- NOT in the event of OD on antiarrhythmic - d/w poisons centre
- unhelpful in hypothermia but can use
-
or LIGNOCAINE (LIDOCAINE)
- 1 mg/ kg IV/ IO
-
MAGNESIUM 25-50 mg/ kg (max 2g)
- low magnesium
- polymorphic VT (torsades de pointes) - regardless of cause
- DC shock 4 J/kg
-
NON-SHOCKABLE = Asystole + PEA
Do procedures in cardiac arrest algorithm occur sequentially?
NO. They occur simultaneously with coordination by the team leader.
How does adrenaline work in cardiac arrest management?
ADRENALINE
- a-adrenergic action
- Vasoconstriction - aorta
- increased aortic diastolic pressure during chest compressions
- increased coronary perfusion pressure
- increased delivery of oxygenated blood to the heart
- Inotropic action
- increased cardiac muscle contractility
- stimulates spontaneous contractions of the heart
- increased vigour and intensity of ventricular fibrillation (in shockable rhythms) - increased success of defibrillation
What are the ONLY indications for stopping compressions during cardiac arrest Mx?
CARDIAC ARREST
ONLY stop compressions to:
- Check the rhythm
- Deliver Shock
=> Continue uninteruppted compressions at ALL other times
Describe the reversible causes of cardiac arrest.
CARDIAC ARREST
REVERSIBLE CAUSES
4 H’S & 4 T’s
- Hypoxia - most common
- Hypovolaemia - “ (e.g. trauma, anaphylaxis, sepsis)
- Hypothermia e.g. drowning
- Hypo/ Hyperkalaemia, Hypocalcaemia, other metabolic abnormalities e.g. in renal failure
- Calcium gluconate 10% - 0.3 ml / kg
- WHEN:
- HYPERkalaemia
- HYPOcalcaemia
- calcium channel blocker OD
- Trauma incl. cardiac tampanade (PEA)
- Toxins e.g. accidental, deliberate OD, iatrogenic
- Thromboembolism e.g. massive PE (rare)
- Tension PTX (PEA)
Is there any role for the use of atropine in the management non-shockable cardiac arrest?
ATROPINE
CARDIAC ARREST
NON-SHOCKABLE RHYTHM
NO.
Used in PERFUSING pts to combat BRADYCARDIA
due to excessive vagal tone.
Is there any role for the use of calcium in non-shockable cardiac arrest?
CALCIUM
CARDIAC ARREST
NON-SHOCKABLE RHYTHMS
- NO evidenc of efficacy
- Evidence of HARMFUL effects - involved in REPERFUSION injury
- following ischaemia
- reperfusion of ischaemic organs
- calcium enters cells
- accumulates in cytoplasmic reticulum
- cell death
- Use ONLY if DOCUMENTED:
- HYPOcalcaemia
- Calcium channel blocker OD
- HYPERkalaemia
- HYPERmagnasemia
Is there any role for the use of alkalinising agents in non-shockable cardiac arrest?
ALKALINISING AGENTS e.g. bicarbonate
CARDIAC ARREST
NON-SHOCKABLE RHYTHM
- Bicarbonate
- 1 mmol / kg
- 1 ml/ kg of an 8.4% solution
- Routine use - NO benefit
- ONLY use if:
- PROLONGED cardiac arrest - following
- effective BLS (more effective at raising myocardial pH)
- assisted ventilation with O2 (increases intracellular CO2)
- PROFOUND ACIDOSIS
- which is likely to affect the action of adrenaline
- NB children w/ asystole will be acidotic as usually due to resp. arrest/ shock (i.e inadequate circulation - anaerobic respiration)
- HYPERkalaemia
- TCA OD
- PROLONGED cardiac arrest - following
What should be used to guide further alkalinising therapy if such agents are used and why?
ALKALINISING AGENTS
CARDIAC ARREST
NON-SHOCKABLE RHYTHM
GUIDE TO FURTHER Tx - USE:
- MIXED or CENTRAL venous pH
- WHY?— ARTERIAL pH does not correlate well with TISSUE pH in arrest
What important considerations must be made when administering alkalinising agents e.g. sodium bicarbonate?
SODIUM BICARBONATE ADMINISTRATION
IMPORTANT POINTS
- do NOT give in the same line as CALCIUM –> precipitation
- FLUSH with SALINE before ADRENALINE/ DOPAMINE (inactivated by bicarbonate)
What are the most common causes of VF and pulseless VT?
VF and pulseless VT
SHOCKABLE RHYTHMS
Causes:
- Hypothermia
- Toxins - TCA poisoning
- Cardiac disease (usually congenital)
NB:
- more likely if sudden witnessed collapse
- less common + causes more varied than in adults
Why is it imperative to immediately resume CPR following DC shock in the management of cardiac arrest with shockable rhythm?
CARDIAC ARREST
SHOCKABLE RHYTHM
- VITAL to immediately resume CPR after shock
- do NOT reassess rhythm/ feel for a pulse
- BECAUSE
- there is a pause b/w successful defibrillation and the appearance of a rhythm on the monitor
- stopping compressions reduces the chance of successful CPR if a 2nd shock is needed
- no harm from ‘unnecessary’ compressions
What is the appropriate size, placement & type of defibrillator for different age groups?
DEFIBRILLATION PADS
- SIZE
- < 10 kg = 4.5 cm
- > 10 kg = 8-12 cm
- PLACEMENT
- Usual = anterolateral
- apex, midaxillary line, 1 finger below L nipple
- to the R of the sternum, 1 finger below R clavicle
- Only adult pads/ too large for child = Anteroposterior
- just to the LEFT of the lower part of the sternum
- below the tip of the LEFT scapula
- Neonate
- appropriate size pad
- pad too large –> manual defib paddles w/ paediatric attachments
- Usual = anterolateral
- TYPE
- adhesive defibrillation pads
- manual defibrillator pads
- first choice for < 1 yo
- can be adjusted to give correct dose
- AED (automatic external defbrillator)
- > 8 years: standard adult shock
- < 8 years: attenuated paeds pads
- NB high degree of sensitivity & specificity for detecting shockable rhythms in all age groups
- use with paediatric attenuation pads/ leads (decrease energy level)
- NB both monophasic & biphasic wave form defibrillators acceptable
- Neonates
- Manual defibrillator (first choice)
- AED WITH dose attenuator
- AED w/o dose attenuator
What is the purpose of (1) DC shock and (2) the use of anti-arrhythmic drug in the management of shockable cardiac arrest?
CARDIAC ARREST
SHOCKABLE RHYTHMS
- DC shock
- converts the heart back to a perfusing rhythm
- Anti-arrhythmic drug e.g. amiodarone, lidocaine
- stabilises the converted rhythm
What is the role of capnography in cardiac arrest Mx? What are its limitations and what can it be affected by?
CAPNOGRAPHY
ETCO2 MONITORING
CARDIAC ARREST
- Absence of waveform
- tube misplacement/ displacement
- very poor or absent pulm. perfusion (more likely)
- < 2 kPa –> ? chest compression adequacy
- Prence of exhaled CO2 encouraging evidence of
- good CPR
- ROSC (if sudden rise)
- Affected by medications
- Adrenaline - reduced ETCO2
- Bicarbonate - increased ETCO2
What type/ amount of O2 should be used in the management of cardiac arrest? How should this be monitored and why?
OXYGEN USE
CARDIAC ARREST
- 100% high flow O2
- Monitor with pulse ox
- AFTER ROSC aim 94-98%
- Hyperoxia can be detrimental to recovering tissues
What is the role of active temperature regulation in cardiac arrest management and what effects does fluctuation in temperature have?
CARDIAC ARREST
TEMPERATURE MANAGEMENT
- Therapeutic (mild) hypothermia
- cool to 32- 34 degrees for at least 24 hrs post arrest
- may be beneficial for neurological recover in newborns
- avoid shivering - increases metabolic demand (sedation +/- neuromuscular blockade)
- Normothermia - actively maintain
- 36 - 37.5 degrees
- avoid Hyperthermia - 10-13% increase in metabolic demand for each degree above normal
- treat with active cooling
What is the role of glycaemic control in cardiac arrest?
HYPOGLYCAEMIA
CARDIAC ARREST
- All children can become hypoG when ill esp. infants (low reserves)
- Correct hypoG
- Avoid hyperG - causes osmotic diuresis
- Both hypoG and hyperG - worse neuro outcome in animal studies
How should newborns be resuscitated (using which algorithm)?
NEWBORN RESUSCITATION
- Use the resuscitation protocol with which you are most familiar (newborn or infant & child protocol)
- If suspected cardiac cause –> INFANT + CHILD PROTOCOL
When should resuscitation efforts be stopped in cardiac arrest?
WHEN TO STOP RESUSCITATION
CARDIAC ARREST
- No single predictor for when to stop
- Unlikely to be successful if no ROSC with up to 20 mins of cumulative life support + absence of recurring/ refractory VF/pVT
- Exceptions to the 20 min rule where prolonged CPR occasionally successful:
- poisoning
- hypothermia
- NB d/w PICU/ toxicologist
