arrest
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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