Cardiac Arrest

Cardiac Arrest
Dr. Agus Subagjo SpJP (K), FIHA

Tyagita Verdena
CARDIOVASCULAR EMERGENCIES COURSE
Bumi Surabaya Hotel, November 7-8th, 2015
Definition
Cardiac Arrest = Loss of cardiac function as resultant of :
1) Acute myocardial infarction, OR
2) Ischemia without infarction, OR
3) Structural alterations of heart
Priori et al, 2015
Cardiac Arrest
360,000 people experience out-of-hospital cardiac arrest every year
in USA.
From 1000 px in Europe, 1-5 % suffered from cardiac arrest and

only 20% can survive and out from hospital.
Most die within an hour of the onset of acute symptoms

The majority of these deaths the presenting rhythm is Ventricular
Fibrillation or pulseless Ventricular Tachycardia, (VF/ pulseless VT)
Sandroni, et al, 2007
Risk Factors of Cardiac Arrest
Fibrous scar tissue formation on cardiac muscle

Ischemia; chronic or acute
Cardiomyopathy
Drugs
Abnormality in conduction system
Abnormality in heart anatomy
Miscellaneous
Zipes et al, 2006

Cardiac Arrest
Sign and Symptoms
Unresponsive
Gasping
Pulseless
Supporting Asessement
1. ECG
2. Examine 5H,
5T (Hypovolemia, Hypoxia, Hydrogen ion, Hypo-hyperkalema,
Hypothermia, tension pneumothorax, tamponade cardiac, toxins, trombosis

pulmonary, thrombosis coronary)
Pathology of Cardiac Arrest

Cardiac arrest generally progresses through several
cardiac rhythm disburbances
V-Tach
without
pulse
V-Fib
High
survival
potential!
Poor
Asystole/
PEA
prognosis
for
survival
Management Cardiac Arrest
Chain of Survival
Chain of Survival
Early Access
Early CPR
Early Defibrilation
Effective ACLS
Integrated post cardiac arrest care
BLS algorithm
Good
CPR
Opioid
intoxic
ation
2010
2015
-30:2
-minimal
100x/m
-mimimal 5 cm
depth
- Not too fast,

max 120 bpm
- Not too deep,
max 5-6 cm
- 10 breath per
minute
-CAB
Compression
only is not
endorsed for
trained provider
naloxone
Recognise sign and symptom of cardiac arrest

Call for help!
Dont leave the victim
. Perform good CPR

. External chest compressions and
ventilation will slow down the
rate of deterioration of
the brain and heart
CPR
1. Place both hands on the lower half of the sternum bone
2. With an upright body position, press the the victim's chest wall by
the force of rescuers weight on a regular basis
Rate: 100
120/min
Depth: Between 2 in (5cm) and 2.5in (6cm)

Allow full
recoil of the chest between compressions
Minimize Interruptions
Airway
Check the airway
Open the airway, place one hand on the victims
forehead and gently tilt head back
Remove any visible obstruction from the victims mouth,

including dislodged dentures.
DO NOT ATTEMPT ANY FINGER SWEEPS
Breathing
Consists of two stages:
1. Ensuring adequate victim breathing / not breathing (not
exceed 10 seconds)
2. Provide assistance breath.
Defibrilation
Use
AED if out of hospital
Often defibrillation only can restores the heart rhythm

But to sustain circulation, further advanced life support is
required
ACLS follow the rules of Circulation, Airway,

Breathing, Defibrilation.
C A B D
ACLS 2010 vs 2015

Vasopressin :
is out !
Drugs
2010
2015
Vasopressin
Considered as
alternative theraphy
of epinefrin
2010
Not
recomennded
Less attention
Considered as good
equipment in ACLS
2015
Equipment
Capnography
(ETCO2)
Echocardiography
during CPR
2015
recommended
ACLS Cardiac Arrest

Algorithm 2015
CPR in ACLS
CPR is advised in patients with cardiac arrest (Class I, LOE B).
delay of a few seconds compression will reduce the success of
resuscitation.
The use of automatic CPR is not recommended, except in

circumstances where the rescuer to do CPR is less.
ACLS: Airway and Breathing

At the time the decision was made to install invasive
airway and breathing devices to patients, do not interfere
the process of CPR
in 2015 AHA recommendation emphasized for the use of

100% oxygen during resucitation.
In the airway and breathing resuscitation suggested

giving artificial breath as much as 10x/min.
Defibrilation Strategy in
ACLS
Type of Waves and Energy:
If the type of biphasic defibrillator is available:

recommended dose of electric shock is 120 to 200 J
to cope with ventricular fibrillation (Class I, LOE B).
If defibrillation is needed again, it is advisable to use
the maximum power of 200 joules (class IIb, LOE B).
If available monophasic defibrillator

Use 360
J and the dose can be repeated on

The 2015 AHA recommendations:
The succes rate of biphasic defibrillator defibrillation in the first shock

is higher than monophasic defibrillation, as well as side effects postshock myocardial dysfunction are lower than monophasic defibrillator.
The success of defibrillation assessed if VF / VT without pulse gone 5

seconds after defribrilation.
Drugs in Cardiac Arrest Life

Support
1. Vasopressor
2. Antiarhytmic
Vasopressor
Epinephrine
Epinephrine work on -adrenergic receptor that serves as a
vasoconstrictor increase cerebral perfusion pressure during
resuscitation.
Epinephrine have side effects increase miocard contraction and
decrease myocardial perfusion subendocardium.
The AHA recommendations dose of epinephrine in cardiac arrest
recommended is 1 mg IV / intraosteal every 3-5 minutes (class IIb, LOE
A).
If venous access / osteal not available, can be administered
endotracheal dose of 2 to 2.5 mg5.
Other vasopressors
No other vasopressors (eg, norepinephrine) that may indicate increase life
expectancy with equivalent results with epinefrin
Antiarrhytmia
Amiodarone
Intravenous amiodarone affects:
sodium channel
potassium channel
Calcium channel
has the effect of and -adrenergic blocker
Amiodarone may be considered on the condition of VF or VT without

pulse that is not a response to CPR, defibrillation, and vasopressors
(class IIb, LOE B).
The administration of amiodarone at a dose of 300 mg or 5 mg / kg
followed by 150 mg IV / IO reduce the time of hospitalization when
compared with placebo or 1.5mg / kg lidokain.
Lidocaine
The initial dose is 1 to 1.5 mg / kg IV, with a repeat dose is 0.5 to 0.75
mg / kg every 5 to 10 minutes with a maximum dose of 3 mg / kg.
Lidocaine can be given on the condition:
stable monomorphic VT with ventricular function is still good
stable polymorphic VT with a normal QT interval when ischemia
condition
electrolyte abnormalities have been overcome
stable polymorphic VT with prolongation of the QT interval.
Lidocaine no longer used as first choice drug in arrhytmia
Magnesium Sulfate
Magnesium sulfate give good therapeutic effect on:
the condition of torsades de pointes (irregular / polymorphic VT with
prolongation of the QT interval): administered IV / IO bolus of 1 to 2 g
diluted in 10 cc D5 (class IIb, LOE C)
Magnesium sulfate can not stop polymorphic VT with a normal QT interval.
Magnesium sulfate can provide hypotensive effects.
Administration of magnesium sulfate on condition of impaired renal function
should be cautious.
Post cardiac arrest care

If the cardiac
arrest victims
can survive
further the
comprehensive
treatment
prevent cardiac
arrest reset
Prognostic
Cardiac Arrest prognostic depends on former condition
before arrest:
Age (elderly or infancy)
Race
Chronic illness (diabetes mellitus, CKD, sepsis,
stroke)
Quality of chain survival
Stopping the life support

The chances of survival fall
rapidly with time
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
Stopping the life support

(cont)
CPR can be stopped in some conditions like
the signs of death present: rigor mortis
asystole persisting more than 10 minutes
there is a demand from the nuclear family
the patient will
terminal illness
Resucitation harm the rescuer
Conclusion
Cardiac Arrest unexpected event
Cardiac arrest could be a reversible moment
Good quality of the chain of survival is the key of
an successful resusitation

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Dr. Agus Subagjo SpJP (K), FIHA

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Priori et al, 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

From 1000 px in Europe, 1-5 % suffered from cardiac arrest and

Most die within an hour of the onset of acute symptoms

Sandroni, et al, 2007

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Risk Factors of Cardiac Arrest

Fibrous scar tissue formation on cardiac muscle

Zipes et al, 2006

Bumi Surabaya Hotel, November 7-8th, 2015

5T (Hypovolemia, Hypoxia, Hydrogen ion, Hypo-hyperkalema,

Hypothermia, tension pneumothorax, tamponade cardiac, toxins, trombosis

Bumi Surabaya Hotel, November 7-8th, 2015

Pathology of Cardiac Arrest

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Management Cardiac Arrest

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Bumi Surabaya Hotel, November 7-8th, 2015

- Not too fast,

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Recognise sign and symptom of cardiac arrest

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

. Perform good CPR

Bumi Surabaya Hotel, November 7-8th, 2015

Depth: Between 2 in (5cm) and 2.5in (6cm)

recoil of the chest between compressions

Bumi Surabaya Hotel, November 7-8th, 2015

Remove any visible obstruction from the victims mouth,

DO NOT ATTEMPT ANY FINGER SWEEPS

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

2. Provide assistance breath.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

AED if out of hospital

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

Often defibrillation only can restores the heart rhythm

ACLS follow the rules of Circulation, Airway,

Bumi Surabaya Hotel, November 7-8th, 2015

ACLS 2010 vs 2015

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

ACLS Cardiac Arrest

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

The use of automatic CPR is not recommended, except in

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

ACLS: Airway and Breathing

in 2015 AHA recommendation emphasized for the use of

In the airway and breathing resuscitation suggested