CVS

PACEMAKERS:
Q) 56 years old man scheduled for elective hernia repair. He has an implant PPM.

a) What are the different types of pacemakers?

b) How will you assess pacemaker function in this patient?
c) What are anesthetic concerns in this patent?
d) What is meant by VVI pacemakers?

A) TYPES OF PACEMAKER:

1. Temporary:
a) Single pacing
b) Dual pacing.
2. Permanent:
a) Asynchronies (AOO, VOO, DOO)
b) Single chamber demand pacing (VVI, AAI)
c) Dual chamber AV sequential pacing (DDD)
VVI and DDD are most commonly used

B) ASSESSMENT OF PACEMAKERS FX:

1. Assess ECG which will show pacing spikes.

Spike rate should be identical to set (TPM) or programmed (PPM)
2. Slower rate may indicate low battery.
3. Every impulse should be followed by palpable arterial pulse
4. A CXR is useful in excluding fracture or displacement of pacing leads.
5. If pacemaker malfunction is suspected cardio logical consultation is
necessary.

C) ANESTHETIC CONCERNS /MANAGEMENT:

1. Determine whether EMI (electromagnetic interference) is likely to occur or not if likely

it will suppress the pacemaker generator minimized by limiting its use to
short bursts, limiting its power output, placing its grounding plate as far as
from pacemaker generator and using bipolar cautery
2. It is advisable to use bipolar electrocautery system.
3. Determine the need to reprogram use pacemaker or convert it to
asynchronous mode, if needed it should be done preoperatively.
4. Continuous monitoring of arterial pulse wave is mandatory to ensure
continuous perfusion during electrocautery.
5. Suxamethonium induced fasciculation or post-operative shivering can
suppress pacemaker generator.
6. Hypo/ hyperkalemia alters pacing and can result in failure of ventricular
depolarization.

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Dr. Tariq Mahar
 7. If PPM malfunctions intra-operatively, it should generally be converted to an
asynchronous mode.
8. Myocardial ischemia, infarction or scarring can also cause failure of
ventricular capture.
9. All anesthetic agents can be used safely in pacemaker patients
10.LA with light I/V sedation usually needed for placement of pacemaker

D) VVI pacemakers:

1. Single chamber demand pacing

2. Most commonly used
3. Ventricular inhibition pacer.
4. Suppress by normal activity of QRS complex.

IHD (Ischemic heart disease)

Q2- A 55years old male K/C of IHD, scheduled for lapchole.

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Dr. Tariq Mahar
 a) What are the risks factors involved?
b) What measures would you take to minimize the risk?

Ans. a)

RISK FACTORS

Cardiac:

Major
1. Recent MI < 1 month to planned surgery
2. USA (unstable angina)
3. DHF (decompensated heart failure)
4. Significant arrhythmias
5. Severe valvular disease (AS/MS)
6. CABG/ PTCA < 6 weeks

Intermediate:
1. Prior MI > 1month to planned surgery
2. Stable mild angina
3. Compensated heart failure
4. DM
5. Renal insufficiency

Minor:
1. Advance age
2. Abnormal ECG
3. Rhythm other than sinus e.g. AF
4. Low functional capacity
5. H/O stroke.
6. Uncontrolled systemic HTN.

Major risk factors of CAD

1. age 7.) DM
2. Male sex 8.) Obesity
3. +ve family history 9.) H/O CVA
4. Smoking 10.) Menopause
5. HTN 11.) Use of OCP (Oral contraceptive pills).
6. Hyperlipidemia 12.) Sedentary life style Physical inactivity,
High stress

Surgical:

High risk (cardiac risk >5%)

1. Emergency major operations particularly in the elderly
2. Major vascular surgery e.g. aortic.
3. Peripheral vascular surgery.
4. Anticipated prolonged surgeries associated with large fluid shifts/blood

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Dr. Tariq Mahar
Intermediate risk (cardiac risk < 5%)
1. Carotid endarterectomy
2. Head and neck surgery.
3. Intra-peritoneal and intra-thoracic surgery
4. Orthopedic surgery.
5. Prostate surgery.

Low risk (cardiac risk< 1%)

1. Endoscopic procedures.
2. Superficial procedures.
3. Cataract surgery.
4. Breast surgery.

FUNCTIONAL CAPACITY:
Exercise tolerance expressed in METS
(Duke Activity Status Index) (DASI)
1-4 METS Minor exercise (dress change) slow walk
4.10 ETS Moderate exercise (climb on stares) Play golf
>10 METS Vigorous exercise (swimming)

MANAGEMENT OF IHD:
OBEJETIVES: To maintain a balanced myocardial oxygen supply-demand relationship

PREOP MANAGEMENT:
History is of prime importance in IHD
Ask about symptoms, treatment, complications and results of previous evaluations
provide enough estimates of disease severity and ventricular function.
Functional class, activity level (walking, climbing stairs)
Medications, allergies, smoking, previous anesthetics
General physical examination:
Airway assessment (MD, TM distance, loose teeth, artificial dentures etc)

Investigations:

a) ECG e) ETT (FC, ischemia)

b) Cardiac enzymes f) ECHO (WMA wall motion abnormality, EF)
c) CXR (cardiomegaly) g) MP myocardialc perfusion scans (Thallium,
Dobutamine)
d) Holter monitoring, (Ischemic episodes) h) Coronary angiography

Premedication: Benzodiazepine alone or in combination with opioid Is most

commonly used, to allay fear, anxiety, pain and prevents adverse affects of
sympathetic activation on myocardial oxygen supply demand balance.

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Dr. Tariq Mahar
Prophylactic -blockers have shown to reduce incidence of intraoperative and
postoperative ischemia complications.

INTRAOP MANAGEMENT:

1) Tachycardia and B.P should be controlled by deep anesthesia or -blockers.

2) Avoid hypotension, hypoxemia and Hypercarbia.
3) Hb >9-10 g/dl.
4) Standard monitoring + invasive monitoring with arterial line, CVP and
pulmonary artery catheters are advised.
5) TEE in cardiac surgeries.
6) If ICD (implantable cardioverter defibrillator) patient problems with the use of surgical
electrocautery
7) RA is a good choice for procedures involving extremities; perineum and
possibly lower abdomen avoid hypotension by phenyl-ephedrine, ephedrine
or epinephrine.
8) Propofol, barbiturates, etomidate, benzodiazepines, opioids and various
combinations can be used (Etomidate+ fentanyl +atracurium).
9) Ketamine is contraindicated in IHD
10) Rocuronium, Vecuronium and atracurium are good relaxants for IHD
11) Reversal of relaxants by glycopyrrolate instead of atropine
tachycardia

POSTOP MANAGEMET:

1. Anticipate/ avoid hypertension and tachycardia @ emergence by giving

lidocaine, esmolol etc.
2. Post op ICU care.
3. If major surgery supplemental O2 for 3-4 days.
4. Shivering meperidine 20-30 mg I/V.
5. Hypothermia forced air warming blanket.
6. Post op pain generous analgesia or RA e.g. epidural.
7. If fluid overload CXR congestion furosemide 20-40mg I/V
8. Unexplained hypotensionischemia 12 lead ECG.
9. Altered mental status Neurophysician consultation.

HTN
Long standing uncontrolled hypertension accelerates atherosclerosis and
hypertensive organ damage.
HTN is a major risk factor for cardiac, cerebral, renal and vascular diseases.
Complications: MI, CHF, stroke, renal failure, peripheral occlusive disease and aortic
dissection
Definition: Consistently elevated diastolic BP > 90-95 mmHg and a systolic pressure
> 140-160 mmHg

CLASSIFICATION:

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Dr. Tariq Mahar
Category of BP Systolic B.P Diastolic BP
Normal _________________ <130 ___________ <85
High normal _____________ 130-139 __________ 85-89
Stage 1 mild _____________ 140-159 __________ 90-99
Stage 2 moderate ________ 160-179 __________ 100-109
Stage3 sever ____________ 180-209 __________ 110-119
Stage4 very sever ________ >210 __________ >120
Malignant HTN ___________ Medical Emergency

Pathophysiology: Essential (Idiopathic) accounts for 80-95% of HTN Associated with

abnormal baseline elevated in Cardiac output and systemic vascular resistance (CO
&SVR) or both.
Extracellular fluid volume and plasma rennin activity may be low normal or high.
The chronic in after load results in LVH & altered diastolic function. HTN also alters
cerebral auto-regulation (limit may be in the range of mean blood pressures of 110-
180mmhg)

TREATMENT: (ARBs) Angiotensin II receptor blockers

(ACE) Angiotensin-converting enzyme
Reverse LVH & altered cerebral auto-regulation. (CKD) Chronic kidney disease
HTN low dose thiazide diuretic is 1st choice. (SNP) Sodium nitroprusside
ACE inhibitor 1 line choice pts with LV dysfunction or HF.
st (GTN) Nitroglycerin

ACE inhibitor or ARB 1st line choice pts with hyperlipidemia, CKD and DM
-Blocker 1st line choice pts with CAD
In black patients diuretic or Ca+ channel blocker.
In elderly patients diuretic with or without -Blocker or Ca + channel blocker alone.
Pts with moderate to severe HTN requires 2nd or 3rd drugs Diuretics, -Blocker,
ACE-inhibitors.

MANAGEMENT OF HTN:
OBJECTIVES: To maintain an appropriate stable blood pressure range within 10-20%
of baseline level
PREOP MANAGEMENT:
1. Antihypertensive drug therapy should continue till surgery
2. Surgery should be postponed until DBP < 110, particularly those with
evidence of end organ damage.
3. History Ask about severity and duration, drugs, complications functional
class, edema, syncope and claudication.
4. Physical examination: Ophthalmoscopy most useful examination after BP
readings. S4 gallop common in pts with LVH.
5. Measure BP in both supine and standing positions.
6. Preoperative fluid administration prevents severe hypotension @ induction
7. Airway assessment
8. Investigations:
a.) ECG. d.) Cr. & BUN. c.) ECHO (for LVH)

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Dr. Tariq Mahar
 b.) CXR (boot shape). e.) UCE (hypokalemia should be
corrected)
9. Premedication: reduces anxiety and is highly desirable in hypertensives
Mild to moderate HTN anxiolytic agent midazolam
Antihypertensive continue till surgery.

INTRAOP MANAGEMENT:
1. Arterial blood pressures should generally be kept within 10-20 % of
preoperative levels. If severe HTN > 180/120 is present then kept within high
normal range 150-140/90-80 mmHg to maintain CBF in longstanding HTN.
2. Standard monitoring with intra arterial monitoring reserved for major
procedures associated with rapid or marked changes in cardiac preload and
after load. Other include ECG, Urine Output
3. Several techniques may be used before intubation to attenuate the
hypertensive response:
a.) Deep anesthesia with a patent volatile agent for 5-10 minutes
b.) The duration of laryngoscopy should be as short as possible.
c.) Administer a bolus of an opioid e.g. fentanyl 5 g/kg
d.) Administering lidocaine 1.5mg /kg I/v
e.) -adrenergic blockade with esmolol, propranolol or labetalol.
f.) Using topical airway anesthesia e.g. lidocaine 4mg spray.
Ketamine is contraindicated sympathetic stimulation HTN, Parkinsonism and
vasopressors used very cautiously.
Intraoperative hypertension not responding to anesthetic depth can be treated
with parenteral antihypertensive e.g. GTN, SNP, labetalol, hydralazine etc.
Reversible causes such as inadequate depth of anesthesia, hypoxemia or
Hypercapnia should always be excluded before starting antihypertensives.

POSTOP MANAGEMENT:
Postoperative HTN is common and anticipated in pts having uncontrolled HTN
Close BP monitoring in recovery.
Sustained HTN can cause formation of wound hematomas and disruption of
vascular sutures line.
HTN could be enhanced by respiratory abnormalities, pain, volume overload or
bladder distension Treat the cause.
Parenteral antihypertensive like labetalol given if necessary
When patient resumes oral intake, preoperative medications restarted.
MYOCARDIAL OXYGEN SUPPLY-DEMAND BALANCE

Q.45, years old gentleman had major MI 8 weeks ago. He requires an urgent
laparotomy
a) Write down factors governing myocardial O2 supply demand?
b) How will you evaluate and prepare this patient?
c) What problems do you anticipate intra/ postop?

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Dr. Tariq Mahar
Ans a) FACTORS AFFECTING MYOCARDIAL OXYGEN SUPPLY-DEMAND BALANCE

SUPPLY:
1. Heart rate (diastolic time)
2. Coronary perfusion pressure (aortic diastolic BP, Ventricular EDP)
3. Arterial oxygen content (arterial oxygen tension, Hb. concentration)
4. Coronary vessel diameter.

DEMAND:
1. Basal requirement
2. Heart rate
3. Wall tension (Preload, Afterload)
4. Contractility

Ans b) Cardiac risk factors and surgical risk factors for evaluation /assess
preoperative management of IHD for preparation.

Ans c)
INTRAOP PROBLEMS
Sympathetic stimulation due to
1. Light anesthesia 5. Blood loss
2. Inadequate analgesia 6. Hypoxia
3. Surgical stimulus 7. Hypercarbia
4. Large fluid shifts 8. Hypovolaemia
These all can provoke HR and hypertension, which then increase demand and
decrease supply deteriorating myocardial oxygen balance.

TOP PROBLEMS
1. Tachycardia due to inadequate analgesia, emergence and Hb < 9 gm. /dl.
2. myocardial ischemia during emergence and extubation.
3. Hypotension ECG Ischemia.
4. Respiratory abnormalities like hypoxia and Hypercarbia.
5. Fluid overload.
All these factors can also influence and deteriorate myocardial oxygen supply-
demand balance.
MITRAL STENOSIS:
Q. A 20 year old female pt. presents with # shaft of femur as a result of RTA; ORIF is
planned. She is diagnosed case of MS for last 5 years.
a) What is pathophysiology of MS?
b) Write down pre anesthetic evaluation?
c) Write down anesthetic technique with special reference to hemodynamic
goals?
d) Write down normal MV area?
e) Complications of MS during anesthesia and how will you prevent them?

Ans.a) PATHOPHYSIOLOGY OF MS

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Dr. Tariq Mahar
 1. MS almost always occurs as a delayed complication of acute rheumatic fever.
2. Rheumatic process causes valve leaflets to thicken, calcify and become
funnel shaped. Annular calcification also present.
3. Mitral commissure fuses.
4. Chordae tendineae fuses and shorten
5. Valve cusp become rigid valve leaflets typically display bowing or doming
during diastole on echo.
6. Significant restrictions of blood flow through mitral valve results in higher
trans-valvular pressure gradients.
7. LA dilates and promotes SVT particularly AF and thrombus in LA appendage
8. LA pressures pulmonary edema PVR and pulmonary HTN.
9. Lung compliance and WOB (work of breathing) chronic dyspnea.
10.RVH TR & PR (pulmonary valve regurgitation)
11.Incidence of pulmonary emboli, infarction, hemoptysis and recurrent
bronchitis
12.LA compression of left recurrent laryngeal nerve hoarseness.
13.LV function normal, but is small and poorly filled.

Ans b) PER ANESTHETIC EVALUATION:

History: Ask about exercise tolerance, fatigability, SOB, dyspnea, orthopnea, PND.
NYHA functional class is useful for grading severity of HF.
Chest pain, neurological Sx, and prior procedures like valvotomy or valve
replacement
Review of medications, especially digoxin for its toxicity.

PHYSICAL EXAMINATION:
Mitral facies Malar flush on cheeks.
Peripheral cyanosis
Signs of RHF (JVP, hepatosplenomegaly, ascites, pedal edema)
Tapping apex beat (loud S1, opening snap, diastolic murmur)

INVESTIGATIONS:
ECG: P mitral, AF, Notched P wave if SR
CXR: Calcification, LA, kerley-B line.
ECHO:Pressure gradients/ valvular areas
LFTs: assessing hepatic function
ABGs: If significant pulmonary Sx
Coagulation profile: PT, APTT, INR.

ANESTHETIC TECHNIQUE:
Because surgery of lower extremity is planned, the delivered anesthetic technique is
Epidural anesthesia because more gradual onset of sympathetic blockade then
spinal.

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Dr. Tariq Mahar
GOALS (HAEMODYNAMIC)
The principal hemodynamic goals are to maintain a SR sinus rhythm (if present
preoperatively) and to avoid tachycardia, large increase in CO and both
hypovolaemia and fluid overload by judicious fluid therapy. Adequate preload, high
normal SVR
Avoid hypoxia, Hypercarbia and acidosis exacerbation PHTN.

MONITORING: full hemodynamic monitoring of direct intra arterial pressure and PA

pressures is generally indicated for all major surgeries particularly those associated
with large fluid shifts.

If GA then avoid ketamine, Pancuronium and N2O

Intra-operative tachycardia can be controlled by deepening anesthesia with an
opioid (fentanyl, morphine) or -Blocker (esmolol).
In the presence of AF, ventricular rate can be controlled by digoxin
Marked hemodynamic deterioration from sudden SVT necessitates cardioversion.
Phenylephrine is preferred over ephedrine as a vasopressor.
Marked HTN or after load reduction should be treated with vasodilator only with full
hemodynamic monitoring.

Ans d) Normal mitral valve area 4-6cm2

1. Symptom free until 1.5- 2.5 cm2
2. Moderate stenosis 1-1.5cm2
3. Critical / severe stenosis < 1 cm2

Ans e) Complications of MS during anesthesia

1. Pulmonary edema 6. AF
2. PAH 7. CVA
3. RHF 8.MI
4. Lung compliance 9. Renal artery embolism.
5. Pulmonary emboli/ infarction.
BRADYCARDIA
A patent presents for prostatectomy has a pulse of 38b/m
a) Enumerate the common causes of bradycardia?
b) How will you evaluate this patient preoperatively

Ans) Any cardiac rhythm with a rate < 60 b/m is bradycardia

CAUSES:
PREOPRATIVE:
1. Pre-existing cardiac disease.
2. CHB (complete heart block)
3. Drugs (-Blocker, CCB Calcium channel blockers, Digoxin)
4. Hypothyroidism
5. ICP

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Dr. Tariq Mahar
 6. IOP
7. Myocardial ischemia
8. Hypothermia

INTRAOPERATIVE:
1. Deep anesthesia
2. Repeated dose of Suxamethonium
3. Rapid acting opioids
4. Halothane
5. Propofol
6. Surgical stimulation (eye ball traction, cervical/ anal dilatation)
7. Hyperkalemia
8. Low dose atropine
9. Sick sinus syndrome
10.ICP

POSTOPERATIVE:
1. Hypoxia
2. Hypothermia
3. Intraoperative use of -blocker/CCB
4. High spinal
5. Inadvertent intravascular injection of local anesthesia during epidural

Ans b.) EVALUATION OF PATIENT:

1.History
Any co-existing cardiac disease (previous MI) (previous CHB)
Drug history (Ant-arrhythmic, -Blocker, CCB, Digoxin)
Malfunctioning implanted PPM (low battery)
Evaluation of hypothyroidism
2.Examination:
1. B.P.
2. HR (rate, rhythm, volume)
3. Apex beat
4. Auscultation (any additional sound)
5. Carotid bruit.

3. Investigations:
1. ECG (long lead II)
2. Holter monitoring
3. ECHO
4. Electrophysiological study
5. CXR

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Dr. Tariq Mahar
 6. Cardiac enzymes
7. Electrolytes
8. Thyroid fx test
9. Serum digoxin level

TREATMENT:
1. Treat the cause (hypoxemia) (stop surgical shunt)
2. Anticholinergics (atropine, glycopyrrolate)
3. Epinephrine
4. If refractory TPM/PPM

PEA
Q. What is pulseless electrical activity?
Q. What causes it? Algorithm for PEA

Pulseless Electrical Activity: Rhythm on monitor, without palpable pulse

Cause:
1. Severe hypovolaemia
2. Cardiac tamponade
3. Ventricular rupture
4. Dissecting aortic aneurysm
5. Tension Pneumothorax
6. Profound hypoxemia
7. Severe acidosis
8. Pulmonary embolism
9. Drugs related after prolong CPR
atropine induced

Pulseless electrical activity

algorithm.
VF/VT, ventricular fibrillation and

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Dr. Tariq Mahar
 ALGORITHM
FOR PEA
1-Pulse less
electrical activity
(PEA = rhythm on monitor, without detectable pulse)

2-Primary ABCD survey
Focus: basic CPR and defibrillation.
Check responsiveness
Activate- emergency response system
Call- for defibrillator
a- Airway open the airway
b- Breathing provide positive pressure ventilations
c- Circulation give chest compression
d- Defibrillation assess +shock for VF/VT

3-Secondary ABCD survey
Focus: more advanced assessment and treatments
a) Airway place airway device ASAP
b) Breathing confirm and secure airway device.

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Dr. Tariq Mahar
 c) Breathing confirm effective oxygenation and ventilation.
d) Circulation-establish IV access.
e) Circulation identify rhythm-monitor.
f) Circulation administer drugs appropriate for rhythm & conduction
monitor
g) Circulation assess for occult blood flow
h) D/D search for and treat identified reversible causes

4-Review For Most Frequent Causes

Hypovolaemia Tamponade (cardiac)

Hypoxia Tension pneumothorax
Hydrogen ion-acidosis Thrombosis, coronary (ACS)
Hyper/hypokalemia Thrombosis, pulmonary (embolism)
Hypothermia
Tablets (drug OD, accidental)

5-Epinephrine
1mg IV push, repeat every 3 to 5 minutes

6-Atropine 1mg IV
Repeat every 3 to 5 min as needed to a total dose of 0.04mg/kg.

ASYSTOLE
Q. a) List the causes of cardiac arrest during operation?
b) Write down algorithm for pulse less VT?

Ans. a) CAUSES OF CARDIAC ARREST

1 Procedures associated with excessive vagal activity (eye traction, cervical
dilatation)
2 Pre-existing CHB, second degree HB, or trifascicular block.
3 Disconnected ECG leads.
4 Excessively low voltage on ECG.
5 Hypoxia (obstructed airway, bronchial or esophageal, intubation, oxygen
failure)
6 Hypovolemia (hemorrhagic shock, anaphylaxis)
7 Hypo/ Hyperkalemia (renal failure, Suxamethonium induced Hyperkalemia
after burns).
8 Hypothermia
9 Tension Pneumothorax
10 Cardiac tamponade.
11 Drug over dosage (Propofol, -blocker, LA toxicity).
12 Thromboembolism
13 Equipment failure

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Dr. Tariq Mahar
 14 High spinal
15 Total spinal

Cardiac arrest can only be diagnosed clinically by palpating carotid artery (absent
pulse)

CAUSES OF VT:
1 IHD
2 Ventricular scarring after MI or previous cardiac surgery.
3 Right ventricular failure
4 Electrolyte abnormalities in pts with prolong QT interval
(TCA, antihistamines, phenothiazines or Brugada syndrome)
5 SVT e.g. WPW syndrome may cause a broad complex tachycardia

TORSADE DE POINTES: is a specific polymorphic form of VT.

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Dr. Tariq Mahar
PULSELESS VT
Ans b)
ALGORYTHM FOR PULSELESS VT
If not already done, give O2 and establish IV access

Pulse No use VF protocol

yes

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Dr. Tariq Mahar
 Adverse signs
SBP<90
Chest pain
Heart failure
Rate > 150bpm
No yes

If hypokalemia Synchronized DC shock

100-360 J

Give KCL up to 60mmols

Give MgSO4 5ml 50% in 30 min

Amiodarone 150 mg IV If hypokalemia

Over 10min

or
Lidocaine 50mg IV over Amiodarone 150mg I in 10min
2 min repeated every 5 min
To a maximum of 200 mg
Further cardio version as necessary
Synchronized DC shock
100-200-360J

If necessary, further Amiodarone For refractory cases consider

150mg IV over 10min, then 300mg additional pharmacological agents
Over 1hour and repeat shock Amiodarone, lidocaine, Sotalol,
Procainamide, or over drive pacing
Note:
1 For torsade pointes, use MgSO4 or overdrive pacing (expert help
recommended)
2 DC shock always given under sedation / GA.

ADULT BLS ALGORHYTHM

Collapsed/ sick patient

Shout for HELP and assess pt.

Signs

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Dr. Tariq Mahar
 No of life yes

Call resuscitation team Assess

ABCDE
Reorganize & treat
O2
Monitoring IV
access
CPR 30:2
With O2 & airway adjuncts

Apply pads/monitor Call resuscitation

team
Attempt defibrillation if
appropriate
If appropriate

Advance life support Handover to

When resuscitation team arrive
Resuscitation team

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Dr. Tariq Mahar
 ADULS ALS ALGORYTHM
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Dr. Tariq Mahar
 Unresponsive

Open airway
Look for signs of life
Call rescue team

CPR 30:2
Until defib/monitor attached

Assess rhythm

Shock-able Non shock-

able
(VF/Pulse less VT)
(PEA/asystole)

1 shock During CPR

360J -correct reversible causes
Mono phasic -check electrodes & contact
-IV access, airway, O2
-Uninterrupted, compressions
-When airway secures
-Give epinephrine every 3-5 min
Atropine
-Consider Amiodarone and Mg.

Immediately resume
CPR 30:2
For 2min

Reversible cause:
1. Hypoxia 5. Tension pneumothorax
2. Hypovolaemia 6. Tamponade, cardiac
3. Hypo/hyperkalemia 7. Toxins (drug )
4. Hypothermia 8. Thrombosis coronary and pulmonary.

SYNCOPE

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Dr. Tariq Mahar
Q. a) why should anesthesiologist be concerned about H/O syncope?
b) Causes of syncope?

Ans. a)
A history of syncope in elderly patients should always raise the possibility of
arrhythmias and underlying organic heart disease.
Cardiac syncope results form an abrupt arrhythmia that suddenly
compromises CO and impairs cerebral perfusion.
Both Brady and tachyarrhythmias can produce syncope.

b). Causes:
Cardiac:
1. Tachyarrhythmias >180 b/min 7. Primary pulmonary HTN
2. Brady-arrhythmias < 40 b/min 8. Pulmonary embolism.
3. Aortic stenosis. 9. Cardiac tamponade.
4. Hypertrophic cardiomyopathy.
5. Massive MI
6. TOF

Non cardiac
1. Vasovagal (vasodepressor reflex) 6. Autonomic dysfunction
2. Carotid sinus hypersensitivity 7. Sustained valsalva maneuver
3. Neuralgias 8. Seizures
4. Hypovolaemia 9. Metabolic (-Hypoxia,
5. Sympathectomy -Hypocapnia
-Hypoglycemia)

CARDIAC CYCLE
7 Phases
1 Atrial systole
2 Isovolumetric ventricular contraction
3 Rapid ventricular ejection
4 Reduced ventricular ejection

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Dr. Tariq Mahar
5 Isovolumetric ventricular relaxation.
6 Rapid ventricular filling
Reduced ventricular filling.

CHAIN OF SURVIVAL: The 5 links in adult chain of survival are

Immediate recognition of cardiac arrest and activation of emergency
response
Early CPR with an emphasis on chest compressions
Rapid defibrillation
Effective advanced life support.

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Dr. Tariq Mahar
 Integrated post cardiac arrest care
A strong chain of survival can improve chance of survival and recovery for victims of
heart attack, stroke and other emergencies

CARDIOVERSION
Q.) A 55 years old man with new onset AF is scheduled for elective cardioversion
A) What are the indications and complications of cardioversion?
B) How would you evaluate this patient?
C) What minimum monitors and anesthetic equipment required.

a) INDICATIONS FOR DC CARDIOVERSION:

1. To terminate SVT and VT caused by reentry
2. To terminate AF and Flutter, pre-excitation syndromes and VT or VF
3. Emergency cardioversion for any tachyarrhythmias associated with
significant hypotension, CHF or angina.
COMPLICATION OF CARDIOVERSION:
1. Myocardial depression.
2. Post shock arrhythmias (VF)
3. Arterial embolism.

b) EVALUATION FOR CARDIOVERSION:

1. Pt. should be evaluated and treated like GA.
2. Should fast for 6-8hrs to aspiration risk.
3. Airway reflexes will be depressed by sedatives and anesthetics.
4. 12 lead ECG for confirmation of arrhythmias just before and after the
procedure.
5. Preoperative laboratory investigations should be normal.
6. Antiarrhythmic e.g. quinidine should be started in pt. with AF 1-2days prior to
procedure. Anticoagulation also started.
7. TEE must be performed immediately before to rule out an atrial thrombus.

c) MINIMUM MONITORING
ECG, BP & pulse oximetry,
Precordial stethoscope breath sounds,
Conscious level continuous verbal contact

EQUPMENTS
DC fibrillator
Transcutaneous pacing
Reliable IV access

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Dr. Tariq Mahar
 A functional bag-mask device capable of delivering 100% O 2
An Oxygen source (from pipeline or cylinder)
Airway trolley (laryngoscopes, ETT, LMA, bougie, Guedel airway
A functioning suction apparatus
Anesthetic drug kit
Crash cart that includes all necessary drugs and equipment for CPR
PAIN PATHWAY

Primary afferent neurons

(Dorsal root ganglia @ each spinal cord level) 1st order neurons

Gray matter of ipsilateral dorsal horn

(1st six lamina of dorsal horn modulation of pain)

Contralateral spinothalamic tract 2nd order neuron

Lateral & medial spinothalamic tract

Thalamus
3rd order neuron
Postcentral gyrus of parietal cortex & sylvian fissure

ALLODYNIA: Perception of ordinary non noxious stimulus as pain

ANALGESIA: Absence of pain perception
ANESTHESIA: Absence of all sensations
DYSESTHESIA: unpleasant or abnormal sensation with or without stimulus
HYPERAESTHESIA: response to mild stimulus
HYPOAESTHESIA: cutaneous sensation
PARESTHESIA: Abnormal sensation without stimulus
HYPOALGESIA: response to noxious stimulation
HYPERALGESIA: response to noxious stimulation
HYPERPATHIA: Hyperaesthesia + allodynia+hyperalgesia

Referred pain: Phenomenon of convergence b/w visceral and somatic sensory

input is called referred pain
Pain measurement: Numerical rating scale, faces rating scale, visual analog scale
& McGill Pain Questionnaire most commonly used

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Dr. Tariq Mahar
Psychological evaluation: Minnesota multiphasic Personality Inventory MMPI
and Beck depression inventory

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Dr. Tariq Mahar