Cardiac Arrest Flashcards
(28 cards)
What is sudden cardiac arrest
Sudden cardiac arrest = unexpected and abrupt event in somebody who has been well up to the point of collapse or a very short time before that. Must be witnessed, heard or have very short credible down time.
Main principles of IMPACT
IMPACT is designed around a set of principles intended to make sure the quality of care is at its best and is being delivered by a high functioning group of personnel who communicate well, interact well and prioritise actions as appropriate with task focus.
Main objectives:
* Provide consistent high quality resuscitation with a focus on defibrillation, oxygenation and excellent compressions that are minimally interrupted
* Create conditions to optimise a shockable rhythm being successfully reverted
* Have a mind set that achieving Return of Spontaneous Circulation as early as possible to influence survival with good neurological outcomes
CPR procedure
Treatment
* Status check
* Commence CPR
* Assess shockable vs non shockable every 2 minutes and rotate compressors
* Oxygenate early (passive high flow mask, controlled bvm)
* Airway adjuncts (OPA, NPA, I gel)
* Iv/Io access
* Adrenaline after 2nd shock or as soon as access established repeated every 2nd loop
* Amiodarone after 3 shocks given including AED
* Change pads to anterior posterior if persistent pVT/VF
* Repeated amiodarone after a further 2 shocks (5 total)
* Consider lignocaine after 5 shocks
* Fluid therapy
* Consider Hs&Ts (hypoxia, hypovolaemia, metabolic, temperature, tension pneuothorax, tamponade, toxin, thrombin)
* Work as a team and establish a “hands off” overview position
What are the 9 core elements?
Working environment = Good resuscitation canning be delivered in poor environment. Rapid and dynamic risk assessment should be done to either create space or move patient
Standardised equipment placement = The right equipment in the right place as soon as possible
high quality compression Focused compressions (attention to quality) that are minimally interrupted CPR feedback pucks are mandatory
Swap compressors every 2 minutes = Fatigued compressor delivers poor quality compressions. Prioritising skills over a swap in resource poor cases should not routinely occur unless critical to do so
Create overview = Scene leadership should be established as soon as possible. This person SHOULD NOT be delivering skills
Maintain calm, coordinated scene = Encourage calm and controlled scene with closed loop communication between team, using functional language
ventilation = Use of bvm should be viewed as an important task in providing controlled ventilations, controlled rate without excessive volumes under pressure
Witnessed arrest
Early defibrillator, 3 stacked shocks when rhythm change is witnessed (peri arrest), shockable rhythm, well oxygenated prior, first shock is 20 seconds of arrest occurring and manual mode is available/rhythm recognised in under 10 seconds . No ROSC in 10 seconds post 3 shocks start CPR. Stacked shocks are considered one shock with mediation timing
Persistent shockable rhythm
ensure correct joules and pad placement. Amiodarone administered, lignocaine considered if appropriate. Anterior and posterior pad placements. Ecmo facilities considered. Consider double sequential defibrillation if authorised staff at scene.
Mechanical CPR
only on transport unless there is insufficient space or clinicians to perform manual compressions safely or effectively, fatigue and prolonged resuscitations attempts, extricating and transporting with ongoing cpr attempts
CPR included consciousness
Movement or show signs of life whilst in arrest due to cerebral perfusion being maintained in high quality CPR. Confirm still in cardiac arrest (pulse check), continue resuscitation attempts. If movement is significant enough to interfere with efforts obtain access as rapidly as possible and provide sedation with 0.3-0.5mg/kg Ketamine and ASMA consult for further management options. Not intended for peri-arrest, conscious VT or post ROSC. These patients are known to have better outcomes
Pregnancy CPR
manual uterine displacement to relive aortocaval compression, can place padding under right hip to tilt 15 to 30 degrees, consider rapid extrication and transport and ecmo
Anaphylactic arrest
Adrenaline high priority, fluid bolus to manage hypovolaemia, airway difficulties follow vortex approach, may need more fluid and adrenaline in this cohort and should consult for such
Asthma arrest
airway high priority, ventilate slower aim for 4-6bpm and allow air release between ventilations, adrenaline next priority, may need to release air trapping by squeezing patients chest. Do not decompress, CCP can finger thoracostomy if needed
Drowning arrest
airway and ventilation is priority, use two person mask seal grip, do not suction any foam only liquid, Consider c-spine immobilisation.
Hanging arrest
airway and ventilations are priority, consider c-spine, medications are low priority, caution in cric due to possible laryngeal fractures
Hypoglycaemia arrest
must have a clear history, do not base treatment solely on finger prick bsl as it is inaccurate in poor perfusion states
Hypothermia arrest
<30 degrees withhold adrenaline and other medications until over 30 degrees. Typically have positive outcomes after long resuscitations consider transport and ecmo
Hypovolaemia arrest
control external bleeding if possible, fluid therapy is priority, only permissive hypotension in post ROSC
Paediatric arrest principles
Majority are secondary to hypoxaemia and/or hypotension. Sudden cardiac arrest can also be seen in young people, due to dysrhythmias caused by underlying channelopathy, cardiomyopathy or myocarditis. Up to 25% are shockable.
3 hours old up to 12 years of age.
Bradycardia is an ominous sign in infants and paediatrics, if their pulse is <60 they are unconscious and signs of poor perfusion commence CPR
Consider early transport of for non-asystole patients as they will not meet termination criteria. Padding of airway is needed, airway and ventilation is high priority for favourable outcomes.
Working space, standardised equipment placement, high quality compressions, swap every 2 minutes, create overview, calm/coordinated scene and ventilation principles
Shocking at 4 joules per kilo
Do not passively oxygenate, controlled ventilation with BVM as soon as possible
CPR puck only >6 years or 20kg
15 compressions to 2 breaths, adapting compression to fit patient size (1 hand vs 2)
Adrenaline 10mcg/kg
Amiodarone 5mg/kg
Newborn resuscitation principles
Infant in the first minute to 3 hours following birth
Most initiate spontaneous respiration 10 to 30 seconds at birth, 10% need ventilation, 1% need extensive compressions and medications. Transport all newborn resuscitation measures
* Suction mouth and nose using penguin suction
* Stimulate to induce crying
* Ensure lung inflation, 30 seconds of BVM on RA, premature <32 weeks ventilate with 1l/min
* Do not oxygenate over 90%
* Pulse <60 chest compressions 3:1
* Pulse 60-100 only ventilate 40-60 per min until pulse >100
* Pulse >100 progress with APGAR scores 1, 5, 10 minutes
* Use drug calculators
Traumatic arrest principle
- Traumatic cardiac arrest identified
- Obvious non reversible cause DO NOT RESUSCITATE
- c-spine
- Airway OPA, NPA, Igel
- BVM
- Bilateral chest decompression in suspected pneuothorax/chest trauma
- Stop haemorrhages CAT tourniquet, TPOD
- Bilateral IV/IO access
- Defibrillation only 7.5% are in shockable rhythms
- Compression
- Extrication (7minutes)
- Notify hospital (9minutes)
- Transport (10minutes)
- Prolonged CPR in blunt trauma after reversible causes addressed is never associated with good outcomes.
- If delivery to ED can not be achieved in 25 minutes it is acceptable to terminate resuscitation if no ROSC after 10 minutes post correction of reversible causes
Obvious death
if there is no doubt about the following criteria:
* Decomposition, larva, infestation or putrefaction OR
* signs of rigor mortis OR gravitational dependent post mortem hypostatis in association with determination of death criteria OR
* Major traumatic injuries incompatible with life (decapitation, cranial destruction, truncated destruction, trans-lumbar amputation, profound blood loss inconsistent with life) OR
* Major incidents/multi casualty
Determination of death
no central pulses at all, asystole for >30 seconds, fixed and dilated pupils with no corneal reflexes at all, no signs of breathing at all AND no auscultated heart sounds(scope dependent). If in doubt contact ASMA
Withholding CPR
unwanted or very unlikely to reverse favourably unless compelling reasons or special circumstances. No doubt about the following criteria :
* Prolonged cardiac arrest ( >15 minutes) AND
* Generally unwitnessed AND
* First assessed rhythm a-systole AND
* Not received a defibrillated shock AND
* No compelling reasons or special circumstances to continue
Expected death
credible evidence that death was expected as result of terminal illness, individual has taken voluntary assisted dying substance, patient wishes to not be resuscitated and previously communicated clearly and seems reasonable, residential care facility patient who is >80 & obviously frail, in the community with >80, asystole, AND clearly frail
Termination of resuscitation
if criteria for ROLE or withholding are met then efforts may be terminated and determination of death can be made. Special circumstances or compelling reasons to continues are identified efforts should extend (young age, refractory VF/recurrent arrest or timely ECMO) any decision to terminate should be discussed with CSP & ASMA
Clinical judgement and reasoning should always apply and take into consideration many factors and prognostic indicators.
May terminate if:
* Oresenting rhythm asystole, not SJA witnessed and remains in asystole after 20 minutes of maximally directed resuscitation OR
* Presenting rhythm shockable, not witnessed and progressed quickly and remains asystole or wide slow PEA <40 after 20-30 minutes with no other favourable signs of response to efforts (high EtCO2) OR
* Destination hospital is >15 minutes away from location, 20 minutes or more of maximally directed resuscitation ROSC has not been achieved and no other circumstances or reasons to continue OR
* Specifically authorised clinician makes reasonable decision based upon prognostic futility either on scene or via CSP or ASMA OR
* Blunt traumatic arrest after reversible causes addressed and delivery to ED cannot be achieved in 25 minutes from arrival on scene, can terminate if ROSC not achieved in 10 minutes
* ANY TERMINATION OF PEA NARROW COMPLEX 40 or higher must have consult with CSP and ASMA prior to termination
