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Cardiac Arrest: Difference between revisions
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* <b>Asthma:</b> Patients with asthma who experience a cardiac arrest usually have a long period of hypoxaemia, however cardiac arrest is not necessarily related to asthma severity. Patients with acute severe asthma require oxygen, aggressive medical therapy and should be admitted to the critical care area. The main troubles encountered in the resuscitation of patients with asthma relates to the underlying lung disease. In general increased lung resistance makes ventilation of these patients difficult and can increase the risk of gastric inflation. Early intubation is indicated in these patients during the ALS setting. Due to the hyperinflation of the lungs more energy might be required in defibrillating these patients, as the heart is isolated by air. | * <b>Asthma:</b> Patients with asthma who experience a cardiac arrest usually have a long period of hypoxaemia, however cardiac arrest is not necessarily related to asthma severity. Patients with acute severe asthma require oxygen, aggressive medical therapy and should be admitted to the critical care area. The main troubles encountered in the resuscitation of patients with asthma relates to the underlying lung disease. In general increased lung resistance makes ventilation of these patients difficult and can increase the risk of gastric inflation. Early intubation is indicated in these patients during the ALS setting. Due to the hyperinflation of the lungs more energy might be required in defibrillating these patients, as the heart is isolated by air. | ||
* <b>Cardiac arrest after cardiac surgery: </b>Cardiac arrest after cardiac surgery is usually caused by specific causes related as a consequence of the cardiac surgery, such as tamponade, hypovolaemia, myocardial ischaemia, tension pneumothorax, or pacing failure. Early resternotomy can be the key to survival, especially after repeated defibrillation has failed or if asystole is observed. When the sternum is opened internal cardioversion (output of 5-20J) and cardiac compression can be applied across the ventricles. | * <b>Cardiac arrest after cardiac surgery: </b>Cardiac arrest after cardiac surgery is usually caused by specific causes related as a consequence of the cardiac surgery, such as tamponade, hypovolaemia, myocardial ischaemia, tension pneumothorax, or pacing failure. Early resternotomy can be the key to survival, especially after repeated defibrillation has failed or if asystole is observed. When the sternum is opened internal cardioversion (output of 5-20J) and cardiac compression can be applied across the ventricles. | ||
* <b>Drowning: </b>Drowning is a common cause of accidental death. There are no differences between victims of salt water and fresh water drowning. Correction of hypoxia is critical in the outcome of these victims as cardiac arrest is a consequence of the hypoxia. Care should be taken to start immediate resuscitation and restore oxygenation, ventilation and perfusion. During BLS it is recommended to start the BLS with 5 rescue breaths. Rescue breathing is difficult after drowning due tot the presence of fluid in the airway and the high inflation pressure required after drowning. Furthermore regurgitation is common and removal of the regurgitated material during resuscitation is required. It is common for hypothermia to be present in victims of drowning, complicating the resuscitation attempt. After return of spontaneous circulation, pneumonia is common and patients are prone to develop acute respiratory distress syndrome (ARDS). | * <b>Drowning: </b>Drowning is a common cause of accidental death.<cite>Peden</cite> There are no differences between victims of salt water and fresh water drowning. Correction of hypoxia is critical in the outcome of these victims as cardiac arrest is a consequence of the hypoxia. Care should be taken to start immediate resuscitation and restore oxygenation, ventilation and perfusion. During BLS it is recommended to start the BLS with 5 rescue breaths.<cite>Youn</cite> Rescue breathing is difficult after drowning due tot the presence of fluid in the airway and the high inflation pressure required after drowning. Furthermore regurgitation is common and removal of the regurgitated material during resuscitation is required.<cite>Manolios</cite> It is common for hypothermia to be present in victims of drowning, complicating the resuscitation attempt. After return of spontaneous circulation, pneumonia is common and patients are prone to develop acute respiratory distress syndrome (ARDS).<cite>Gregorakos, Berkel</cite> | ||
* <b>Electrocution:</b> Electrocution can result in multi-system injury and usually occur in the workspace in adult or at home in children. The direct effects of an electric shock on tissues, for instance paralysis of the respiratory system or muscles, VF in the myocardium, ischemia due to coronary artery spasm or asystole can result in a cardiac arrest. Electrical burns can complicate the resuscitation and care should be taken to avoid further complications resulting from these burns. Adequate fluid therapy is required if there is significant tissue destruction. Due to electrical burns around the neck and muscular paralysis early intubation and prolonged ventilatory support may be required. | * <b>Electrocution:</b> Electrocution can result in multi-system injury and usually occur in the workspace in adult or at home in children. The direct effects of an electric shock on tissues, for instance paralysis of the respiratory system or muscles, VF in the myocardium, ischemia due to coronary artery spasm or asystole can result in a cardiac arrest. Electrical burns can complicate the resuscitation and care should be taken to avoid further complications resulting from these burns. Adequate fluid therapy is required if there is significant tissue destruction. Due to electrical burns around the neck and muscular paralysis early intubation and prolonged ventilatory support may be required. | ||
* <b>Electrolyte disorder:</b> Electrolyte abnormalities are among the most common causes of cardiac arrhythmias. Potassium disorders are commonly seen, especially hyperkalaemia has a high risk of malignant arrhythmias. During cardiac arrest treatment of these abnormalities is no different than in the normal clinical setting, and aggressive treatment of the electrolyte disorder should be initiated. | * <b>Electrolyte disorder:</b> Electrolyte abnormalities are among the most common causes of cardiac arrhythmias. Potassium disorders are commonly seen, especially hyperkalaemia has a high risk of malignant arrhythmias<cite>Niemann</cite>. During cardiac arrest treatment of these abnormalities is no different than in the normal clinical setting, and aggressive treatment of the electrolyte disorder should be initiated.<cite Alfonzo, Mahoney</cite> | ||
* <b>Hyperthermia:</b> Exogenous or endogenous hyperthermia can result in heat stress, progressing to heat exhaustion and results in heat stroke. Heat stress can provoke edema, syncope and cramps and is treated with rest, cooling and oral rehydration and salt replacement. Heat exhaustion is a systemic reaction to prolonged heat exposure and is accompanied by headaches, dizziness, nausea, vomiting, tachycardia, hypotension, muscle pain, weakness and cramps. Treatment is similar as in a heat stroke, but active cooling might be required in severe cases with ice packs or cold intravenous fluids. Heat stroke is a systemic inflammatory response with a core temperature above 40,6<sup>o</sup>C. It can lead to varying levels of organ dysfunction accompanied by mental changes. It can occur during high environmental temperatures or during strenuous physical exercise in high environmental temperatures. Rapid cooling of the victim should occur as soon as possible. Patients with heat-stroke usually have electrolyte abnormalities and hypovolaemia. | * <b>Hyperthermia:</b> Exogenous or endogenous hyperthermia can result in heat stress, progressing to heat exhaustion and results in heat stroke. Heat stress can provoke edema, syncope and cramps and is treated with rest, cooling and oral rehydration and salt replacement. Heat exhaustion is a systemic reaction to prolonged heat exposure and is accompanied by headaches, dizziness, nausea, vomiting, tachycardia, hypotension, muscle pain, weakness and cramps. Treatment is similar as in a heat stroke, but active cooling might be required in severe cases with ice packs or cold intravenous fluids. Heat stroke is a systemic inflammatory response with a core temperature above 40,6<sup>o</sup>C. It can lead to varying levels of organ dysfunction accompanied by mental changes. It can occur during high environmental temperatures or during strenuous physical exercise in high environmental temperatures. Rapid cooling of the victim should occur as soon as possible. Patients with heat-stroke usually have electrolyte abnormalities and hypovolaemia. | ||
* <b>Hypothermia:</b> In hypothermia (<35<sup>o</sup>C) it is difficult to detect signs of life. Therefore resuscitation should proceed according to standard protocols until the patient has reached normothermia. Second to resuscitation, warming of the body temperature by passive or active external and internal methods should be started. Examples of passive rewarming are drying and insulation of the body, whilst examples of active rewarming are infusion of warmed intravenous fluids or forced air rewarming. As a result of rewarming vasodilatation occurs and fluid administration may be required.Resuscitation during hypothermia is difficult, the thorax is stiff and the heart is less responsive to medication and defibrillation. Furthermore drug metabolism is slowed, resulting in increased plasma levels of medication. Medication should be administered at double intervals in patients <35<sup>o</sup>C and withheld in patient <30<sup>o</sup>C. Rhythm disturbances usually seen at rewarming after hypothermia are bradycardia, atrial fibrillation, VF and asystole. Bradycardia and atrial fibrillation revert to normal sinus rhythm as the core body temperature increases. | * <b>Hypothermia:</b> In hypothermia (<35<sup>o</sup>C) it is difficult to detect signs of life. Therefore resuscitation should proceed according to standard protocols until the patient has reached normothermia. Second to resuscitation, warming of the body temperature by passive or active external and internal methods should be started. Examples of passive rewarming are drying and insulation of the body, whilst examples of active rewarming are infusion of warmed intravenous fluids or forced air rewarming. As a result of rewarming vasodilatation occurs and fluid administration may be required.Resuscitation during hypothermia is difficult, the thorax is stiff and the heart is less responsive to medication and defibrillation. Furthermore drug metabolism is slowed, resulting in increased plasma levels of medication. Medication should be administered at double intervals in patients <35<sup>o</sup>C and withheld in patient <30<sup>o</sup>C. Rhythm disturbances usually seen at rewarming after hypothermia are bradycardia, atrial fibrillation, VF and asystole. Bradycardia and atrial fibrillation revert to normal sinus rhythm as the core body temperature increases. | ||
* <b>Poisoning:</b> Accidental poisoning in children or by therapeutic or recreational drugs in adults are the main causes of poisoning, however rarely causes cardiac arrest. It is important to identify the poison to start antidote treatment or decontamination. During the BLS and ALS care should be taken when performing mount-to-mouth ventilation in the presence of certain chemical types of poisoning. Respiratory arrest and airway depression is more common after poisoning. Early intubation can prevent cardiac arrest and pulmonary aspiration. When confronted with a poisoning in an ALS setting, temperature should be monitored as hypo- or hyperthermia my occur after drug overdose. Furthermore, due to the slow metabolization or excretion of certain poisons the resuscitation can continue for a long period. | * <b>Poisoning:</b> Accidental poisoning in children or by therapeutic or recreational drugs in adults are the main causes of poisoning, however rarely causes cardiac arrest.<cite>Bronstein</cite> It is important to identify the poison to start antidote treatment or decontamination.<cite>Zimmerman</cite> During the BLS and ALS care should be taken when performing mount-to-mouth ventilation in the presence of certain chemical types of poisoning. Respiratory arrest and airway depression is more common after poisoning.<cite>Yanagawa</cite> Early intubation can prevent cardiac arrest and pulmonary aspiration. When confronted with a poisoning in an ALS setting, temperature should be monitored as hypo- or hyperthermia my occur after drug overdose. Furthermore, due to the slow metabolization or excretion of certain poisons the resuscitation can continue for a long period. | ||
* <b>Pregnancy:</b> If a cardiac arrest occurs during pregnancy the safety of the fetus should always be considered. Due to the growth of the uterus compression of the inferior vena cava can occur and as a result venous return and cardiac output is compromised. During CPR displace the uterus to the left or apply a left lateral tilt of the surface the patient is lying upon to minimize compression from the uterus. Furthermore the increased abdominal pressure can increase the risk of pulmonary aspiration and can hamper proper ventilation; therefore early intubation can lower risks and ease cardiopulmonary resuscitation. During ALS normal defibrillator shock energies can be used. An emergency hysterotomy or cesarean section needs to be considered, if gestational age is after 20 weeks. After 20 weeks the size of the uterus is large enough to compromise cardiac output, however fetal viability begins at approximately 24-25 weeks. | * <b>Pregnancy:</b> If a cardiac arrest occurs during pregnancy the safety of the fetus should always be considered. Due to the growth of the uterus compression of the inferior vena cava can occur and as a result venous return and cardiac output is compromised. During CPR displace the uterus to the left or apply a left lateral tilt of the surface the patient is lying upon to minimize compression from the uterus. Furthermore the increased abdominal pressure can increase the risk of pulmonary aspiration and can hamper proper ventilation; therefore early intubation can lower risks and ease cardiopulmonary resuscitation. During ALS normal defibrillator shock energies can be used. An emergency hysterotomy or cesarean section needs to be considered, if gestational age is after 20 weeks. After 20 weeks the size of the uterus is large enough to compromise cardiac output, however fetal viability begins at approximately 24-25 weeks. | ||
* <b>Traumatic Cardiorespiratory Arrest:</b> Cardiac arrest caused by trauma has low chance of survival. Blunt trauma can cause commotio cordis if there is an impact to the chest wall over the heart. This impact can cause arrhythmias (usually ventricular fibrillation) and occurs often during sports. Penetrating trauma or can be cause for and emergency thoracotomy. Emergency thoracotomy has to be performed early after onset of CPR. It is important to treat the resuscitation according to protocol and treat reversible causes. | * <b>Traumatic Cardiorespiratory Arrest:</b> Cardiac arrest caused by trauma has low chance of survival. Blunt trauma can cause commotio cordis if there is an impact to the chest wall over the heart. This impact can cause arrhythmias (usually ventricular fibrillation) and occurs often during sports. Penetrating trauma or can be cause for and emergency thoracotomy. Emergency thoracotomy has to be performed early after onset of CPR. It is important to treat the resuscitation according to protocol and treat reversible causes. | ||