als cardiac arrest and rosc

DR. NAJAH YOUSUF
ICU RESIDENT
MGH
September 2014

1. DR. NAJAH YOUSUF
ICU RESIDENT
MGH
September 2014

2. Describe the relationship of the chain of survival to
successful resuscitation of the cardiac arrest
patient.
Review AHA BLS guidelines.
Demonstrate cardiac arrest management following
ACLS guidelines.
Discuss the interventions required to ensure good
outcomes with Return of Spontaneous Circulation.

3. Cardiovascular disease is the number one
cause of death in the U.S., and many times
the first indication of this disease is an
acute coronary event
Cardiac arrest is the most severe
manifestation of an acute coronary
syndrome, and with rapid intervention EMS
providers can make the difference between
life and death

4. However, not every cardiac arrest is
preceded by chest pain or discomfort, nor
do all patients with chest discomfort or pain
proceed to cardiac arrest, but for those who
do, rapid intervention is vital. Without it,
such patients will almost surely die. As
such, the EMT must be prepared to treat all
patients with signs and symptoms of
cardiac compromise as cardiac
emergencies.

5. Few cardiac arrest patients survive outside a
hospital without a rapid sequence of events.
◦Chain of survival:
Early recognition and activation of EMS
Immediate bystander CPR
Early defibrillation
Early advanced cardiac life support
Integrated post-arrest care

6. Why is CPR Important
◦Studies have shown that the general population will
start CPR only 1/3 of the time and only 15% of that
total is done correctly
◦Chest Compressions can be started within 18
seconds of arriving at the patient, whereas airway
management first can delay compressions by 1-2
minutes or more
◦CPR prolongs the period during which defibrillation
can be effective

7. Ventricular fibrillation is the most frequent
rhythm found in cardiac arrest
Defibrillation is the most effective treatment
for VF
Probability of successful defibrillation
diminishes with time
VF will lead to asystole quickly without
proper treatment

8. “Hearts and Brains
are going to die”
◦Peter Safar MD
EMS has the most
opportunity to
perform CPR, so we
should be good at
performing good,
quality CPR

9. 2010 AHA Guidelines

10. 1.Make sure the scene is SAFE!
2.Check responsiveness and breathing..!
3.If alone call for helpand announce for
code blue
4.Check for a pulse and if no pulse present
begin CPR
Always start CPR with Compressions First!

11. Always start CPR with Compressions First!
Push hard and fast
Rate should be at least 100 per minute&
depth B/W 3-5 cm
Provide 30 compressions then 2 breaths
Make sure the chest is allowed to re-expand
completely at the end of each compression

12. Chest compressions and breaths are the same
for adults, child, and infant if you are alone
◦Adult age starts at the onset of puberty
(12-14 years of age)
◦Child is age 1year to the onset of puberty
◦Infant is anyone under the age of 1year

13. 5.Open the airway with head tilt-chin lift
6.Place the mask on the patient’s face
7.Use the E-C clamp technique
8.Deliver each breath over 1 second

14. Adult Cardiac Arrest

16. 1.Initiate CPR and attach monitor/defibrillator
2.Defibrillate at 360j or equivalent biphasic shock
3.Resume CPR immediately following defibrillation
and continue for 2 minutes
4.Initiate vascular access; manage airway
5.Reevaluate rhythm; defibrillate if needed; resume
CPR
6.Administer Epinephrine 1mg every 3-5 minutes
7.Defibrillate if needed; resume CPR
8.Administer Amiodarone 300mg; may repeat at
150 mg IV/IO in 5 minutes if needed.
9.Continue cycles of CPR and defibrillation as needed

17. 1.Initiate CPR and attach monitor/defibrillator
2.Initiate vascular access; manage airway
3.Administer Epinephrine 1mg every 3-5
minutes
4.Consider possible causes and treatments
•“H’s and T’s”

18. 1)Hypoxia.
2)Hypotension.
3)Hypothermia.
4)Hypoglycemia.
5)Acidosis (H
+
).
6)Hypokalemia
(electrolyte
disturbance).
1)Cardiac Tamponade.
2)Tension
pneumothorax.
3)Thromboembolism
(pulmonary,
coronary).
4)Toxicity (eg. digoxin, local
anesthetics, TCA, insecticides).

20. IMMEDIAT & URGENT … IS URGENT & PRIOR
TO DISCHARGE ADEQUAT …

21. Optimize ventilation and oxygenation
O2 Saturation > 94%
Advanced Airway
10-12 per minute
PETCO2 35-40 mm/Hg
Do not hyperventilate
< cerebral perfusion
Oxygen toxic

22. ◦Treat hypotension (SBP <90 mm Hg)
Fluid Bolus –1-2 liters
Vasopressors
Epinephrine 0.1-0.5 mcg/kg/minute
Dopamine 5-20 mcg/kg/minute

23. ◦Induced Hypothermia
If not following commands
Improved neurological recovery
32º -34º C for 12-24 hours
◦Coronary reperfusion by emergent coronary
intervention (PCI)
If STEMI
May do concurrently with hypothermia
AGGRESSIVE Control of hyperglycemia
Early weaning from M.V

24. GOOD NEWS IS AGGRESSIVE POST
RESUCITATION CARE
 LONG TERM NEUROLOGICAL
INTACT …

26. Answer the
following
questions
as a group
discussion

27. 44 year old male Haji at Meqaat mosque
sitting to performing prayer complaining of
chest pain. As you begin your assessment,
he loses consciousness and becomes
pulseless and apneic. The cardiac monitor
shows this rhythm:

28. 1.According to the Region 6 protocols, what is
the appropriate next step in treating this
patient?
A.Provide 2 minutes of CPR prior to
defibrillation.
B.Initiate CPR, secure the airway and establish
vascular access
C.Immediately defibrillate at 360j or
equivalent biphasic shock
D.Deliver a synchronized shock at 200j

29. 2.True/False: After defibrillation you should
immediately resume CPR and continue for 2
minutes.
3.According to the Region 6 protocols, what is
the maximum dose of amiodarone that may
be given to this patient?

30. 92 year old man in the nursing home.
Found in cardiac arrest. No DNR present.
The cardiac monitor shows this rhythm:

31. 4.According to the Region 6 protocols, what is
the appropriate next step in treating this
patient?
A.Begin CPR, initiate vascular access and manage
the airway
B.Immediately defibrillate and then resume CPR
C.Begin CPR and prepare to pace the rhythm
D.Do not start resuscitation

32. 5.What is the appropriate ratio of
compressions to breaths in adult CPR with 2
rescuers?
6.What medication(s) would be appropriate for
treating this rhythm?

33. 7.According to the 2010 ACLS guidelines,
what are the 4 components of Post Cardiac
Arrest Care following return of spontaneous
circulation?