Cardiac Arrest

by Abdel Noureldin and Falak Sayed

Introduction

A 23-year-old female was brought into the emergency department. Her frantic family members said they found her on the bathroom floor, not breathing, unresponsive, and with no pulse. EMS brought the patient to the ED.

Cardiac arrest is a condition that every emergency physician must be an expert in managing. The EM doctor will face it and have a love/hate relationship with it. You love it when the patient is resuscitated and breathing on his own; you can then tell the family their loved one is alive. You feel great because, after all, we are here to save lives, and it’s the reason we joined this specialty. You hate it when your eyes are tearing up as you inform the parents of the newborn that he or she did not make it.

This illness is due to the lack of effective perfusion of the organs of the body 2nd to the abrupt failure of the heart to pump blood. Every year, over a quarter of a million lives are lost because of cardiopulmonary arrest, and most of these cases occur outside of the hospital. However, the mortality rate can be improved with the early and effective initiation of cardiopulmonary resuscitation (CPR) and advanced cardiopulmonary life support (ACLS).

Cardiac Arrest Rhythms

The pulseless cardiac arrest is caused by 4 different types of primary arrhythmias that consist of 2 shockable rhythms (ventricular tachycardia and ventricular fibrillation), and 2 non-shockable rhythms (pulseless electrical activity and asystole).

Shockable rhythm

Ventricular Tachycardia

Ventricular tachycardia (VT) has 2 different types. The most common is the monomorphic (VT) and is defined as 3 or more consecutive ectopic ventricular beats (QRS complexes) of the same type.

The 2nd type is the polymorphic (Torsade’s De pointes) that consists of ectopic ventricular beats (QRS complexes) of different types of morphology.

Ventricular Fibrillation

Ventricular fibrillation is rapid and unorganized electrical impulses which makes the ventricles of the heart quiver while no pumping of the blood occurs.

Non-shockable rhythms

Pulseless Electrical Activity

Pulseless electrical activity (PEA) shows organized electrical rhythm on the electrocardiogram with no mechanical contractions of the heart muscle (no pulse). It is also called electromechanical dissociation.

Asystole

Asystole is defined as no electrical activity in the heart and no mechanical contraction of the heart muscle (no pulse). It is also called flat line or cardiac standstill.

Medications for Cardiac Arrest

Thara are only 3 emergency drugs you should now in any cardiac arrest patient. These are Epinephrine, Amiodarone, and Magnesium.

Epinephrine

Concentration 1:10,000

Pediatric dosage 0.1 mL/Kg (20 kg child = 2 mL)

Adult dosage 10 mL or basically 1 mg

Frequency Every 2 cycles (3 to 5 minutes)

Indication All pulseless cardiac arrest rhythms

Mechanism : An agonist for the beta and alpha receptor which increases the perfusion pressure in the coronary and cerebral vessels

Amiodarone

Pediatric dosage 5 mg/Kg (can be repeated up to 300 mg)

Adult dosage 300 mg (can be repeated at 150 mg)

Indication shockable rhythm (VT and VF)

Frequency 1st dose after the 3rd shock and repeat dose after the fourth defibrillation

Mechanism: Class III antiarrhythmic drugs.

Magnesium

Pediatric dosage 25 to 50 mg/Kg (maximum 2 grams)

Adult dosage 1 to 2 grams

Indication Torsade de Pointes

Frequency Once when the diagnosis is made

Mechanism: Shorten the prolonged QT interval

Imperative Concepts for The Team During Cardiac Arrest Management

The compressors

Must push hard (2 to 2.4 inches or 5 to 6 cm)
Should push fast (100 -120/minute)
Ought to allow the chest to recoil completely
Rotate with another person every 2 minutes

Airway

Do not hyperventilate
2 ventilations to 30 compressions while using ambo bag
Give one breath every 6 seconds when the patient is intubated
Use wave capnography to monitor CPR (CO2 should be >10)
If the advance airway is needed, use supraglottic devices or endotracheal intubation
Confirm endotracheal intubation by wave capnography

Shock delivery

Biphasic – 200 Joules
Monophasic – 360 Joules
Make sure everyone is clear before you shock the patient
Attach the patient to the monitor

Drug therapy

Start IV or IO
Epinephrine: (1:10,000) 0.1ml/KG for pediatric and 10 ml for adult
Amiodarone: 5mg/kg for pediatric and 300 mg for adult
Amiodarone 2nd dose: up to 15 mg/kg (max-300) and 150mg adult
Magnesium: 25 to 50 mg/KG- pediatric and 1 to 2 grams – adult

Recorder

Must record all the drugs given and the time it was given
Inform the team members at the end of each cycle
Keep track of the total time of resuscitation

Team leader

Must have mutual respect for all members of the team
Look for ROSC (RETURN OF SPONTANEOUS CIRCULATION)
- The sudden increase in the PETCO2 (>40)
- Return of pulse and pressure
Make sure the interruption of chest compression is <10 seconds
Remember the reversible causes (Hs and Ts)
- Hypovolemia
- Hypoxia
- Hydrogen Ion (acidosis)
- Hypo-hyperkalemia
- Hypothermia
- Tension pneumothorax
- Tamponade
- Toxins
- Thrombosis (coronary and pulmonary)
- Trauma

Cardiac Arrest Management Made Easy

If the patient developed a pulse at any time during resuscitation

Stop CPR
Intubate the patient and secure the airway
Start post resuscitation care
Induced hypothermia
Admit to ICU

If the patient remained pulseless

Stop CPR after 20 minutes of resuscitation of the non-shockable rhythm or after 20 minutes from the last shock that was delivered.

Case Presentation

A 23 year old female was brought into the emergency department. Her frantic family members said they found her on the bathroom floor, not breathing, unresponsive, and with no pulse. EMS brought the patient to the ED.

Q1: What is your first step in managing this case?

Q1 Answer

BASIC LIFE SUPPORT ACTIONS

Check for responsiveness – no response – ACTIVATE THE SYSTEM/CODE
Does the patient have a pulse? – no pulse
Is the airway patent? – airway patent but must use jaw thrust (found on floor)
check for breathing – patient is apneic
Start Chest compression, oxygen by BVM and connect to a monitor

Your monitor showed this

Q2: What is your next step?

Q2 Answer

ADVANCE CARDIAC LIFE SUPPORT

The rhythm above is ASYSTOLE (non- shockable rhythm)
Give Epinephrine (1-10.000) with a dose of 10 ml
Stop CPR after 2 minutes (5 cycles of 2 ventilation and 30 compressions)
Check rhythm and pulse (less than 10 seconds)

The patient has no pulse, and the monitor showed this

Q3: What is your next step?

Q3 Answer

This is PEA (Pulseless electrical activities)
Continue CPR for 2 minutes
Prepare epinephrine for next cycle
Think of reversible causes (Hs & Ts)
Use ultrasound (if available)

The patient has no pulse, and the monitor showed this

Q4: What is your next step?

Q4 Answer

This is VENTRICULAR TACHYCARDIA
Defibrillation is needed
Prepare the shock (200 for Biphasic machines, 360 for monophasic macgines), and contnue chest compressions during charging
Shock the patient, then
Continue CPR for 2 minutes

Quick link to Spanish Version

References and Further Reading

Jameson, J. N. St C.; Dennis L. Kasper; Harrison, Tinsley Randolph; Braunwald, Eugene; Fauci, Anthony S.; Hauser, Stephen L; Longo, Dan L. Harrison’s principles of internal medicine. McGraw-Hill Medical Publishing Division. 2005
Mahadevan, S.; Garmel, Gus. An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department. Cambridge UP. 2005.
Selecting and Inserting Airway Adjuncts – Link
ACLS Airway Management – Link
Airway Management with Simple Adjuncts – Link
ACLS ECG Rhythm Review – Link
Core ACLS ECG Rhythm playlist – Link
American Heart Association ACLS Megacode – Link
ACLS Megacode Practice Scenario – 1 – Link
ACLS Megacode Practice Scenario – 2 – Link
Official Webcast of the 2015 Guidelines Update for CPR, ECC and First Aid – Link
Cardiac Arrest and ACLS in 2015 – Amal Mattu – Resuscitation 2015 – Link