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Cardiac Arrest: An Overview of Defibrillation v/s Cardioversion
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- 2. Cardiac Arrest An Overview of Defibrillation v/s Cardioversion PRESENTER Dr Muhammad Umair Shafique HOUSE OFFICER SKBZH/ AK CMH MZD 2 SUPERVISOR Dr Babar Bilal Consultant Cardiologist SKBZH/ AK CMH MZD
- 3. 3 • Case Presentation • Literature Review SEQ
- 5. • 60 yrs old male, known case of IHD • Brought into the ER by his attendants in unconscious state • Apprehension • Drowsiness for last 3 hours • Followed by unconsciousness 8 BRIEF HISTORY
- 6. • Discharged from hospital one day ago after MI (being late for SK) • He experienced sudden apprehension and drowsiness followed by unconsciousness • Chest pain ̊̊̊̊ , palpitations ̊̊̊̊ , SOB ̊̊ , fits ̊̊ and urinary incontinence ̊̊ 9 HOPI
- 7. • Was found to be PULSELESS and CPR was started 1 0 EXAMINATION Blood Pressure 80/ 60 mmHg Resp Rate Gasping Temp Afebrile Oxygen Saturation 80% at Room Air Blood Sugar Random 90 mg/dl
- 8. ECG INTERPRETATION • Rate: 190 • Rhythm: – R-R: Regular – P- wave: Absent – AV Dissociation – Wide QRS Ventricular Tachycardia
- 9. • Diagnosis SUDDEN CARDIAC ARREST Secondary to PULSELESS VENTRICULAR TACHYCARDIA • Pt was immediately defibrillated 12 MANAGEMENT IN ER
- 10. 1 3 POST DEFIBRILLATION ECG • Rate: 90 • Rhythm: – R-R: Regular – P-wave: Present – No AV Dissociation – Normal QRS – ST elevations in Inf leads
- 11. • Pt was shifted to CCU – Inj Heparin IV 5000 units ×stat – Inf Heparin IV 1000 units/ Hr – Inf Dobutamine IV at 10-12 micro drops/ min • Titrated against B.P – Tab Lowplat Plus 75/75 mg PO ×OD – Tab Rosuvastatin 20 mg PO ×HS – Cap Omeprazlo 40 mg PO ×OD 14 TREATMENT IN HOSP
- 12. • 2D-Echo showed – Proximal 2/3rd Inf, lat and post wall hypokinesia – 40-45% EF • Was discharged on 5th day of admission and referred for PCI to higher cardiac center 15 FOLLOW UP
- 14. • Death following Sudden Cardiac Arrest (SCA) • Sudden Cardiac Arrest (SCA)* is the sudden cessation of mechanical cardiac activity making the person unresponsive, with no normal breathing and no signs of circulation • SCA restored spontaneously or by CPR/ defibrillation is called Aborted Sudden Cardiac Death *American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) 17 CARDIAC ARREST VS DEATH
- 15. SHOCKABLE 1) Ventricular Fibrillation(VF) 2) Pulseless Ventricular Tachycardia (pVT) 1 8 RHYTHMS IN CARDIAC ARREST NON SHOCKABLE 1) Pulseless Electrical Activity (PAE) 2) Asystole
- 16. • Coronary Artery Disease (CAD) – 80% – Acute MI, Dissection & Anomalies • Cardiomyopathies – DCM, HCM • Structural Heart Disease – Severe AS, MVP, WPW • Trauma – Cardiac Tamponade 1 9 CAUSES OF SCD • Neurological – Epilepsy • Respiratory – Massive PE, Asthma, OSA • Metabolic – Electrolyte imbalance NON CARDIAC CARDIAC
- 18. • An act of administering a transthoracic electrical current to a person experiencing dysrhythmias • Brief history – 1899 – Discovery of defibrillation – 1947 – First successful defibrillation – 1965 – Portable defibrillation 2 1 CARDIAC DEFIBRILLATION
- 19. Electrical current traverses the myocardium 22 MECHANISM OF ACTION Heart cells depolarize simultaneously Termination of abnormal electrical rhythm Sinus Node resumes pacemaker activity
- 21. 1. Monophasic 2. Biphasic 2 4 MODES OF SHOCK
- 22. 2 5 • Unidirectional • Less consistent • Low success rate • More energy is needed MONOPHASIC SHOCK
- 23. 2 6 • Bidirectional • More consistent • High success rate • Less energy is needed BIPHASIC SHOCK
- 24. 1. Defibrillation 2. Electrical Cardioversion 2 7 TYPES OF SHOCK
- 25. • Defibrillation is an A-SYNCHRONOUS random administration of shock during a cardiac cycle • It is administered in case of cardiac arrest due to shockable rhythms 2 8 DEFIBRILLATION
- 26. 1) Pulseless Ventricular Tachycardia (VT) 2) Ventricular Fibrillation (VF) 29 RHYTHMS FOR DEFIBRILLATION MONOMORPHIC VT COARSE VF MONOMORPHIC VT
- 27. • Cardioversion is a synchronized administration of shock • In synch with the R waves or QRS complex • Two types 1) Emergency Cardioversion 2) Elective Cardioversion 3 0 CARDIOVERSION
- 28. 3 1 RHYTHMS FOR CARDIOVERSION 1) Supra Ventricular Tachycardia (SVT) AVRT and AVNRT 2) Atrial Fibrillation 3) Atrial Flutter 4) VT with Pulse 5) Any re-entrant tachycardia with un-stability AVRT ATRIAL FIB ATRIAL FLUTTER
- 30. Paddle placement on the chest wall has 2 conventional positions a) Anterolateral b) Anteroposterior 33 PADDLE POSITIONING
- 31. 34 ANTEROLATERAL POSITIONING 1) Left 4th or 5th ICS on the mid axillary line 2) Right of the sternal edge on the 2nd or 3rd ICS below clavicle
- 32. 35 ANTERIOPOSTERIOR POSITIONING • Back of chest between tip of the left scapula and the spine • More effective in setting of • Atrial fibrillation • Implantable devices
- 33. Rhythm Monophasic (J) Biphasic (J) Atrial Fibrillation 200 120-200 Atrial Flutter 100 50-100 VT with Pulse 200 100 Pulseless VT and V Fib 360 120-200 36 ENERGY SELECTION In emergency, go for the MAXIMUM
- 34. • For Defibrillation and Emergency Cardioversion – Desired rhythms • Inj Heparin 1cc IV Stat in case of Atrial Arrhythmias 37 EMERGENCY PREPARATION
- 35. • Prior to cardioversion a) Stop digoxin 48 hours before the procedure b) Base line investigations (like Serum Electrolytes, TFT etc to rule out reversible cause) c) 2D-Echo to rule out any intra cardiac clot d) Anticoagulation for 3-4 wks 38 ELECTIVE PROCEDURE PREPARATION
- 36. • At the time of cardioversion a) Written and informed consent b) NPO for 8 hours c) Afebrile d) Remove dentures e) 12-lead ECG f) Peripheral venous access g) Attach Oxygen h) Airway equipment and emergency trolley on stand-by 39 ELECTIVE PROCEDURE PREPARATION
- 37. 4 0 TECHNIQUE PREPARE THE PATIENT PLACE ELECTRODES SEDATE THE PATIENT SELECT ENERGY LEVEL SYNCHRONIZE THE SHOCK DELIVER THE SHOCK REASSESS
- 38. CARDIOVERSION – Atrial Thrombus – Sinus Rhythm – Digitalis Toxicity – Unsafe Sedation – Tachycardias with increased automaticity • MAT • Junctional Tachycardia 4 1 CONTRAINDICATIONS DEFIBRILLATION – Asystole – PAE – DNR
- 39. • Thromboembolism • Arrhythmias • Harmless premature beats • VF • Injuries Local Skin Burn • Airway compromise • Myocardial Depression 42 COMPLICATIONS
- 40. 4 3 DEFIBRILLATION ALGORITHM PATIENT RECEIVED IN ER WITH HEMODYNAMIC COMPROMISE CHECK FOR PULSE NO PULSE START CPR & CHECK RHYTHM SHOCKABLE RHYTHM DEFIBRILATE IMMIDIATELY CONTINUE CPR FOR 2 MINUTES AND REASSESS
- 41. 4 4 EMERGENCY CARDIVERSION ALGORITHM PATIENT RECEIVED IN ER WITH HEMODYNAMIC COMPROMISE CHECK FOR PULSE PULSE PRESENT CHECK RHYTHM UNSTABLE TACHYARRHYTHMIAS CARDIOVERT URGENTLY REASSESS
- 42. 4 5 ACLS CARDIAC ARREST ALGORITHM
- 43. ACLS CARDIAC ARREST ALGORITHM
- 44. POST CARDIAC ARREST ALGORITHM RETURN OF SPONTANEOUS CIRCULATION (RCOS) OPTIMIZE VENTILATION AND OXYGENATION TREAT HYPOTENTION GET 12-LEAD ECG ST ELEVATIONS 2 MINS POST DEFIBRILLATION TREAT AS MI ADVANCE CRITICAL CARE
- 45. • Morphology Monomorphic Polymorphic • Symptoms With pulse Pulse less 4 8 CLASSIFICATION
- 46. • Time is MYOCARDIUM • Start CPR in 10 seconds • Defibrillate only the shockable rhythms • Clear the pt before delivery of shock • Continue CPR 2 mins post defibrillation • Initiate Post cardiac arrest care immediately after ROSC 49 TAKE HOME MESSAGE
- 47. • Topol, Manual of Cardiovascular Medicine, 4th Edition • Manual of ACLS • Internet resources for videos 50 RESOURCES
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- 49. THANK YOU 52
Editor's Notes
- I Muhammad Umair Shafique, welcome you all to today’s CPC. The topic for todays discussion is Cardiac Arrest An Overview of Defibrillation v/s Cardioversion, that a\has been prepared under the
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- My pt a 60 yr old male known case of IHD was Brought into the ER by his attendants in unconscious state with history of Apprehension, Drowsiness Followed by unconsciousness for last 3 hours
- Pt was in usual state of health, was discharged from hosp one day ago after infro-posto-lat wall MI being late for SK. While sitting comfortably at home he developed sudden apprehension and drowsiness followed by unconsciousness. There was no history of Chest pain̊̊ , palpitations̊̊, SOB̊, fits̊ and urinary incontinence. He was trf immediately to hosp on ambulance
- On arrival in ER pt was assessed immediately and Was found to be PULSELESS and CPR was started immediately as per ACLS guidelines. He was afebrile with a blood pressure of 80/60 was gasping with an oxygen saturation of 80% at room air
- A 12 lead-ECG was obtained immidiately showing ventricular tachycardia
- Based upon history, short examination and ECG findings a diagnosis of SUDDEN CARDIAC ARREST Secondary to PULSELESS VENTRICULAR TACHYCARDIA was made. Pt was immediately defibrillated and reverted back to normal SR
- This was the post defib ECG where you can see that the rhythm has reverted back to normal SR. Pt regained consciousness and became vitally stable. Please take a note of these ST elevations in inferior leads post defibrillation, I shall talk about them in the end.
- Post cardiac arrest care was initiated immediately and pt was shifted to CCU on following treatment.
- Pt remained stable and improved clinically, the 2D-Echo done on next day showed, Normal sized cardiac chambers , with proximal 2-3rd Infro-posto-lateral wall hypokinesia, an EF of 40-45% and Mild MR, pt was discharged on 5th day of admission and referred for PCI to higher cardiac center
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- AHA defines SCD as the Death following Sudden Cardiac Arrest (SCA) While SCA is the sudden cessation of mechanical cardiac activity making the person unresponsive, with no normal breathing and no signs of circulation SCA restored spontaneously or by CPR/ defibrillation is called Aborted Sudden Cardiac Death
- Rhythms in cardiac arrest may be Shockable like VF and VT And non-shockable like PAE and asystole
- The causes may be cardiac or non cardiac. Cardiac causes include CAD which accounts for more than 80% of SCD Followed by Cardiomyopathies and Structural Heart Disease. Cardiac tamponade is the main cause of SCD in the setting of chest trauma Non cardiac causes include epilepsy, Massive pulmonary embolism, severe Asthma and electrolyte imbalances
- This animation shows the normal electrical activity of heart coupled with mechanical activity. As you can see that being the pacemaker the SA node generates the current that travels across both the atria, It then relays in the AV node from where it travels down via bundle of His and bundel branches and is finally distributed to whole of ventricle via Purkinji Fibers. In the event of an MI, the effected area TAKES OVER the SA node causing arrhythmias like VT as shown in this animation
- Cardiac defibrillation is An act of administering a transthoracic electrical current to a person experiencing dysarrhythmias. This depolarizes the whole myocardium and resets the pacemaker activity of SA node. Defibrillation was discovered in 1899, while in 1947 first successful human defibrillation was done and In 1965 portable defibrillator devices were made They dramatically revolutionized the realm of cardiac resuscitation
- When shock is delivered the current traverses the myocardium heart cells depolarize simultaneously any abnormal electrical rhythm is terminated SA resumes the NORMAL PACEMAKER ACTIVITY
- So the when heart goes into VF Defibrillation is done And sinus rhythm is restored JUST LIKE THAT
- The electric shock can be delivered in two modes that are MONOPHASIC and BIPHASIC
- Monophasic Current as evident by this animation is Unidirectional, less consistent, has low success rates and requires more ENERGY
- While biphasic Current is bidirectional, more consistent, has high success rates and requires less amount of ENERGY
- Based upon the SYNCHRONICITY OF ELECTRIC SHOCK WITH THE R-WAVE, there are two types of shock Defibrillation and Electrical Cardioversion
- Defibrillation is an A-SYNCHRONOUS random administration of shock during a cardiac cycle not in synch with the R wave It is administered in case of cardiac arrest due to shockable rhythms
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- Cardioversion is administration of shock in synch with the R waves or QRS complex Emergency cardioversion is for hemodynamically unstable tachyarrhythmias while Elective cardioversion is for stable tachyarrhythmias
- Unstable tachyarrhthymias needing cardioversion include
- This figure correlates the electrical activity of heart with the phases of cardiac cycle. At the peak of R wave, myocardium is in ABSOLUTE REFRACTORY PERIOD thus no arrhythmias can be induced by external stimulations. Synchronization of the external current with R wave avoids energy delivery near the apex of the T wave, which coincides with a vulnerable RELATIVE REFRACTORY PERIOD for induction of life threatening arrhythmias
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- In anterolateral position, one paddle is placed in Left 4th or 5th ICS on the mid axillary line while the other is placed on Right of the sternal edge on the 2nd or 3rd ICS below clavicle
- In anteroposterior positioning, the left paddle stays in the same position while the other one is placed on the back of the chest between tip of the left scapula and the spine. This is more effective in setting of atrial fibrillation as atria lies in proximity of post wall of chest ensuring maximum delivery of current and in Patients with implantable devices shunting the current away from those devices
- Here is the energy selection for various arrhythmias however for emergency situations, rule of thumb is to go for the maximum level of energy.
- For defibrillation and emergency cardioversion, all you need is a shockable rhythm, no other preparation is needed as such. A stat shot of 1cc IV heparin should be given simultaneously.
- Cardioversion should be done in CCU setting. Written and informed consent must be taken, pt must be NPO for 8 hours, he should be Afebrile and not wearing any dentures. A 12-lead ECG be obtained to confirm the rhythm. Supplemental Oxygen and cardiac monitor must be attached and Peripheral venous access be secured. Airway equipment and emergency trolley must be on stand-by in case of any untoward complication.
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