Cardiac arrest

1. Cardiac arrest قل ان الموت الذي تفرون منه فانه ملاقيكم ثم تردون الى عالم الغيب والشهادة فينبئكم بما كنتم تعملون By Dr. Zuhair Al-Samarrae FRCS, FICS, CABS, DS, MBCHB

2. Cardiac arrest • سهل • واضح • بسيط

3. Cardiac arrest rythmssss: 4 • 1.بازلاء • 2.VF & • 3.Pulseless VT • 4.Asystole • What is common to all?

4. No cardiac output • Thats why patient will lose conciosness. • PEA (Pulseless Electric Activity) • VF/ VT • Asystole • Approach is same ,

5. BLS +ACLS 2 things contribute significantly to survival: Early CPR (bystander CPR) Early Defibrillation All of the above is BLS EVERY MINUTE COUNTS

6. Given the choice to take one coursewhich one u prefer: BLS or ACLS? BLS Early CPR & Effective D

7. BLS vsACLS • Basic CPR&early DF--- PRIMARY IMPORTANCE • DRUGS---------------secondary importance, where only few drugs are supported by strong evidence • ACLS therapies such as advaced airway insertion and drugs have not been shown to increase survival to hospital discharge!!!! • Basically u need defibrillator& face mask i.e BLS

8. BLS is ABCD, which letter most important? • D is more important than the Almond Board of California(ABC) • So how can you get an EFFECTIVEDF? How to increase chance of successful DF?

9. Energy reserve-determine success • The more delay in DF—the more energy loss--- the less likely DF to be successful • Witnessed arrest vs unwitnessed arrest. • WITNESSED arrest--good reserve—more response to DF ---IMMEDIATELY DEFIBRILLATE

10. Unwitnessed arrest---poor reserve what to do-how to increase reserve • 2 min of a GOOD CPR – improve coronary perfusion-improve reserve-more response to DF. • Do 2 min CPR after each defib.- EVEN if rhythm change to normal –many of whom donot have a perfusing rhythm.

11. Defibrillation 360 j سهل واضح بسيط • Monophasic 360j • Biphasic 120j • If u donot know your machine :give 200j

12. Concept of CPR • سهل • واضح • بسيط • Simply support your patient and give him what he needs----if not breathing –give him breathing - ---if no pulse—give him a pulse

13. What is new in BLS? • EarlyCPR before DF in unwitnessed arrest • 30:2 cycles UNIVERSAL formula-for unintubated patients eg at the time of collapse • 2min CPR after each shock even if revert to sinus rythm,as this rhythm is often not perfusing • This formula applies forALL AGES • Emphasis on uninterrupted compressions • Avoid hyperventilation

14. Approach to cardiac arrest • Act quickly • Support your patient ABCD • loooooooooooooooooook for the cause

15. Approach to the cardiac arrest- do not waste time • Call first and fast • Start CPR immediately • New formula 30:2( 30 comp:2 vent)-cycles-this reduce interruption of cardiac compression • Note 30:2 cycle only for unintubated , but once intubated –no more سيكل , i.e continuos compresssion(100/min) ventilation 8-10/min • It looks slow ventilation? • No , avoid overventilation-it reduce venous return (as hyperventilation create +ve pressure in the chest)

16. action sequence in cardiac arrest • Check responsiveness • Call first( for AED) • Start CPR cycle: 2 rescue breaths(each over 1 second to devote more time to compression (30)and then shock if it is VF. • Once intubated : no more سيكل i.e no synchronization: uninterrupted compression100/min

17. What if you donot want to give mouth to mouse فارة الى فارة • You can do chest compression only!!! • Remember : avoid hyperventilation • ---it is unnecessary(C.O is 25% -33% at best) • ---can create +ve pressure in the chest (further reducing C.O) , • ---more gastric distension--may vomit and…

18. Ventricular fibrillation-management • Witnessed- (good energy reserve) so DF 360 فورا Unwitnessed-(poor reserve) what to do ? -improve reserve(2min CPR) then DF 360, Where often they respond,what if no response?

19. VF—WHAT IF 1ST SHOCK FAIL? CPR-shock-CPR-shock-CPR-SHOCK shock-2minCPR-shock-2min CPR-shock- 2min CPR • NO MORE 3STACKED SHOCKS i.e NO MORE SHOCK-SHOCK –SHOCK If available: intubate , give vasopressors(epinephrine) early

20. So basically what are the new changes in VF management? • 2 min CPR interposed among shock shock shock sequence… WHY? • To maximize chance of response to shock • 2min CPR even if revert to normal rhythm as this rhythm is often not perfusing-PEA • Earlier use of ACLS therapies i.e intubation & medicines.

21. Management of cardiac arrestsupport the patient+treat the cause Support the patient:Epinephrine+_Atropine Epinephrine: in ALL 4 arrest rhythm(1 mg /3-5min) Atropine :in VF/VT No atropine in PEA only ifبازلاء is slow in Asystole ALL patients Atropine dose: 1 mg every 3-5 min (max 3 doses)

22. Treat specific cause • This applies to ALL cases of arrest rhythm Not just PEA( pulseless electrical activity) All the time consider 5 Hs &5 Ts in ANY arrest rhythm Unless you address the underlying cause….

23. Treat the cause e.g • Unless u treat HypoMg of alcoholic…. • Unless treat arrythmia +the clot of MI…. • Unless treat eletrolyte imbalance in CRF…

24. Word of caution about Dx of PEA? • A severely hypotensive patient may have no pulse+ sins rhyrhm • Also PEA : no pulse+ sinus rhythm? • How to differentiate?

25. Post resuscitation support • Remember many of these patients need hemodynamic support i.e hypotensive and need vasopressors e.g dopamine Keep searching for treatable causes

26. THANK YOU