Part 12: Cardiac Arrest in Special Situations2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular CareTerry L. Vanden Hoek, Ketua; Laurie J. Morrison; Michael Shuster; Michael Donnino; Elizabeth Sinz; Eric J. Lavonas;

Farida M. Jeejeebhoy; Andrea Gabrielli

Presented by:Susi Muharni RismaRaihanun Nisa Dinur

Cut ChairaniMaulina Fusya

Supervisor:dr. Yusmalinda, Sp.An

IntroductionThis journal discuss 15 spesific cardiac arrest situations such as:

Asthma Anaphylaxis Pregnancy Morbid obesity Pulmonary embolism Electrolyte imbalance Ingestion of toxic

substances Trauma

Accidental hypothermia

Avalanche Drowning Electric

shock/lightning strikes Percutaneous

coronary intervention (PCI)

Cardiac tamponade cardiac surgery.

Pathophysiology

•Bronchoconstriction•Airway inflammation•Mucous plugging

Clinical aspect

•Wheezing

Cardiac Arrest Associated with Asthma

Primary Therapy• Oxygen• Inhaled β2-

Agonists (Albuterol,Levalbuterol)

• Corticosteroids (Methylprednisolone, Dexamethasone)

Adjunctive Therapy• Anticholinergics• Magnesium Sulfate• Epinephrine or

Terbutaline• Ketamine• Heliox• Methylxanthines• Leukotriene

Antagonists• Inhaled Anesthetics

Assisted Ventilation• Noninvasive

Positive-Pressure Ventilation

• Endotracheal Intubation with Mechanical Ventilation

Management of Asthma

•Hypersensitivity reaction

•Tachycardia•Faintness cutaneous•Flushing•Urticaria•Pruritus•Stridor, wheezing•Cardiovascular colaps

• Airway• Fluid resuscitation• Vasopressor • Antihistamin• Extracorporeal

support of circulation

• Airway• Circulation

(Epinephrine IM 0,2-0,5 mg)

Definition Signs & Symptomps

ACLS Modifications

BLS Modifications

Cardiac Arrest Associatedwith Anaphylaxis

Place the patient in the full left lateral position

Give 100% oxygen

Establish intravenous access above the diaphragm

Asses for hypotension

Consider reversible causes of critical illness and treat conditions that may contribute to clinical deterioration as early as possible.

Cardiac Arrest Associated with Pregnancy

• Positioning (left-lateral tilt position)

• Airway (bag-mask ventilation,suctioning)

• Breathing (oxygenation, ventilation,monitor oxygen saturation)

• Circulation (Chest compressions)

• Defibrillation (AED)

•Airway (ETT or supraglottic airway, bag-mask ventilation)

•Circulation•Defibrillation

BLS Modification ACLS Modification

Masalah pada ibu hamil

Penyakit jantung

Infark miokard

Aterosklerotik

Penyakit jantung bawaan

Keracunan magnesium sulfat

Kelainan jantung

Neurologis

gastrointestinal

Preeklampsia/ eklampsia

kegagalan organ bahkan sistem

Edema pulmonal/ Emboli cairan

ketuban

Henti Jantung pada Ibu yang Tidak Segera Membaik dengan BLS dan ACLS

Seksio sesaria darurat< 5 menit• Jika uterus gravid

di atas umbilikus> kompresi aortocaval> mengganggu hemodinamik

Pertimbangkan histerektomi

Hipotermia terapeutik sebagai perawatan post henti jantung

Henti Jantung pada Ibu yang Tidak Segera Membaik dengan BLS dan ACLS

Tidak ada modifikasi BLS standar atau perawatan ACLS yang terbukti berkhasiat, meskipun teknik mungkin perlu disesuaikan dengan fisik pasien.

Cardiac Arrest in the Morbidly Obese

Ekokardiografi darurat untuk diagnosa emboli pulmonal

Modifikasi ACLS

• Fibrinolitik• Trombektomi mekanik perkutan

• Embolektomi bedah

Emboli Pulmonal

Cardiac Arrest Associated with Pulmonary Embolism

Kalium

• Hiperkalemia• Hipokalemia

(pemberian bolus kalium)

Sodium (Na)

• tidak menyebabkan henti jantung

Magnesium (Mg)

• Hipermagnesemia(>2,2 mEq/L)

• Hipomagnesemia (<1,3 mEq/L)

Kalsium

• Diduga akibat penggunaan kalsium klorida atau kalsium glukonat

Cardiac Arrest Associated with Life Threatening Electrolyte Disturbances

-> Calcium gluconate [10%] 15-30 mL IV 2-5 minutes

->Bolus MgSO4 IV 1-2 gr

Electrolyte Disturbanc

e

Use of calcium chloride [10%] 5-10 mL or calcium gluconate [10%] 15-30 mL IV over 2-5 minutes is suspected as the cause of cardiac arrest

Definisi• konsentrasi

kalium serum > 6.5 mmol/L

Etiologi:• gagal ginjal, • Obat-obatan

Klinis

• flaccid paralysis, paresthesia, depresi refleks tendon dalam, atau kesulitan pernapasan

• EKG: T memuncak, gelombang P yang rata atau tidak ada, interval PR memanjang, kompleks QRS melebar, gelombang S dalam, dan penggabungan gelombang S dan T

akibat• aritmia• henti jantung

Hyperkalemia

Menstabilkan membran sel miokard:

• Kalsium klorida (10%): 5 -10 mL (500 sampai 1000 mg) IV lebih dari 2-5 menit atau kalsium glukonat (10%): 15-30 mL IV lebih dari 2-5 menit

Pergeseran kalium ke dalam sel:

• Natrium bikarbonat: 50 mEq IV lebih dari 5 menit• Glukosa ditambah insulin: campurkan 25 g (50 mL D50) glukosa dan 10 U

insulin reguler dan memberikan IV selama 15 -30 menit• Nebulasi albuterol: 10 -20 mg nebulized lebih dari 15 menit

Meningkatkan ekskresi kalium:

• Diuresis: furosemide 40 -80 mg IV• Kayexalate: 15 -50 g ditambah sorbitol per lisan atau rektum• Dialisis

ACLS Modifications in Management of SevereCardiotoxicity or Cardiac Arrest Due to

Hyperkalemia

Cardiac Arrest Associated WithToxic Ingestions

Alters the function of a

cellular receptor,

ion channel, organelle, or

chemical pathway

Respiratory depressionHypotension

Alteration of cardiac

conduction

Single dose activated charcoal can be

administered within 1 hour of poisoning

Multiple dose activated charcoal for patient who have ingested a

life threatening amount of specific toxins (carbamazepine, dapson, phenobarbital,quinine

or theophylin)

Charcoal should not be administered for ingestion

of caustic substances, metals or hydrocarbon

Opioid Toxicity• Naloxone administration should begin

with a low dose (0.04 to 0.4 mg)

Benzodiazepines • Flumazenil

β-Blockers• High-dose insulin, or IV calcium

salts.

Glucagon• Dopamine alone or in combination

with isoproterenol

Calcium Channel Blockers • Insulin high dose

Digoxin• One vial of antidigoxin Fab is

standardized to neutralize 0.5 mg of digoxin

Cocaine• 1 mL/kg of sodium bicarbonate

solution (8.4%, 1 mEq/mL) IV as a bolus.

Cyclic Antidepressants• Sodium bicarbonate boluses of 1

mL/kg• Vasopressor

Local Anesthetic Toxicity

• Consider 1.5 mL/kg of 20% long-chain fatty acid emulsion as an initial bolus epeated every 5 minutes until cardiovascular stability is restored

Hyperbaric Oxygen• A treatment regimen of 100% oxygen

and hydroxocobalamin, with or without sodium thiosulfate

Toxidromes

Cardiac Arrest AssociatedWith Trauma

Modifikasi BLS

Multisystem trauma: jaw thrust should be used instead of a head tilt– chin lift to stablish a

patent airway

Ventilation should be providedwith a barrier device, a pocket mask

Stop any visible hemorrhage using direct compression and appropriate dressings

CPR and defibrillation as indicated

Cardiac Arrest in Accidental Hypothermia

Patients with mild hypothermia (34°C [93.2°F]),moderate (30°C to 34°C [86°F to 93.2°F]), severe hypothermia (30°C [86°F])

Focus on interventions that prevent further loss of heat and begin to rewarm the victim immediatelyvasopresor (epinefrine or vasopresin)

Cardiac Arrest in Avalanche Victims

Causes ofavalanche-

related death

Caridac Arrest in Drowning

Recovery

From the

Water

Airway

Breathing

Circulation

The routine use of abdominal thrusts or the Heimlich maneuver for drowningvictims is not recommended

If vomiting occurs, turn the victim to the side and remove the vomitus using your finger, a cloth, or suction

Cardiac Arrest Associated withElectric Shock and Lightning Strikes

Electrical Shock

•Tetanic skeletal muscle contractions•Ventrikel fibrilation

Lightining Strikes

•Simultaneously depolarizing the entire myocardium•Respiratory arrest (thoracic muscle spasm and suppression of the respiratory center)•Producing extensive catecholamine release (hypertension, tachycardia)•Brain hemorrhages, edema, and small-vessel and neuronal injury•Hypoxic encephalopathy

Standard BLS resuscitation care -> early intubation should be performed for patients with evidence of extensive burns -> Fluid administration should be

adequate

Cardiac Arrest duringPercutaneous Coronary Intervention

Mechanical CPR During PCI

Cough CPR

Intracoronary Verapamil

Emergency

Cardiopulmona

ry Bypass

Rapid diagnosis and drainage of the pericardial fluid are required to avoid cardiovascular collapse. Pericardiocentesis guided by echocardiography is a safe and effective method of relieving tamponade in a nonarrest setting

Cardiac Arrest caused byCardiac Tamponade

Cardiac surgery

Ventricular

fibrillation,

hypovolemia

, cardia

c tamponade,

or tensio

n pneu

mothorax

Resternotom

y and internal

cardiac

compression

Extracorporeal

membrane

oxygenation and cardiopulmonary bypass

+ Pharmacological Interven

tion (epinephrine and antiarrhythmics)

Cardiac Arrest followingCardiac Surgery

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