arrest

CARDIAC ARREST rekaman 18

Dr. Suhaemi, SpPD, Finasim

HENTI JANTUNG

Henti jantung adalah terhentinya fungsi pompa jantung secara tiba tiba, yang dapat saja reversibel tetapi akan mengakibatkan kematian jika tidak dilakukan penanganan segera.

Henti jantungh dapat disebabkan 4 gangguan irama jantung yaitu :

1. Fibrilasi Ventrikel 2. Takikardi ventrikel tanpa nadi 3. PEA( pulseless electric activity ) 4. Asistol

Survival henti jantung ini membutuhkan penanganan bantuan hidup dasar serta bantuan hidup lanjut kardiovaskular serta perawatan terpadu pasca henti jantung.

Dasar keberhasilan bantuan hidup lanjut kardiovaskular adalah resusitasi jantung paru yang berkualitas tinggi dan pada fibrilasi ventrikel/takikardi ventrikel tanpa nadi adalah dilakukanya defibrilasi dalam menit menit awal henti jantung.

Survival henti jantung ini membutuhkan penanganan bantuan hidup dasar serta bantuan hidup lanjut kardiovaskular serta perawatan terpadu pasca henti jantung.

Dasar keberhasilan bantuan hidup lanjut kardiovaskular adalah resusitasi jantung paru yang berkualitas tinggi dan pada fibrilasi ventrikel/takikardi ventrikel tanpa nadi adalah dilakukanya defibrilasi dalam menit menit awal henti jantung.

Cardiac Arrest

Mechanisms Ventricular Fibrillation Pulseless Ventricular Tachycardia Asystole Pulseless Electrical Activity (PEA)

A condition; Not an ECG rhythm

Cardiac Arrest Most common rhythms

Adults: ventricular fibrillation Children: Asystole, Bradycardic PEA Pediatric V-fib suggests:

Drug toxicity Electrolyte imbalance Congenital heart disease

Cardiac Arrest ABCs come first!

Airway - unobstructed? manually open Breathing - no or inadequate ventilate Circulation - no pulse in 5 sec chest

compressions Do NOT wait on equipment Assure effective BLS before going to ALS

Rise and fall of chest Air movement in lung fields Pulse with compressions

Cardiac Arrest

First ALS priority is defibrillation Only cure for v-fib is defib The quicker the better

Probability of resuscitation decreases 7-10% with each passing minute

Cardiac Arrest

Vascular access Antecubital space

Arm, EJ, Foot (last resort) IO in peds < 6 y/o

14 or 16 gauge LR or NS 30 sec - 60 sec of CPR to circulate drug

Cardiac Arrest

Intubation as time allows Less emphasis today as compared to

past Epi, atropine, lidocaine may be

administered down tube 2x IV dose IV is preferred

Analyze the Rhythm

Ventricular Fibrillation (VF) Characteristics

Chaotic, irregular, ventricular rhythm Wide, variable, bizarre complexes Fast rate of activity Multiple ventricular foci No cardiac output Terminal rhythm if not corrected quickly Most common rhythm causing sudden

cardiac death in adults

Ventricular Fibrillation (VF) Treatment ABC’s Witnessed arrest: Precordial thump

Little demonstrated value but worth a try CPR until defibrillator available Quick Look for VF or pulseless VT

Treat pulseless VT as if it were VF Defibrillate

200 J, 300 J, 360 J Quickly and in rapid succession

Identify cause if possible

Ventricular Fibrillation Treatment If still in VF/VT arrest, continue CPR for 1

minute Establish IV access and Intubate

If sufficient personnel, attempt both simultaneously If not, quick attempt at IV access then attempt ETT

Vasopressor Medication Epinephrine

1 mg 1:10,000 IVP Repeat every 3-5 mins as long as arrest persists

Vasopressin (alternative to Epinephrine) 40 units IVP one time only

Ventricular Fibrillation Treatment

Shock @ 360 J after each medication given as long as VF/VT arrest persists Alternate epi-shock & antidysrhythmic-shock sequence

Antidysrhythmic Medication amiodarone 300 mg IVP single dose lidocaine 1-1.5 mg/kg IVP, q 5 min, max 3mg/kg total procainamide 100 mg IV, q 5 min, max 17 mg/kg total magnesium 10% 1-2 g IV

if hypomagnesemic or prolonged QT

Ventricular Fibrillation Treatment

Consider NaHCO3 if prolonged Only after effective ventilations

In many EMS systems, consider terminating resuscitation efforts in consult with med control

Ventricular Fibrillation

The ultimate unstable tachycardia Shock early-Shock often Sequence is drug-shock-drug-shock

Sequence of drugs is epi-antiarrhythmic-epi-antiarrhythmic

Analyze the Rhythm

Asystole Characteristics

The ultimate unstable bradycardia A terminal rhythm

poor prognosis for resuscitation best hope if ID & treat cause

No significant positive or negative deflections

Asystole Possible Causes

Hypoxia: ventilate Preexisting metabolic acidosis:

Bicarbonate 1 mEq/kg Hyperkalemia: Bicarbonate 1 mEq/kg,

Calcium 1 g IV Hypokalemia: 10mEq KCl over 30

minutes Hypothermia: rewarm body core

Asystole

Possible Causes Drug overdose

Tricyclics: Bicarbonate Digitalis: Digibind (Digitalis

antibodies) Beta-blockers: Glucagon Ca-channel blockers: Calcium

Asystole & PEA Differentials (The 5Hs & 5Ts) Hypovolemia Hypoxia Hydrogen ions (Acidosis) Hyper/hypo-kalemia Hypothermia

Tablets (Drug OD) Tamponade Tension Pneumothorax Thrombosis, Coronary Thrombosis, Pulmonary

Asystole Treatment Primary ABCD

Confirm Asystole in two leads Reasons to NOT continue?

Secondary ABCD ECG monitor/ET/IV Differential Diagnosis (5Hs & 5Ts) TCP (if early) Epinephrine 1:10,000 1 mg IV q 3-5 min. Atropine 1 mg IV q 3-5 min, max 0.04 mg/kg Consider Termination

Analyze the Rhythm

What are you going to do for this patient?

Case PresentationThe patient is a 16-year-old male who was stabbed in the left lateral chest with a butcher knife. He responds only to pain. His respirations are rapid, shallow, and labored. Central cyanosis is present. Breath sounds are absent on the left side. The neck veins are distended. The trachea deviates to the right. Radial pulses are absent. Carotids are rapid and weak.

Now, what are you going to dofor this patient?

PEA Possibilities

Massive pulmonary embolus Massive myocardial infarction Overdose:

Tricyclics - Bicarbonate Digitalis - Digibind Beta-blockers - Glucagon Ca-channel blockers - Calcium

PEA Identify, correct underlying cause if possible Possibilities:

Hypovolemia: volume Hypoxia: ventilate Tension pneumo: decompress Tamponade: pericardiocentesis Acute MI: vasopressor Hyperkalemia: Bicarbonate 1mEq/kg Preexisting metabolic acidosis: Bicarbonate

1mEq/kg Hypothermia: rewarm core

PEA Treatment ABCDs ETT/IV/ECG monitor Differential Diagnosis

Find the cause and treat if possible Epinephrine 1:10,000 1 mg q 3-5 min. If bradycardic,

Atropine 1 mg IV q 3-5 min, Max 0.04 mg/kg TCP

In many systems, consider termination of efforts

Hypothermia-Initial Therapy

Remove wet garments Protect against heat loss & wind chill Maintain horizontal position Avoid rough movement and excess

activity

Hypothermia – No Pulse CPR Defibrillate X 3 if VF/VT ETT with warm, humidified O2 IV access with warm fluids Temp >30C/86F:

Continue as usual with longer intervals Repeat defibrillation as temp rises

Temp <30C/86F Continue CPR Withhold medications and further defibrillation Transport for core warming

Hypothermia – No Pulse

Remember: A hypothermic patient is not dead until he is WARM & DEAD!!!

Managing Cardiac Arrest

Check pulse after any treatment or rhythm change

Post-resuscitation Care

If pulse present: Assess breathing

Present? Air moving adequately? Equal breath sounds? Possible flail chest?

Post-resuscitation Care

If pulse present: Protect airway

Position to prevent aspiration Consider intubation

100% Oxygen via BVM or NRB Vascular access

Post-resuscitation Care

Assess perfusion Evaluate

Pulses Skin color Skin temperature Capillary refill BP

Key is perfusion, not pressure

Post-resuscitation Care

Management of Decreased Perfusion Fluid challenge Catecholamine infusion

Dopamine, or Norepinephrine

Titrate to BP ~ 90 to 100 systolic

Post-resuscitation Care Suppression of ventricular

irritability If VT or VF converted before lidocaine

given, lidocaine bolus and drip If lidocaine or bretylium worked, begin

infusion Suppress irritability before giving

vasopressors