1. Dr. Shreyash Trived Dr. (Prof.) V. Priyadarshi Unit

2. INTRODUCTION Sudden cardiac arrest (SCA) and sudden cardiac death (SCD) refer to the sudden cessation of cardiac activity with hemodynamic collapse. If an intervention (e.g., defibrillation) restores circulation, the event is referred to as SCA. If uncorrected, an SCA event leads to death and is then referred to as SCD. 3. DEFINITION OF SUDDEN CARDIAC DEATH Sudden cardiac death is defined as natural death due to cardiac causes in a person who may or may not have previously recognized heart disease but in whom the time and mode of death are unexpected. 4. In the context of time, sudden is defined for most clinical and epidemiologic purposes as 1 hour or less between a change in clinical status heralding the onset of the terminal clinical event and the cardiac arrest itself. To satisfy clinical, scientific, legal, and social considerations, four temporal elements must be considered: (1) prodromes, (2) onset of terminal event, (3) cardiac arrest, and (4) biologic death 5. SCD viewed from four temporal perspectives 6. EPIDEMIOLOGY OF SCD Approx. 5,00,000 CASES IN U.S.A PER ANNUM Accounts for 10-15% of natural deaths and 50 % deaths from cardiac causes. BIMODAL AGE DISTRIBUTION with peaks between birth and 6 months of age & after 65 yrs of age Male preponderance May be the first presentation of cardiovascular disease in 25% of patients 7. AGE RELATED RISK FOR SCD 8. Prior Episode of V.TACH Low LVEF. Previous Myocardial Infarction. Coronary Artery Disease Family History of SCD. Cardiomyopathy Congestive Heart Failure Long QT Syndrome. Right Ventricular Dysplasia. Risk Factors of Sudden Cardiac Death (SCD) 9. SUDDEN CARDIAC ARREST Abrupt cessation of cardiac mechanical function, which may be reversible by a prompt intervention (e.g., defibrillation) but will lead to death in its absence. 10. Three Basic ECG Patterns with Cardiac Arrest Ventricular tachyarrhythmia-- ventricular fibrillation (VF)/sustained type of pulseless ventricular tachycardia Ventricular asystole or a brady-asystolic rhythm with an extremely slow rate Pulseless electrical activity (PEA), previously referred to as electromechanical dissociation. 11. Ventricular Tachycardia 12. SUDDEN CARDIAC ARREST The probability of achieving successful resuscitation from cardiac arrest is related to- Interval from onset of loss of consciousness to institution of resuscitative efforts The setting in which the arrest occurs The mechanism ( VT, VF, PEA, ASYSTOLE) of CA Clinical status of the patient before the cardiac arrest. 13. SUDDEN CARDIAC ARREST Return of circulation and survival rates as a result of defibrillation decreases almost linearly from first to 10th min. 14. SUDDEN CARDIAC ARREST After 5 min, survival rates are no better than 25-30% in out of hospital setting Outcome in ICU and other in-hospital environments is heavily influenced by patients preceding clinical status 15. SUDDEN CARDIAC ARREST When the mechanism is pulseless VT, the outcome is best VF is the next most successful Asystole and PEA generate dismal outcome statistics 16. Successful resuscitation following cardiac arrest requires an integrated set of coordinated actions represented by the links in the Chain of Survival 17. The links include the following: Immediate recognition of cardiac arrest and activation of the emergency response system Early CPR with an emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post cardiac arrest care 18. Signs and symptoms The most reliable sign is absence of pulse Unconsciousness/Unresponsiveness No respiratory movements No blood pressure Pupils begin dilating within 45 secs. Seizures- may or may not occur Death like appearance Lips and nail beds turn blue and skin turns pale 19. INITIAL RESPONSE As soon as a cardiac arrest is suspected , confirmed, or even considered to be impending, calling an emergency rescue system is the immediate priority 20. BLS (Basic Life Support) 21. The goal of this activity is to maintain viability of the CNS, heart and other vital organs until definitive intervention can be achieved. Fundamental aspects of BLS include- Immediate recognition of SCA and activation of emergency response system Early CPR Rapid defibrillation with an automated external defibrillator (when appropriate) 22. Immediate recognition and activation of emergency response system If a lone rescuer finds an unresponsive adult or witnesses an adult who suddenly collapses, after ensuring that the scene is safe, the rescuer should check for a response by tapping the victim at the shoulder and by shouting at him The trained or untrained bystander should activate the community emergency response system, or if in an institution with an emergency response system call that facilitys emergency response number 23. Unresponsiveness If the victim also has absent or abnormal breathing(ie, only gasping) the rescuer should assume that the victim is in cardiac arrest 24. PULSE CHECK: Studies have shown that both lay rescuers and health care providers (HCP) have difficulty detecting a pulse. The lay rescuer should not check for a pulse If the HCP doesnt definitely feel a pulse within 10 secs he should start chest compressions. 25. EARLY CPR A change in the 2010 AHA guidelines for CPR is to recommend the initiation of compressions before rescue breaths Change from ABC to CAB 26. RESCUER SPECIFIC CPR STRATEGIES Untrained lay rescuer:- Hands-only (chest compression only) CPR, with an emphasis on push hard and push fast until an AED arrives or HCP take over Trained lay rescuer:- should start chest compressions first. add rescue breaths in the ratio of 30 compressions to two breaths if able to do so HCP:- Cycle of 30:2 until an advanced air way is placed; then continuous chest compressions with 1 breath every 6 to 8 secs. 27. Technique : chest compressions Place victim on a firm surface in supine position Rescuer kneeling besides victims chest (out of hospital) or standing besides bed (in hospital) Place heel of one hand over the lower half of sternum. Heel of the other hand should be on top of the first so that they overlap and are parallel. Arms should be straight and perpendicular to chest of victim 28. Technique: Rescue breaths Open airway- Head tilt and chin lift/ Jaw thrust Mouth to mouth Mouth to barrier device Mouth to nose and mouth and stoma Ventilation with bag and mask Ventilation with supraglottic airway- LMA, esophageal combitube, king airway device 29. Technique: Rescue breaths To provide mouth-to-mouth rescue breaths, open the victims airway- pinch the victims nose- and create an airtight mouth-to-mouth seal. Give 1 breath over 1 second, take a regular (not a deep) breath, and give a second rescue breath over 1 second Advanced airway- 1 breath every 6-8 secs ASYNCHRONOUS with compressions 30. Opening the airway 31. Providing basic ventilation Mouthtomouthventilation Mouthtonoseventilation Mouthtobarrierdevice Bag mask ventilation 32. Advanced airways ETtube combitube LMA 33. Summary of Key BLS Components for Adults, Children and Infants 34. ADVANCED CARDIAC LIFE SUPPORT 35. This next step in resuscitative sequence is designed to achieve a stable Return of Spontaneous Circulation ( ROSC), and hemodynamic stabilization There should not be an abrupt cessation of BLS, rather a merging and transition from one level of activity to the next. 36. Goals of ACLS Revert the cardiac rhythm to one that is hemodynamically effective-by defibrillation/cardioversion To optimize ventilation-through placement of an advanced airway (i.e., intubation) To maintain and support the restored circulation- monitoring and use of drugs 37. Basics of ACLS Immediately after activating emergency response, start CPR Attach monitor/defibrillator minimizing interruptions in CPR Shockable rhythm- defibrillate with recommended shock energy and immediately resume CPR for 2 mins (5 cycles) 38. Rhythm-Based Management of Cardiac Arrest 39. Paddles and electrode pads: anterior-lateral position Any doubt about the presence of a pulse chest compressions Rhythm can be diagnosed before CPR is initiated 40. Defibrillation: Electrode Placement 41. VF/Pulseless VT 42. Resume CPR while charging the defibrillator Chest compressions should switch at every 2-minute cycle to minimize fatigue 43. Defibrillation Strategies Waveform and Energy Biphasic defibrillator: manufacturers recommended energy dose (120-200 J) Unaware of the effective dose range: maximal dose 44. Defibrillation Strategies Waveform and Energy Second and subsequent energy levels should be at least equivalent, and higher energy levels may be considered if available. Monophasic defibrillator: 360 J Subsequent shocks at the previously successful energy level 45. Drug Therapy in VF/Pulseless VT Amiodarone: first-line antiarrhythmic agent Magnesium sulfate Torsades de pointes associated with a long QT interval 46. Treating Potentially Reversible Causes of VF/Pulseless VT Refractory VF/pulseless VT: AMI 47. PEA/Asystole 48. Drug Therapy for PEA/Asystole Vasopressor can be given as soon as feasible Available evidence suggests that the routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit . For this reason atropine has been removed from the cardiac arrest algorithm. 49. Treating Potentially Reversible Causes of PEA/Asystole PEA reversible conditions treated successfully if those conditions are identified and corrected Hypoxemia: advanced airway severe volume loss or sepsis: administration of empirical IV/IO crystalloid. severe blood loss: blood transfusion pulmonary embolism: empirical fibrinolytic therapy (Class IIa, LOE B) tension pneumothorax: needle decompression 50. Treating Potentially Reversible Causes of PEA/Asystole Asystole end-stage rhythm that follows prolonged VF or PEA, and for this reason the prognosis is generally much worse 51. MONITORING DURING CPR Mechanical parameteres Rate of compression: 100/min Depth of compression: 2 inches (5 cm) Rate of ventilation: 1 breath every 6-8 s (8-10 breath/min) 52. Physiologic Parameters Pulse End-Tidal CO2 Coronary Perfusion Pressure and Arterial Relaxation Pressure Central Venous Oxygen Saturation Pulse Oximetry Arterial Blood Gases Echocardiography 53. End-Tidal CO2 If PETCO2 is