1. Adult Cardiac Arrest Part II:
Advanced Life Support
General Emergency Medicine Topics
With Julianna Jung, MD
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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2. Learning Objectives
• You will be able to identify the three major cardiac arrest
rhythms (ventricular fibrillation/tachycardia, pulseless
electrical activity, and asystole).
• You will be able to list the differential diagnoses and
describe the underlying physiology for each arrest type.
• You will be able to identify key similarities and differences
between the treatment algorithms for each arrest type.
• You will be able to describe the pathophysiologic and
evidentiary rationale for major interventions within each
algorithm.
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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3. Three Major Cardiac Arrest Rhythms
Absence of electrical
activity in the heart
Definition
Ventricular fibrillation/
Pulseless ventricular
tachycardia
Asystole
Absence of clinically
detectable pulse despite
the presence of organized
electrical activity in the
heart
Abnormal and accelerated
electrical activity
originating in the
ventricles and leading to
loss of effective circulation
Pulseless electrical
activity
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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4. Usually caused by primary
cardiac disease, most
commonly ischemia
Less commonly caused by
systemic conditions
(electrolyte disturbances,
toxins, autoimmunity)
Can also be caused by
structural heart disease or
channelopathies
Ventricular Fibrillation/Tachycardia Etiology
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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5. Ventricular Fibrillation
Jafary FH - The "incidental" episode of ventricular fibrillation: a case report., cropped and resized https://openi.nlm.nih.gov/detailedresult.php
?img=PMC2000884_1752-1947-1-72-1&query=ventricular+fibrillation&it=xg&lic=by&req=4&npos=5, CC BY 2.0
Diagnosis
No mechanical contraction =
no pulse!
Incompatible with life
Randomly fluctuating, no
pattern, no QRS complexes
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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6. Ventricular Tachycardia
ps://openi.nlm.
nih.gov/detailedresult.php?img=PMC4320716_pjms-30-1281-g003&query=ventricular+tachycardia&it=xg&lic=by&req=4&npos=27, CC BY 2.0
Diagnosis
Wide, bizarre QRS complexes,
but organized and regular
May be pulseless, stable, or
unstable
Rapid rate (> 100 by
definition; usually > 150)
150 100
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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7. Ventricular Fibrillation/Tachycardia Management
What is the single most important intervention for these arrest types?
Defibrillate!
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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8. Ventricular Fibrillation/Pulseless Ventricular Tachycardia - Algorithm Management
Call for help,
start CPR
Defibrillate
Rhythm
check/defib
Epinephrine
If rhythm is not
restored, 5 cycles
30:2 CPR (or 2 min)
Rhythm
check/defib
Consider
amiodarone
If rhythm is
not restored,
5 cycles 30:2
CPR (or 2
min)
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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9. Nonselective adrenergic
agonist
Very little supporting
evidence
Increases systemic
vascular resistance,
increasing perfusion to
heart and brain
Epinephrine Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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10. Only one randomized controlled trial:
Epinephrine
Jacobs IG, Finn JC, Jelinek GA, Oxer HF, Thompson PL. Effect of adrenaline on survival in out-of-hospital cardiac arrest: A randomised
double-blind placebo-controlled trial. Resuscitation. 2011;82(9):1138-1143.
Management
Outcome Placebo (n = 262) Adrenaline (n = 272) OR (95 % CI) P value
ROSC achieved
pre-hospital
22 (8.4 %) 64 (23.5 %) 3.4 (2.0 5.6) < 0.001
Admitted to
hospital
34 (13.0 %) 69 (25.4 %) 2.2 (1.4 3.6) < 0.001
Survived to
hospital
discharge
5 (1.9 %) 11 (4.0 %) 2.2 (0.7 6.3) 0.15
CPC 1 or 2 5 (100 %) 9 (81.8 %) - 0.31
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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11. • Stimulates α receptors to increase
vascular tone
• Optimizes perfusion of the heart and
brain
• Improves short-term survival, which is a
prerequisite for long-term survival
• Stimulates β receptors, which increase
myocardial oxygen demand
• Reduces perfusion to all other organs
• Effect on long-term survival may be
negligible or deleterious
Epinephrine
Pros Cons
Complications
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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12. Epinephrine Bottom Line
Epi is mandatory in current arrest algorithms.
Give 1 mg (10 mL of 1:10,000 solution) IV/IO every 3 5 minutes.
Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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13. • Class III antiarrhythmic indicated for shock-
refractory VF/VT
•
lidocaine not mandatory
• Two studies show improved short-term survival
with amiodarone vs. placebo
• No evidence of superiority of amiodarone over
lidocaine
• No evidence of benefit for long-term survival
Amiodarone Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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14. Amiodarone Bottom Line
Amio is commonly used for refractory VF/VT.
Give 300 mg IV/IO loading dose; consider infusion after ROSC.
Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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15. Ventricular Fibrillation/Tachycardia Algorithm Management
Call for help,
start CPR
Defibrillate
If rhythm is
not restored,
5 cycles 30:2
CPR (or 2 min)
Rhythm
check/defib
Epinephrine
Rhythm
check/defib
Consider
amiodarone or
lidocaine
If rhythm is not
restored, 5 cycles 30:2
CPR (or 2 min)
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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16. Pulseless Electrical Activity
Mugmon M - J PubMed, Is it really sinus tachycardia?, resized, https://openi.nlm.nih.gov/detailedresul
t.php?img=PMC3714029_JCHIMP-1-7241-g001&query=sinus+tachycardia&lic=by&req=4&npos=1, CC BY 2.0
Diagnosis
Electrical activity on the monitor + no pulse on exam = PEA
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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17. Pulseless Electrical Activity
What is the single most
important intervention
for this arrest type?
Identify and reverse
the underlying
pathology!
Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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18. Mechanisms of PEA
Electromechanical dissociation
Electrical conduction in
the heart is normal.
Electrical conduction in
the heart is normal.
Caused by hypovolemia or extracardiac
obstruction to filling (e.g., tamponade,
tension pneumothorax).
Caused by systemic derangements that
impair energy metabolism or directly
impair myocyte function in the heart.
Contraction occurs but is ineffective
because the heart does not fill.
Action potentials yield little or no
cardiac myocyte contraction.
Etiology
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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19. High-yield
Differential Diagnosis of PEA H s and T s Diagnosis
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hyper/hypokalemia
Hypothermia
Tension pneumothorax
Tamponade, pericardial
Toxins
Thrombosis, coronary
Thrombosis, pulmonary
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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20. PEA Identifying the Underlying Cause Diagnosis
History
Physical exam
Bedside
ultrasound
Circumstances surrounding the arrest, past medical/surgical history
Signs of trauma, pregnancy, presence of dialysis catheter/fistula,
temperature, cyanosis, breath sounds, jugular venous distension
Pericardial effusion/tamponade, absence of lung sliding, cardiac ejection
fraction, IVC size
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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21. Ultrasound in PEA Cardiac Tamponade
-5 B, Saunders (Elsevier)
Diagnosis
RV
RA
C
PE
Pericardial
effusion
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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22. Ultrasound in PEA IVC Collapse
Bedside emergency cardiac ultrasound in children, Doniger SJ - J Emerg Trauma Shock (2010), cropped and resized, https://openi.nlm.nih.
gov/detailedresult.php?img=PMC2938495_JETS-3-282-g012&query=IVC+Collapse&it=u&lic=by&req=4&npos=4, CC BY 2.0
Diagnosis
IVC size
(cm)
Resp.
Change
CVP
< 1.5 Total 0 5
1.5 2.5 > 50 % 6 10
1.5 2.5 < 50 % 11 15
> 2.5 < 50 % 16 20
> 2.5 None > 20
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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23. Clinical pearl
Important to Note while Treating Cardiac Arrest
Clinical pearl
Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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24. Empiric Treatments for PEA Management
Suspected diagnosis Management
Hypovolemia/hemorrhage IV fluids, blood
Hypoxia Supplemental O2, intubate
Acidosis Bicarbonate, correct cause
Hyperkalemia
Calcium, insulin/glucose, albuterol,
bicarbonate
Hypothermia Rewarming
Tension pneumothorax Needle decompression
Cardiac tamponade Pericardiocentesis
Toxins Antidotes
Myocardial infarction PCI or thrombolysis
Pulmonary embolism Thrombolysis
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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25. High-quality CPR Rhythm checks
every 2 minutes
Epinephrine 1 mg
every 3 5
minutes
Continue searching
for the underlying
cause and attempt to
reverse it
Other Interventions for PEA Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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26. Pulseless Electrical Activity Algorithm Management
Call for help,
start CPR
Obtain IV access,
search for
underlying cause
Epinephrine,
treat underlying
cause
Continue CPR,
check rhythm
every 2 min
Repeat epi
every 3 5 min
Continue to
search for and
treat cause
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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27. Asystole
Glenlarson, PD
Diagnosis
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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28. Management is the
same as for PEA:
CPR, epinephrine,
search for and treat
cause.
Differential
diagnosis is also
the same as
PEA.
Pay particular
attention to
oxygenation and
ventilation.
Verify asystole in
at least two leads.
Asystole Management
90
95
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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29. Asystole
Asystole is more commonly a confirmation of death rather
than a disease to be treated. Terminate resuscitation when
appropriate.
Clinical pearl
Management
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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30. Perform high-quality CPR for all arrests.
Cardiac rhythm dictates appropriate management.
Defibrillate VF/VT, and give epi/amiodarone or
lidocaine.
Reverse cause of PEA/asystole, and give epi.
Conclusion
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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31. • Ensure appropriate oxygen levels with pulse oximetry monitoring.
• If the patient is hypotensive, treat with IV fluids and vasopressers (e.g. levophed,
norepinephrine, dopamine).
• If the patient has a pulse but is unarousable, induce hypothermia at 32-36 °C.
• If the patient follows commands, get an ECG and treat accordingly.
• Continue evaluating H's and T's. The H's are: hypovolemia, hypoxia, hydrogen ion
(acidosis), hyper/hypokalemia, and hypothermia. The T's are: toxins, tamponade (cardiac),
tension pneumothorax, trauma, and thrombosis.
Post-arrest Care
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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32. Learning Outcomes
✓ You are now able to perform advanced
cardiac life support for all three arrest
rhythms.
✓ You are able to approach the differential
diagnosis of PEA.
✓ You are able to incorporate ultrasound into
patient assessment during cardiac arrest.
Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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33. This document is a property of: Sbonakaliso Gumede
Note: This document is copyright protected. It may not be copied, reproduced, used, or
distributed in any way without the written authorization of Lecturio GmbH.
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Sbonakaliso Gumede, sbonakalisogumede037@gmail.com
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