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Cardiac Arrest: Difference between revisions
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''Sébastien Krul, MD, Jonas de Jong, MD'' | ''Sébastien Krul, MD, Jonas de Jong, MD'' | ||
=Introduction= | =Introduction= | ||
Survival of cardiac arrest continues to be very poor. In-hospital cardiac arrest has a survival to hospital discharge of 17,6% all rhythms<cite>Meaney</cite>. Out-of-hospital cardiac arrest has a worse survival with 10,7% survival to hospital discharge for all rhythms.<cite>Atwood</cite> Survival is dependent on the characteristics of the cardiac arrest (rhythm), on the patient’s medical history, and the time between the cardiac arrest en start of resuscitation.<cite>Waalewijn, Holmberg1, Holmberg2</cite> The introduction of the automated external defibrillator (AED) has dramatically increased survival of out-of-hospital cardiac arrest victims.<cite>ESC, Nolan1</cite> In this chapter we give an overview of basic life support (BLS) and advanced life support (ALS) based on the recommendation of the European Resuscitation Council Guidelines for Resuscitation 2010. | Survival of cardiac arrest continues to be very poor. In-hospital cardiac arrest has a survival to hospital discharge of 17,6% all rhythms<cite>Meaney</cite>. Out-of-hospital cardiac arrest has a worse survival with 10,7% survival to hospital discharge for all rhythms.<cite>Atwood</cite> Survival is dependent on the characteristics of the cardiac arrest (rhythm), on the patient’s medical history, and the time between the cardiac arrest en start of resuscitation.<cite>Waalewijn, Holmberg1, Holmberg2</cite> The introduction of the automated external defibrillator (AED) has dramatically increased survival of out-of-hospital cardiac arrest victims.<cite>ESC, Nolan1</cite> In this chapter we give an overview of basic life support (BLS) and advanced life support (ALS) based on the recommendation of the European Resuscitation Council Guidelines for Resuscitation 2010. | ||
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====Foreign body airway obstruction==== | ====Foreign body airway obstruction==== | ||
An obstruction of the airway is uncommon, but reversible and adequate recognition can prevent cardiac arrest.<cite>Fingerhut</cite> Airway obstruction is usually related | An obstruction of the airway is uncommon, but reversible and adequate recognition can prevent cardiac arrest.<cite>Fingerhut</cite> Airway obstruction is usually related to eating. In a mild obstruction patients can cough and speak and only frequent reassessment is advised. Patients that have a severe obstruction are unable to speak and have problems breathing and coughing. If a patient is still conscious five back blows can be applied between the shoulder blades whilst the patient leans forward. Otherwise five abdominal thrusts can be applied by clenching a fist and grasping it with the other hand. Place the hands it between the rib-cage and the umbilicus and pull sharply inward and upward whilst standing behind the patients.<cite>Guildner, Ruben</cite> If the patient loses consciousness start BLS.<cite>Koster2</cite> | ||
====Basic life support in children==== | ====Basic life support in children==== | ||
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==Preventing in Hosptial Cardiac Arrest== | ==Preventing in Hosptial Cardiac Arrest== | ||
[[File:MEWS.svg|thumb|500px|right|'''Figure 2.''' An example of a MEWS<cite>IHI</cite>.]] | [[File:MEWS.svg|thumb|500px|right|'''Figure 2.''' An example of a MEWS. Adapted from: <cite>IHI</cite>.]] | ||
The best way to prevent sudden death is to early detect deterioration of a patient and to act on early warning signs.<cite>Smith</cite> An early warning score (Figure 2) helps to create consensus among care providers about the sickness of a patient.<cite>Hodgetts, Hillman</cite> If the summed score | The best way to prevent sudden death is to early detect deterioration of a patient and to act on early warning signs.<cite>Smith</cite> Cardiac arrest is rarely unpredictable and is precipitated by a slow deterioration. An early warning score (Figure 2) helps to create consensus among care providers about the sickness of a patient.<cite>Hodgetts, Hillman</cite> If the summed score reached a certain threshold, a doctor should be notified. The notified doctor should assess the patient within 30 minutes and discuss a treatment plan. If the patient does not improve within 60 minutes a reassessment should follow with possible inclusion of a medical emergency team (MET) or intensive care specialist.<cite>Bellomo</cite> | ||
==Advanced Life Support (ALS)== | ==Advanced Life Support (ALS)== | ||
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====Patient assessment==== | ====Patient assessment==== | ||
During a cardiac arrest a structured assessment of the patient is required to detect the effects of the resuscitation, return of spontaneous circulation, reversible causes. To facilitate this assessment, an ABCDE approach can be used.<br> | During a cardiac arrest a structured assessment of the patient is required to detect the effects of the resuscitation, return of spontaneous circulation, reversible causes. To facilitate this assessment, an ABCDE approach can be used.<cite>Thim, Guly</cite><br> | ||
'''Airway:''' During the first step it is important to assess if the airway is clear. Airway obstruction can occur at any level. It can be caused by obstruction from the soft palate and epiglottis, blood, vomit and foreign bodies or airway oedema. It is important to look, listen and feel for airway obstruction. Look for chest and abdominal movements, listen and feel for airflow at the mouth and nose. In partial airway obstruction, the inspiration or expiration is usually noisy by an inspiratory stridor or expiratory wheeze.<br> | '''Airway:''' During the first step it is important to assess if the airway is clear. Airway obstruction can occur at any level. It can be caused by obstruction from the soft palate and epiglottis, blood, vomit and foreign bodies or airway oedema. It is important to look, listen and feel for airway obstruction. Look for chest and abdominal movements, listen and feel for airflow at the mouth and nose. In partial airway obstruction, the inspiration or expiration is usually noisy by an inspiratory stridor or expiratory wheeze.<br> | ||
'''Breathing:''' Hypoxaemia is a reversible cause and after assessment and securing the airway, ventilation of the patient should be optimized. Arterial blood oxygen saturation can be monitored to assess hypoxaemia. If necessary tracheal intubation, sedation and controllered ventilation should be instituted.<br> | '''Breathing:''' Hypoxaemia is a reversible cause and after assessment and securing the airway, ventilation of the patient should be optimized. The airway can be secured using a variety of devices and ventilation methods. Arterial blood oxygen saturation can be monitored to assess hypoxaemia. If necessary tracheal intubation, sedation and controllered ventilation should be instituted.<br> | ||
'''Circulation:''' Myocardial ischemia or infarction is a common cause of cardiac arrest. Furthermore before or after the cardiac arrest tachycardias or bradycardias may occur and acute management is indicated. <br> | '''Circulation:''' Myocardial ischemia or infarction is a common cause of cardiac arrest. Furthermore before or after the cardiac arrest tachycardias or bradycardias may occur and acute management is indicated. <br> | ||
'''Disability:''' This step consist of determining the Glasgow Coma Scale of the patients and look for neurologic symptoms that might cause cardiac arrest. Furthermore it is important monitor glucose and temperature. <br> | '''Disability:''' This step consist of determining the Glasgow Coma Scale of the patients and look for neurologic symptoms that might cause cardiac arrest. Furthermore it is important monitor glucose and temperature. <br> | ||
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====Shock protocol==== | ====Shock protocol==== | ||
When a shockable rhythm is detected, it is important to minimize the time between chest compressions and defibrillation. When the shock is delivered immediately resume with the chest compressions to minimize delay. Even after a successful shock the heart can be stunned and effective circulation can only be maintained through chest compressions. After the first round of shock and compressions reassess rhythm and act according to the protocol. After the third shock has been given, adrenaline 1mg and amiodarone 300mg can be administered intravenously. Further adrenaline 1mg can be administered every 3-5 minutes, there is no further indication for anti-arrhythmic drugs during resuscitation. Continuous monitoring is required for return of spontaneous circulation or for asystole and initiation of the no-shock protocol. | When a shockable rhythm is detected, it is important to minimize the time between chest compressions and defibrillation.<cite>Edelson, Eftestol</cite> When the shock is delivered immediately resume with the chest compressions to minimize delay. Even after a successful shock the heart can be stunned and effective circulation can only be maintained through chest compressions. After the first round of shock and compressions reassess rhythm and act according to the protocol. After the third shock has been given, adrenaline 1mg and amiodarone 300mg can be administered intravenously.<cite>Olasveengen, Dorian</cite> Further adrenaline 1mg can be administered every 3-5 minutes, there is no further indication for anti-arrhythmic drugs during resuscitation. Continuous monitoring is required for return of spontaneous circulation or for asystole and initiation of the no-shock protocol. | ||
====No-shock protocol==== | ====No-shock protocol==== | ||
When asystole or pulseless electrical activity is detected CPR should be started immediately simultaneously with 1mg intravenous adrenaline. Assess the rhythm after 2 minutes of chest compressions and continue according to the rhythm. Continue with adrenaline injections intravenously every 3-5 minutes if no return of spontaneous circulation has been achieved. There is no place for further medical intervention. | When asystole or pulseless electrical activity is detected CPR should be started immediately simultaneously with 1mg intravenous adrenaline. Assess the rhythm after 2 minutes of chest compressions and continue according to the rhythm. Continue with adrenaline injections intravenously every 3-5 minutes if no return of spontaneous circulation has been achieved. There is no place for further medical intervention. | ||
====Post-cardiac arrest treatment==== | ====Post-cardiac arrest treatment==== | ||
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# Geddes pmid=3543629 | # Geddes pmid=3543629 | ||
# Cooper pmid=8570929 | # Cooper pmid=8570929 | ||
# Smith pmid=15071378 | |||
# Hodgetts pmid=12161291 | |||
# Bellomo pmid=20598425 | |||
# Hillman pmid=15964445 | |||
# Pellis pmid=19010581 | |||
# Glaeser pmid=8517560 | |||
# Olasveengen pmid=19934423 | |||
# Nolan5 pmid=18963350 | |||
# Thim pmid=22319249 | |||
# Guly pmid=12835350 | |||
# Balan pmid=17068310 | |||
# Padkin pmid=19460604 | |||
# Froehler pmid=17559883 | |||
# Polderman pmid=19237924 | |||
# Arrich pmid=17334257 | |||
# Laver pmid=15365608 | |||
# Zandbergen pmid=16401847 | |||
# Edgren pmid=3621954 | |||
# English pmid=19604197 | |||
# Wijdicks pmid=16864809 | |||
# Edelson pmid=16982127 | |||
# Eftestol pmid=12010909 | |||
# Dorian pmid=11907287 | |||
# IHI http://www.ihi.org/knowledge/Pages/ImprovementStories/HospitalatNightProgram.aspx | # IHI http://www.ihi.org/knowledge/Pages/ImprovementStories/HospitalatNightProgram.aspx | ||