Cardiac Arrest

Dr. Md. Fakhrul Islam Khaled

Associate Professor, Department of Cardiology, BSMMU
• Concept
• Forms of cardiac arrest
• Causes
• BLS
• ACLS
• Approach to specific form of cardiac arrest
• Self assessment
INTRODUCTION
• Sudden cardiac arrest (SCA) / Cardiac arrest/ Cardiopulmonary
arrest/ Circulatory arrest - Indicates a sudden stoppage in
effective and normal blood circulation due to failure of the heart
to pump blood.
• If an intervention (eg. defibrillation) restores circulation, the
event is referred to as SCA.
i.e: SCA is sudden & reversible loss of cardiac activity.
• If uncorrected, an SCA event leads to death and is then referred
to as SCD
•SCD : Definition
Sudden cardiac death (SCD) is unexpected,
abrupt natural death from cardiac causes
within 1 hour of symptom onset
Cardiopulmonary Resuscitation

A lifesaving emergency procedure that consists of chest

compression and artificial ventilation to maintain
circulatory flow and oxygenation during cardiac arrest.
• Basic Life Support, or BLS, generally refers to the type
of care that first-responders, healthcare providers and
public safety professionals provide to anyone who is
experiencing cardiac arrest, respiratory distress or an
obstructed airway.
• PALS: Pediatric advanced Life Support
Advanced cardiac life support or
Advanced cardiovascular life support (ACLS)
• Refers to a set of clinical interventions for the urgent
treatment of cardiac arrest, stroke and other life-
threatening medical emergencies.
• Includes- BLS + advanced airway Mx, Specific Mx of
Clinical condition
Classification / Morphologic Pattern of
Cardiac arrest:
• Ventricular arrhythmias:
➢Monomorphic VT
➢Polymorphic VT
➢VF
• Bradyarrhythmias:
➢Asystole
➢Pulseless electrical activity (PEA)
TREATABLE CAUSES OF CARDIAC ARREST:
THE H’S AND T’S
H’s T’s

Hypoxia Toxins

Hypovolemia Tamponade (cardiac)

Hydrogen ion(acidosis) Thrombosis, pulmonary

Hypo/hyperkalemia Thrombosis, coronary

Hypothermia Tension pneumothorax

Cardiac causes-
• Coronary Artery Disease : 80%
• Non-ischemic Cardiomyopathies (HCM, ARVC): 10 - 15%
• Channelopathies, Valvular or
• Inflammatory causes : 5 - 10%
 Acute Management
• Efforts for Rapid recovery are critical
• Time between Onset – Resuscitation > crucial for
success
• Irreversible brain damage begins within 5 minutes
of arrest
2015 BLS GUIDELINES
• The change from the traditional ABC (Airway,
Breathing, Compressions) sequence to the CAB
(Compressions, Airway, Breathing)
• The emphasis on early initiation of chest
compressions without delay for airway assessment or
rescue breathing has resulted in improved outcomes
Basic Life Support
Out of hospital setting:
• Purpose -to maintain a minimum level of blood circulation to vital
organs until Return of Spontaneous Circulation (ROSC) or availability
of ACLS.
▪ 4 steps
▪Recognition
▪Shout for help/activate EMS and get AED
▪CPR
▪Defibrillation
 • Make sure the environment is safe for rescuers and victim
Be Safe • Move the person out of traffic/ water and dry the person.
• Be sure you do not become injured yourself.

• Shake the person and talk to them loudly- responsiveness.

Assess the • Check to see if the person is breathing- No breathing or Gasping-.
• Check pulse
Person • Within 10 seconds

• Begin chest compressions and delivering breaths

Call EMS • Send someone for help and to get an AED.

• If alone, call for help while assessing for breathing and pulse.

Defibrillate • Attach the AED when available.

• Listen and perform the steps as directed.
Activation of emergency response system:
• If alone with no mobile phone, leave the victim to activate
the emergency response system and get the AED before
beginning CPR
• Otherwise, send someone and begin CPR immediately; use
the AED as soon as it is available
• In case of unwitnessed collapse of children or infant give CPR
for 2 mins before leaving the victim and getting the AED then
resume CPR
In-
Hospital
Cardiac
Arrest

Out-of-
Hospital
Cardiac
Arrest
INITIATING THE CHAIN OF SURVIVAL
• Early initiation of BLS is the key for survival
TWO-RESCUER BLS/CPR FOR ADULTS
The second rescuer–
• Prepares the AED for use.
• Begin chest compressions and count the compressions
out loud.
• Applies the AED pads.
• Opens the person’s airway and gives rescue breaths.
TWO-RESCUER BLS/CPR FOR ADULTS
• • Switch roles after every five cycles of compressions and
breaths.
• One cycle consists of 30 compressions and two breaths.
• • Quickly switch between roles to minimize interruptions
in delivering chest compressions.
• • When the AED is connected, minimize interruptions of
CPR by switching rescuers while the AED analyzes the
heart rhythm.
• • If a shock is indicated, minimize interruptions in CPR.
• • Resume CPR as soon as possible.
Chain of survival-
Integrated set of coordinated actions
▪ Immediate recognition of cardiac arrest and activation of ERS
(Emergency Response System)
▪ Early CPR
▪ Rapid defibrillation
▪ Effective advanced life support
▪ Integrated post cardiac arrest care
Quality CPR
Hand placement:
• Adult - 2 hands on the lower half of the sternum
• Children – 1 or 2 hands on the lower half of the sternum
• Infants – 2 fingers or 2 thumb defending of the number of rescuers
Chest compressions
• at a rate of 100 to 120 per minute
• at a depth of
Adult: 2 to 2.4 inches (5 to 6 cm), greater depths may result in injury to
vital organs
Children or infant- at least 1/3rd AP diameter of chest
• Full chest recoil in between compressions to promote cardiac filling
Quality CPR cont…
•Compression to ventilation ratio
• Adult 30:2 for an individual without an advanced airway
• Children or infant- 30:2 if one rescuer,
• 15:2 if more than one rescuer
• Interruptions of chest compressions, including pre and post-
AED shocks should be as short as possible
• Individuals with an advanced airway should receive
uninterrupted chest compressions with ventilations at a rate
of one every six seconds
CPR Steps
 AIRWAY AND VENTILATIONS
• Opening airway – Head tilt, chin lift or jaw thrust, in addition explore
the airway for foreign bodies, dentures and remove them. Consider
oropharyngeal tube placement.

• The Health care provider should open the airway and give rescue
breaths with chest compressions
Chin lift

Head tilt
RESCUE BREATHS

• By mouth-to-mouth or bag-mask

• Deliver each rescue breath over 1 second

• Give a sufficient tidal volume to produce visible chest rise

• Use a compression to ventilation ratio of 30 chest

compressions to 2 ventilations
BREATHING DEVICES
For BLS
• Plastic oropharyngeal airways
• Face mask
For ACLS- advanced airway devices
• Esophageal obturators
• Ambu bag- usual method for continuing breathing inhospital
before ET tube can be inserted.
• LMA- laryngeal mask airway
• Endotracheal tube
CPR Steps cont…
ADULT MOUTH-TO-MASK VENTILATION (?!!- think
your safety)
ADULT BAG-MASK VENTILATION IN TWO-RESCUER CPR
Asystole
VT
VF
Out of Hospital Cardiac Arrest Algorithm
ACLS
In hospital Cardiac Arrest Algorithm – BLS
Asystole/ PEA
OHCA
• CPR > AED- Nonshockable rhythm > CPR – until reach to ACLS
IHCA
• CPR> 2min> ?ROSC > Inj. Adrine + Atropine> CPR 2min> Chk ROSC +
Treat correctable cause> CPR continue
• If shockable rhythm appear meanwhile> go for shock
• Inj. Adrine makes the fine VF to coarse VF- which is shockable
VT/ VF
• CPR 2 min + Shock ASAP> ?ROSC > CPR 2min > ? ROSC >
Shock > CPR 2 min > ?ROSC > Shock > CPR + Drug ( Inj.
Amiodaone / Lignocaine/ Treat cause) > Shock > CPR + Drug
(Inj. Mg + Necessary Inv. + Treat cause+ Inj. Sodibicarb) 2 min
> Shock> CPR
• Consider how long to continue????
• For shockable rhythm-
Defibrillation- VF, AF
Cardioversion- VT, SVT

• For Asystole- Standard dose epinephrine (1 mg every

3 to 5 min) is the preferred vasopressor
• Inj. Atropine for bradycardia- 1mg (repeat)
• Inj. Sodium Bicarbonate 1meq /kg IV
DEFIBRILLATION
• Biphasic wave form: 100- 200 J
• SVT- 10J- 20J- 50J
• AF- 50J-100J
• VT- 100J-150J-200J (3-4 times)
• Monophasic wave form: 200- 360 J
• AED- device specific

• Failure of a single adequate shock to restore pulse should be

followed by continued CPR and second shock delivered after
five cycles of CPR
Return of Spontaneous Circulation
• Pulse & Blood pressure
• Abrupt sustained increase in PETCO2 (Typically≥ 40mmHg)
• Spontaneous arterial pressure waves with intra-arterial
monitoring
THE ACLS SURVEY (A-B-C-D)
• • Maintain airway in unconscious patient
• • Consider advanced airway
AIRWAY • • Monitor advanced airway if placed with quantitative
waveform capnography

• • Give 100% oxygen

• • Assess effective ventilation with quantitative
BREATHING waveform capnography
• • Do NOT over-ventilate
THE ACLS SURVEY (A-B-C-D)
• • Evaluate rhythm and pulse
• • Defibrillation/cardioversion
CIRCULATION • • Obtain IV/IO access
• • Give rhythm-specific medications
• • Give IV/IO fluids if needed

• • Identify and treat reversible causes

DIFFERENTIAL
• • Cardiac rhythm and patient history
DIAGNOSIS
• • Assess when to shock versus medicate
Specific History
• Regarding preconditions for cardiac arrest
• Previous medical /or surgical history- MI, Cardiac surgery,
CKD, TB, Cardiomyopathy,
• Preceding symptoms- Chest pain, vomiting,
• Preceding condition- History of Toxin, Drug, Trauma
Emergency Investigations
• Standard 12 lead ECG
• Bed side plasma Glucose
• S. Electrolytes
• ABG
• S. Calcium
• S. Magnesium
• Xray Chest (Portable)- If Pneumothorax suspected
• Bedside Echo- if pericardial tamponade suspected
Advanced Airway:
• Endotracheal intubation or Supraglotic Advanced airway-
LMA
• Waveform capnography or capnometry to confirm & Monitor
ET tube placement
• Once advanced airway is placed- 1 breath / 6 seconds
(10breaths/min) with continuous chest compression
 The Orchestra:
• Maintain an orchestra of activity between physician, nurse
and other health care provider (Ward boy)
• Team leader- Who will guide & coordinate
• Chest compression, airway mx- Two person
• Drug giving- Nurse
• Record keeping- Another nurse
• Support staff- Prepare bed, instruments
SELF-ASSESSMENT
1. Which of the following is true regarding
BLS?
•a) It is obsolete
•b) Recent changes prohibit mouth-to-mouth
•c) It should be mastered prior to ACLS
•d) It has little impact on survival
•1. C
•ACLS providers are presumed to have
mastered BLS skills. CPR is a critical part of
resuscitating cardiac arrest victims.
2. What is the first step in the assessment of an
individual found “down”?
•a) Check blood pressure
•b) Check heart rate
•c) Check to see if conscious or not
•d) Check their pupil size
• 2. C
• When responding to an individual who is
“down,” first determine if he/she is conscious or
not. That determination dictates whether you
start the BLS Survey or the ACLS Survey.
3. What factor is critical in any emergency situation?

• a) Scene safety
• b) Age of the individual
• c) Resuscitation status
• d) Pregnancy status
• 3. A
• Always assess the safety of the scene in any
emergency situation. Do not become injured
yourself.
4. How did the BLS guidelines change with
the recent AHA update?
• a) Ventilations are performed before
compressions
• b) ABC is now CAB
• c) Use of an AED is no longer recommended
• d) Rapid transport is recommended over on
scene CPR
• 4. B
• The focus is on early intervention and starting
CPR. Look, listen, and feel has been removed to
encourage performance of chest compressions.
5. Arrange the BLS Chain of Survival in the proper
order:
• a) Look, listen, and feel
• b) Check responsiveness, call EMS and get AED, defibrillation,
and circulation
• c) Check responsiveness, call EMS and get AED, chest
compressions, and early defibrillation
• d) Call for help, shock, check pulse, shock, and transport
• 5. C
• The focus is on early CPR and defibrillation.
6. After activating EMS and sending someone for
an AED, which of the following is correct for
one-rescuer BLS of an unresponsive individual
with no pulse?
•a) Start rescue breathing
•b) Apply AED pads
•c) Run to get help
•d) Begin chest compressions
• 6. D
• An unresponsive adult without a pulse must
receive CPR, and chest compressions should be
initiated immediately followed by ventilation.
ADVANCED CARDIAC LIFE SUPPORT
1. What is the longest a rescuer should pause to
check for a pulse?
•a) 20 seconds
•b) 10 seconds
•c) 5 seconds
•d) Less than 2 seconds
•1. B
•Pulse checks are limited to no more than 10
seconds. If you are unsure whether a pulse
is present, begin CPR.
2. The following are included in the ACLS
Survey:
• a) Airway, Breathing, Circulation, Differential Diagnosis
• b) Airway, Breathing, Circulation, Defibrillation
• c) Assessment, Breathing, Circulation, Defibrillation
• d) Airway, Breathing, CPR, Differential Diagnosis
•2. A
3. What is the role of the second rescuer during a
cardiac arrest scenario?

• a) Summon help.
• b) Retrieve AED.
• c) Perform ventilations.
• d) All of the above
• 3. D
• Take advantage of any bystander and enlist their
help based on their skill level.
4. Which of the following is not an example of
an advanced airways?
•a) Oropharyngeal airway
•b) Esophageal-tracheal tube
•c) Laryngeal mask airway
•d) Combitube
• 4. A
5. You should_____ in an individual with
ventricular fibrillation immediately following a
shock.
•a) Resume CPR
•b) Check heart rate
•c) Analyze rhythm
•d) Give amiodarone
• 5. A
• Resume CPR
6. _____ joules (J) are delivered per shock
using a monophasic defibrillator.
• a) 200
• b) 150
• c) 300
• d) 360
• 6. A
• 200
7. Which of the following is a shockable
rhythm?
•a) Ventricular fibrillation
•b) Ventricular tachycardia (pulseless)
•c) Torsades de pointes
•d) All of the above
• 7. D
• All of the above
8. An individual presents with symptomatic
bradycardia. Her heart rate is 32. Which of the
following are acceptable therapeutic options?
• a) Atropine
• b) Epinephrine
• c) Dopamine
• d) All of the above
• 8. D
• Atropine is the initial treatment for symptomatic
bradycardia. If unresponsive, IV dopamine or epinephrine is
the next step.
• Pacing may be effective if other measures fail to improve the
rate.
9. _____ access is preferred in arrest due to easy
access and no interruption in CPR.
•a) Central
•b) Peripheral
•c) Intraosseous
•d) Endotracheal
•9. B
•Peripheral
10. The following antiarrhythmic drug(s) can be
used for persistent ventricular fibrillation or
pulseless ventricular tachycardia, except:
•a) Amiodarone
•b) Lidocaine
•c) Atropine
•d) Both A and B
•10. C
11. Which of the following is first line treatment
for ACS?
• a) Morphine
• b) Aspirin
• c) Statin
• d) All of the above
• 11. D
• All of the above
Thank you All