Cardiac Arrest: CPR with AED and Cardiac Emergencies - EMRG 262 Notes

Cardiac Arrest: CPR with AED and Cardiac Emergencies

Management of Adult Cardiac Arrest

Cardiopulmonary arrest is often referred to as a "Code."
Most patients experiencing cardiac arrest show evidence of atherosclerosis or other underlying cardiac disease.
It is crucial to follow an orderly, systematic approach due to the stressful nature of these circumstances.
Key to Survival: Excellent cardiopulmonary resuscitation (CPR) and a short time to defibrillation.
Many Emergency Medical Services (EMS) defibrillators now include CPR quality feedback, indicating ideal rate, depth, and recoil.
For an unresponsive patient, initiate care with the Circulation, Airway, Breathing (CAB) sequence.

Monitoring CPR Quality and Use of Capnography

Five Main Uses for Capnography in Cardiac Arrest:
1. Verify Advanced Airway placement.
2. Identify Advanced Airway displacement.
3. Evaluate CPR quality.
4. Identify return of spontaneous circulation (ROSC).
5. Determine when ROSC is unlikely.
Prognostic Indicator (After $20$ minutes of Advanced Cardiac Life Support (ACLS)):
- ETCO2 levels < 10 ext{ mmHg} are associated with futility of resuscitation.
- ETCO2 levels > 25 ext{ mmHg} are associated with survival.
Monitoring CPR Quality with ETCO2:
- Higher ETCO2 ( $12-15 ext{ mmHg}$ ) indicates higher cardiac output and effective CPR.
  - An increasing ETCO2 suggests CPR is likely effective and ventilation is appropriate; a substantial rise can indicate ROSC.
- Lower ETCO2 (< 10 ext{ mmHg})
  - Suggests a need to change compressors or improve CPR quality.
  - A decreasing ETCO2 warrants observation for chest compressor fatigue, hyperventilation, pneumothorax, airway obstruction, or advanced airway displacement.

Defibrillation

Defibrillation delivers a surge of electric energy to the heart to stop chaotic rhythms.
It is essential to perform defibrillation as soon as possible in cases of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).
Every minute of delay in defibrillation in VF/VT results in a $10\%$ reduction in survival.
Defibrillation is not useful in asystole (flatline) or pulseless electrical activity (PEA).
An implanted artificial pacemaker is not a contraindication to defibrillation.
Automated External Defibrillator (AED) "3Ps" for Setup:
1. Power: Turn on the AED.
2. Pads: Attach adhesive defibrillation pads to the chest as instructed.
3. Plug In: Plug the pads into the AED.
Before Defibrillation Steps:
- Inspect AED equipment at the beginning of each shift.
- Turn on the AED.
- Expose the patient's chest fully.
- Dry any fluids (water, sweat, blood, vomit) from the chest.
- Shave chest hair for better pad adherence if necessary.
- Remove any transdermal patches present on the chest.
- Do not delay shock for metal jewelry removal.
Defibrillation Algorithm (Continued):
- After attaching and plugging in the pads, stop CPR while the AED analyzes the rhythm (takes a few seconds).
- If the defibrillator indicates a shock is advised:
  - Continue chest compressions while the AED is charging (approximately $10-15$ compressions, lasting about $7-10$ seconds).
  - Clear the patient: State clearly, "I’m Clear, your clear, we are all clear!" and perform a visual check to ensure no one is touching the patient BEFORE pressing the shock button.
  - The rescuer initiating the shock must continue looking to ensure no one touches the patient during the shock delivery.
  - Immediately restart CPR with a new rescuer for $2$ minutes, or earlier if the compressor becomes fatigued.
- If the defibrillator indicates no shockable rhythm (meaning ROSC, asystole, or pulseless electrical activity):
  - Immediately restart CPR with a second rescuer and continue for $2$ minutes before reassessing with the AED again.
  - During ongoing CPR, diligently look for signs of life (e.g., breathing, chest rise, swallowing, blinking, moving). If signs are found, the patient's condition has changed, and a full reassessment of ABCs and vitals is necessary.

BLS: Review (with cutting-edge updates)

PCPs must be familiar with the techniques and sequences of adult Basic Life Support (BLS).
BLS focuses on the maintenance of circulation, airway, and breathing through early, high-quality compressions and defibrillation.
Adult BLS Guidelines:
- Concentrate on high-quality compressions, allowing for full chest recoil between each compression.
- Avoid excessive ventilation: each breath should be delivered over one second ONLY, and stop when chest rise is observed.
- Place the heel of the hand in the center of the chest, at armpit level.
- Maintain a compression-to-ventilation ratio of $30$ compressions to $2$ ventilations.
- Achieve a compression rate of $100-120$ compressions per minute.
- Compress the chest to a depth of $5-6 ext{ cm}$ .
- Ensure full chest recoil between compressions.
- Perform $5$ cycles of CPR, which typically takes $2$ minutes.
- CPR compressions should not be interrupted except for defibrillation or moving the patient, and total "off-the-chest" time must be no more than $5$ seconds at a time.

CPR Roles

CPR Triangle (with more personnel if resources allow):
- 1. Airway Person:
  - Deliver each breath over one second only.
  - DO NOT release your head tilt or jaw thrust position while waiting for subsequent breaths.
  - NEW: Start initiating $2$ breaths after $30$ compressions, continuing even if compressions have restarted before the second breath is administered.
  - NEW: Only deliver $350-500 ext{ mLs}$ from the Bag-Valve-Mask (BVM).
  - Consider early IGEL placement.
  - Watch for vomiting and signs of the patient breathing on their own.
  - Suction must be readily available.
- 2. AED Operator:
  - Position the monitor/AED at the patient's left shoulder.
- 3. Compression Person:
  - Pause for one second to allow for the first breath, then immediately continue with compressions, even if the second breath is not yet completed.
If more personnel are available: Designate a leader, a timekeeper, and multiple compressors to switch out.
Hover Method of CPR (New Update):
- For the person delivering breaths: Ensure you are hovering over the patient, immediately ready to start compressions again.
- When switching compressors: The person taking over should be on the opposite side of the patient (if possible), ready to initiate compressions as the original compressor withdraws, ensuring a seamless and uninterrupted rhythm.

Factors Causing Cardiac Arrest

It is vital to determine the underlying cause of the cardiac arrest (e.g., STEMI, NonSTEMI, Respiratory causes).
Consider AEIOUTIPS for potential causes:
- Alcohol, Acidosis
- Environment (temperature extremes), Epilepsy, Electrolytes (imbalance)
- Insulin (hypoglycemia/hyperglycemia)
- Overdose, Oxygen deprived (hypoxia)
- Underdose, Uremia
- Trauma
- Infection
- Psychosis, Poisons
- Sepsis, Stroke, Shock
Consider H's and T's for underlying factors:
- H's:
  - Hypovolemia (low blood volume)
  - Hypoxia (low oxygen)
  - Hydrogen Ion (acidosis)
  - Hyper/Hypothermia (extreme body temperatures)
  - Hyper/Hypoglycemia (blood sugar extremes)
  - Hyper/Hypokalemia (potassium imbalances)
- T's:
  - Toxins (drugs, poisons)
  - Tamponade (cardiac - fluid around the heart)
  - Tension pneumothorax (collapsed lung with pressure)
  - Thrombosis (coronary and pulmonary - blood clots in heart or lungs)
  - Trauma

Return of Spontaneous Circulation (ROCS)

If cardiac rhythm and pulse are restored (ROSC), immediately reassess:
- Airway: Is it clear? Is suctioning needed? Is an airway adjunct still required?
- Breathing: Assess rate and quality. Is there respiratory arrest? Ventilate between $8-10 ext{ bpm}$ . Consider changing the oxygen device. Titrate oxygen to maintain an SpO2 between $92-96\%$ (to avoid hyperoxia).
- Pulse: Check for a radial pulse; if absent, check carotid. Assess rate, rhythm, and quality. Remember that the heart rate might initially be slow; reevaluate frequently.
Post-ROSC Management:
- Obtain a FULL set of vital signs with serial $12$ -lead electrocardiograms (ECGs) every minute for $10$ minutes.
- Maintain ETCO2 levels at $30-35 ext{ mmHg}$ .
- If hypotensive, consider administering Normal Saline. Aim for a Mean Arterial Pressure (MAP) of $65 ext{ mmHg}$ or a Systolic Blood Pressure (SBP) greater than $90 ext{ mmHg}$ .
- Aim for a target temperature between $32-36$ Celsius. Use cold packs, air conditioning (AC), or remove blankets if the patient's temperature is higher than $38$ Celsius.
- Perform a secondary assessment.
- Establish intravenous (IV) access if not already done.
- Refer to the AHS Protocol ROSC (link provided in transcript).
- Crucial Point: There is a high likelihood of returning to cardiac arrest if the underlying cause cannot be reversed, so never remove the AED pads.
Avoid the 3 "H-Bombs" Post-ROSC:
- Hypoxia
- Hyperventilation
- Hypotension: A Systolic Blood Pressure (SBP) less than $80 ext{ mmHg}$ carries a high risk of re-arresting within the next $2-3$ minutes.

Discontinuing or Withholding Resuscitation

Reasons EMS Would Withhold Resuscitation:
- A valid Goals of Care order is in place.
- During a Mass Casualty Incident (MCI), with the exception of lightning strike victims.
- Trauma injuries that are clearly not sustainable with life.
- Obvious signs of death (mnemonic "DRIED" + Frozen Solid):
  - Decapitated / Dependent Lividity
  - Rigor Mortis
  - Incinerated
  - Eviscerated
  - Decomposed
  - Frozen Solid
Criteria for Discontinuing Resuscitation:
- Completion of the appropriate Cardiac Arrest Protocol for a minimum of $30$ minutes.
- The initial rhythm was not shockable (i.e., asystole or pulseless electrical activity).
- There was no Return of Spontaneous Circulation (ROSC) at any point during the resuscitation efforts.
- Questions to consider: What if there was an initial shockable rhythm? What if ROSC was achieved but not sustained? (These situations typically require continued efforts unless other discontinuation criteria are met).
References for Algorithms and Notes:
- Review the AHS - Adult Withholding / Discontinuing Resuscitation Algorithm (link provided in transcript).
- Review the Adult Withholding / Discontinuing Resuscitation Notes (link provided in transcript).