Cardiac arrest resuscitation made easy

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Cardiac arrest resuscitation made easy

• Tony Smith
• Medical Director, St John
• Intensive Care Medicine Specialist, Auckland City
  Hospital

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Cardiac arrest resuscitation

• Talking about cardiac arrest in the accident and
  medical clinic setting, not in the emergency
  department setting
• General overview of out of hospital cardiac
  arrest
• Guidelines
• The evolving emphasis on chest compressions
• Airway
• Drugs
• Defibrillation
• Decision making with regard to starting and
  stopping
• Cases for discussion
• Questions

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Take home messages

• Continually emphasise doing the basic things well
  
• Good BCLS saves more lives than ACLS does
• Chest compressions are the most important part of
  CPR for most patients
• Focus on keeping things simple

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Out of hospital cardiac arrest overview

• 3 cardiac arrests in NZ per day (resuscitation
  attempted)
• One per 4000 people per year
• 80 are primary
• Obvious cardiac cause or no obvious cause
• 20 are secondary
• Due to another obvious non-cardiac cause
  (drowning, trauma, hanging, poisoning)
• For primary cardiac arrest
• Median age is 65
• 70 male
• 80 occur in the home
• 50 receive bystander CPR

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Out of hospital cardiac arrest overview

• Initial rhythm in primary cardiac arrest
• 50 VF
• 30 Asystole
• 18 PEA
• 2 VT
• Overall 20 reach hospital and 8 survive
• Outcomes are very rhythm dependent
• Rhythm Reach Hospital Survival
• VT 80 70
• VF 40 20
• PEA 10 1
• Asystole 5 1

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Out of hospital cardiac arrest overview

• Paediatric cardiac arrest
• A completely different disease to adult cardiac
  arrest
• 5 of out of hospital cardiac arrest
• 90 secondary and 70 asystole
• 15 reach hospital and 1 survive
• ROSC with BCLS is a marker of survival
• Secondary cardiac arrest
• A completely different disease to primary cardiac
  arrest
• 20 of out of hospital cardiac arrest
• 60 asystole and 30 PEA
• 10 reach hospital and 1 survive
• Cardiac arrest in presence of personnel,
  immediately reversible cause, quick ROSC (within
  a few minutes) is a marker of survival

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Guidelines

• There are lots
• NZRC, ARC, AHA, ERC, ILCOR.
• They are all subtly different
• These differences often cause confusion
• But the differences are not important
• Which guideline you follow is not important
• Keeping it simple is
• We (St John Clinical Management Group) have made
  a decision not to align with any one guideline
• We have chosen to do some things differently
  where there is no evidence and we can simplify
  things
• For example ratios, joules and drug doses

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Emphasis on chest compressions

• Chest compressions are the most important part of
  CPR
• CCR rather than CPR (flow is more important than
  content)
• Particularly in primary cardiac arrest
• Particularly early in cardiac arrest (the first
  4-6 minutes)
• Ratio has changed from 152 to 302 for
  non-intubated
• No evidence for either ratio
• The principle is more important than the exact
  ratio
• Focus on the chest compressions
• Minimise pauses, continuous whenever possible
• Rate of approx 100/min
• Adequate depth
• Frequent change of person doing the compressions
  (every two minutes)

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The airway

• The LMA has a rapidly evolving role for airway
  management, including cardiac arrest
• You do not need a cuffed ETT
• The LMA has a high success rate in inexperienced
  hands (and ETT a low success rate)
• I would recommend removing ETTs from clinics and
  replacing them with LMAs
• Ventilation rates are important and often
  overlooked
• 8-10 breaths a minute
• Higher rates cause blood flow to fall during CPR

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Drugs

• No evidence that drugs improve survival from
  cardiac arrest
• High dose adrenaline is no better than normal
  dose
• Amiodarone improves ROSC rates in recurrent VF
• My view keep it simple
• Dont use atropine, calcium, bicarbonate,
  vasopressin, magnesium
• The benefit of using amiodarone is very small and
  probably isnt worthwhile in a clinic where
  cardiac arrest is rare
• Give 1 mg (adults) adrenaline every four minutes
• Use a decent flush (the easiest is a running
  line)
• Keep paediatric dosing simple

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Paediatric dosing

• There is no evidence for current paediatric doses
  of drugs in cardiac arrest
• They are hard to remember
• They are hard to calculate in a rush
• The St John approach
• All children 50kg and above get adult doses
• All other children are rounded off to the nearest
  of 10, 20, 30 or 40kg and dosed accordingly
• Take the adult dose, draw it up to a total of 5ml
  and give 1ml for every 10kg
• Works for all emergency drugs, including cardiac
  arrest
• Dose differs a little from guidelines, but this
  doesn't matter and it simplifies dosing and
  reduces error

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Defibrillation

• All moving away from stacked shocks to single
  shocks
• Reduces pauses in chest compressions
• Still role for initial stacked shocks if cardiac
  arrest occurs in presence of defibrillator
• All recommend immediate CPR after defibrillation
  (without rhythm or pulse check)
• Different recommendations on joules (150-360J)
• Between guidelines
• Between manufacturers
• Between monophasic and biphasic
• There may be a role for CPR before defibrillation
  in some
• Particularly if in VF for more than a few minutes
  
• Right heart dilation an impediment to
  defibrillation
• Confused?

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Defibrillation

• We (St John CMG) recommend a simple approach
• Start with one round of stacked shocks if cardiac
  arrest occurs in presence of defibrillator, then
  go to single shocks
• Always use maximum joules
• Opt for defibrillation first
• Round kids off to nearest 10kg and use 5J/kg

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Defibrillation

• Manual defibrillators are 15,000-20,000
• AEDs are 3000-5000
• In clinics I would recommend an AED rather than a
  manual defibrillator
• All clinical staff should know how to use it

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Starting and stopping

• These decisions can be difficult
• A resuscitation attempt should begin in most
  patients
• Except where the patient is clearly dead (livedo,
  rigor mortis)
• Or where they are clearly dying and it would be
  inappropriate
• A competent patient can decline therapy but
  neither a patient nor their family can demand
  therapy that is medically inappropriate
• Some scenarios have gt99 mortality rates
• Unwitnessed cardiac arrest with initial rhythm of
  asystole

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Starting and stopping

• The chances of survival fall rapidly with time
• Exponential falling curve
• There is no absolute cut off when mortality
  becomes zero
• Resuscitation attempts requiring longer than 20
  minutes of CPR have a very high mortality rate
• We recommend stopping at around 20 minutes unless
  there is a clinical reason to continue for longer
  
• Transport to hospital with CPR enroute usually
  has no role

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Cases for discussion

• Cases
• Invite audience participation
• Reinforce the take home messages

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Case 1

• A 40 year old man is delivered by car to your
  clinic
• He was found collapsed by his family in the
  toilet
• He is in cardiac arrest
• You begin a resuscitation attempt and a
  defibrillator is attached
• He is in asystole
• What are you going to do?

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Case 1 my thoughts

• Check the leads and check the gain
• It could be fine VF
• Make sure it isnt bradycardia
• Which can look like asystole at a quick glance
• Concentrate on good chest compressions
• This is unwitnessed cardiac arrest with asystole
• Predicted mortality is gt 99.9
• The tiny number who survive have a high chance of
  severe disability
• I would not continue for very long (around 5
  minutes) if truly asystolic
• I would then declare him dead

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Case 2

• A 70 year old man attends your clinic with chest
  pain
• Soon after arrival he has a cardiac arrest
• VF
• What are you going to do?

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Case 2 my thoughts

• This is about as good as it gets
• Precordial thump unless you can shock in next
  five seconds
• Start with stacked shocks, then go to single
  shocks (followed by immediate CPR without rhythm
  check)
• Focus on good chest compressions (uninterrupted
  if possible), that is CCR rather than CPR
• Place an LMA (keep ventilation 8-10/min)
• Drugs not an initial high priority
• I would continue with a vigorous resuscitation
  attempt
• I would be prepared to continue for twenty to
  thirty minutes

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Case 3

• Imagine case 2 again
• This time however, the patient has a medic alert
  on his wrist which you notice for the first time
  as you are attaching the defibrillator
• It says not for resuscitation in the event of
  cardiac arrest
• What would you do?

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Case 3 my thoughts

• This is a very difficult situation
• It is very hard not to shock VF
• You could pretend you havent seen the bracelet
• However, this man has made a clear advanced
  directive
• A competent patient has the right to decline
  treatment
• A patient is competent unless proven otherwise
• I would stop resuscitation attempts
• I wouldnt shock him
• If others insisted on a resuscitation attempt I
  would politely decline to be involved

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Case 4

• A 42 year old woman attends your clinic with
  asthma
• She has a long history of asthma, with severe
  attacks requiring hospitalisation
• Despite continuous nebulised salbutamol she
  rapidly gets worse over about ten minutes with
  severe respiratory distress, she is unable to
  talk and is becoming increasingly confused
• Why is she becoming confused?
• What do you do?

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Case 4

• She develops a falling level of consciousness and
  becomes rapidly comatose with agonal gasps and
  ineffective breathing
• The rhythm on the monitor is sinus tachycardia at
  a rate of 140/min, but the rate is rapidly
  slowing
• What do you do?

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Case 4 my thoughts

• This has a high mortality rate if handled badly
  and a low mortality rate if handled well
• She isnt in cardiac arrest yet, but could be
  soon
• I would prioritise
• Avoiding dynamic hyperinflation, use a very low
  ventilation rate of around 6/min (focusing on
  oxygenation rather than ventilation)
• Treating her asthma aggressively (adrenaline a
  high priority)
• Chest compressions not initially high on my list
• Tension pneumothorax is rare in this setting
• Signs are predominantly in the circulation
• Drainage technique important if you think it is
  present
• If she goes on to become asystolic the mortality
  rate becomes 99

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Summary take home messages

• Individual guidelines are not important
• Keeping it simple is
• The chest compressions are the most important
  part of CPR
• CCR rather than CPR
• The LMA can replace the ETT in most cardiac
  arrests
• Adrenaline is the only drug you need to remember
• Paediatric dosing can be made easy
• Defibrillation
• Defibrillation first
• Max joules, stacked followed by single shocks
• Immediate chest compressions without rhythm check
• AEDs have many advantages over manual
  defibrillators

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St John Clinical Procedures

• Developed by the St John CMG
• Issued to St John clinical staff
• Very popular with medical and nursing staff
• 15 a copy
• Tony.Smith_at_stjohn.org.nz

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St John Clinical Procedures
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St John Clinical Procedures
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Thank you

• Tony.Smith_at_stjohn.org.nz