This document summarizes a seminar on the management of cardiac arrest and cardiac arrest survivors. It defines cardiac arrest and discusses mechanisms and causes. It reviews changes to CPR guidelines including a compression to ventilation ratio of 30:2. It discusses factors that affect blood flow during CPR and prognostic factors for poor outcomes. Management strategies are outlined for defibrillation, antiarrhythmic drugs, vasopressors, steroids and extracorporeal CPR. Adjuncts to CPR like oxygen support and monitoring techniques are also summarized.
1. Post resuscitation care involves not only return of spontaneous circulation but return to pre-arrest status through management of global ischemia, cardiovascular dysfunction, and persistent precipitant causes.
2. Immediate goals after ROSC include optimization of cardiovascular function and oxygen delivery, ventilation support, temperature management, etiology investigation, and interventions to prevent recurrence.
3. Prognostication is an essential component using markers like neurological exams, EEGs, imaging and biomarkers to predict outcomes in comatose post-cardiac arrest patients.
1) Cardiac arrhythmias are common in the ICU and represent a major source of morbidity and potential increased mortality. Arrhythmias may be the primary reason for admission or develop during critical illness.
2) Factors that increase the risk of life-threatening arrhythmias in ICU patients include their underlying critical illnesses, drugs, electrolyte imbalances, hypoxia, sepsis and other metabolic disturbances, and fluctuations in intravascular volume.
3) Arrhythmias can be life-threatening if the heart rate is too fast or slow resulting in hemodynamic instability, if it degenerates to ventricular fibrillation, or if associated with severe hypokalemia/hypomagnesemia or underlying
Today, in addition to measurement of left ventricular ejection fraction, the simple 12-lead surface ECG remains the only evidence-based means of identifying patients who may obtain the substantial benefits of CRT
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
Ventricular tachycardia are difficult to understand. it is classified in to two types. 1. VT in structurally normal heart, 2. VT in heart with structural diseases. I have tried to simplify the VT in structurally normal heart, which may be helpful to many students and learners.
Cardiac arrest is the abrupt cessation of cardiac pump function that requires prompt intervention to prevent death. The four rhythms that can cause pulseless cardiac arrest are ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity. Immediate CPR and defibrillation are critical, along with identifying and treating reversible causes such as hypoxia, acidosis, hypothermia, tamponade, pulmonary embolism, or drug overdose. Management involves high-quality CPR, defibrillation for shockable rhythms, intravenous epinephrine and amiodarone, and treating underlying causes.
1) The document discusses the role of cardiac resynchronization therapy (CRT) in treating chronic heart failure based on results from clinical trials.
2) Landmark trials like CARE-HF, MADIT-CRT and REVERSE showed that CRT reduces mortality and hospitalization in patients with heart failure symptoms.
3) Later trials also found benefits of CRT in mildly symptomatic patients with reduced left ventricular function and wide QRS duration, including decreased heart failure events and increased left ventricular ejection fraction, though effects on quality of life and exercise capacity were less clear.
The document provides an overview of basic pacing concepts including:
- Types of pacemakers such as single chamber, dual chamber, and triple chamber systems.
- Components of a pacemaker system including the pulse generator, leads, and electrical concepts such as voltage, current, and impedance.
- Factors that can affect pacing thresholds and how to test the pacemaker circuit including identifying high and low impedance conditions.
1. Post resuscitation care involves not only return of spontaneous circulation but return to pre-arrest status through management of global ischemia, cardiovascular dysfunction, and persistent precipitant causes.
2. Immediate goals after ROSC include optimization of cardiovascular function and oxygen delivery, ventilation support, temperature management, etiology investigation, and interventions to prevent recurrence.
3. Prognostication is an essential component using markers like neurological exams, EEGs, imaging and biomarkers to predict outcomes in comatose post-cardiac arrest patients.
1) Cardiac arrhythmias are common in the ICU and represent a major source of morbidity and potential increased mortality. Arrhythmias may be the primary reason for admission or develop during critical illness.
2) Factors that increase the risk of life-threatening arrhythmias in ICU patients include their underlying critical illnesses, drugs, electrolyte imbalances, hypoxia, sepsis and other metabolic disturbances, and fluctuations in intravascular volume.
3) Arrhythmias can be life-threatening if the heart rate is too fast or slow resulting in hemodynamic instability, if it degenerates to ventricular fibrillation, or if associated with severe hypokalemia/hypomagnesemia or underlying
Today, in addition to measurement of left ventricular ejection fraction, the simple 12-lead surface ECG remains the only evidence-based means of identifying patients who may obtain the substantial benefits of CRT
This document provides an overview of arrhythmias that may present in the intensive care unit (ICU) with a focus on atrial fibrillation, wide complex tachycardia, bradycardia, and supraventricular tachycardia. It discusses approaches to determining whether arrhythmias require rate or rhythm control and outlines treatment strategies including pharmacological and electrical cardioversion. Guidelines for determining the need for anticoagulation based on a patient's CHADS2-VASc score are also reviewed.
Ventricular tachycardia are difficult to understand. it is classified in to two types. 1. VT in structurally normal heart, 2. VT in heart with structural diseases. I have tried to simplify the VT in structurally normal heart, which may be helpful to many students and learners.
Cardiac arrest is the abrupt cessation of cardiac pump function that requires prompt intervention to prevent death. The four rhythms that can cause pulseless cardiac arrest are ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity. Immediate CPR and defibrillation are critical, along with identifying and treating reversible causes such as hypoxia, acidosis, hypothermia, tamponade, pulmonary embolism, or drug overdose. Management involves high-quality CPR, defibrillation for shockable rhythms, intravenous epinephrine and amiodarone, and treating underlying causes.
1) The document discusses the role of cardiac resynchronization therapy (CRT) in treating chronic heart failure based on results from clinical trials.
2) Landmark trials like CARE-HF, MADIT-CRT and REVERSE showed that CRT reduces mortality and hospitalization in patients with heart failure symptoms.
3) Later trials also found benefits of CRT in mildly symptomatic patients with reduced left ventricular function and wide QRS duration, including decreased heart failure events and increased left ventricular ejection fraction, though effects on quality of life and exercise capacity were less clear.
The document provides an overview of basic pacing concepts including:
- Types of pacemakers such as single chamber, dual chamber, and triple chamber systems.
- Components of a pacemaker system including the pulse generator, leads, and electrical concepts such as voltage, current, and impedance.
- Factors that can affect pacing thresholds and how to test the pacemaker circuit including identifying high and low impedance conditions.
Cardiac arrhythmias occur frequently in ICU patients, with the most common being sinus tachycardia. Arrhythmias are often seen in patients with structural heart disease and can be exacerbated by critical illness. Management involves treating any imbalances that may be triggering the arrhythmia as well as directed medical therapy. Arrhythmias in the ICU represent a major source of morbidity and increased length of stay.
Sudden cardiac arrest (SCA)&Sudden cardiac death (SCD)Abdullah Ansari
INTRODUCTION
SCD : Definition
Epidemiology
Etiology
THE INITIAL ASSESSMENT
BASIC LIFE SUPPORT
CPR Steps
SELF-ASSESSMENT FOR BLS
ADVANCED CARDIAC LIFE SUPPORT
PRINCIPLES OF EARLY DEFIBRILLATION
AUTOMATED EXTERNAL DEFIBRILLATOR
SELF-ASSESSMENT FOR ACLS
The document discusses new trends in cardiac arrest management based on research findings. It finds that survival is directly related to how quickly a patient receives treatment. Research showed that chest compressions were only being performed 52% of the time, and when they were being done, 28% were too slow and 40% were not deep enough. It also found ventilations were being done too quickly 60% of the time. The document recommends a "pit crew" approach where rescuers are assigned specific roles like compressions, airway management, and operating the AED to improve coordination during resuscitation efforts. Managing cardiac arrest on scene for 30 minutes before transporting is also discussed as improving outcomes based on studies.
Primary PCI involves performing urgent angioplasty and potentially stenting of the culprit artery in STEMI patients, with the goal of reopening the blocked vessel within 90 minutes of first medical contact. It is the preferred reperfusion strategy when it can be performed promptly by an experienced team. Factors such as patient age, time to treatment, comorbidities, and initial flow in the artery help determine whether primary PCI or thrombolysis is most appropriate. Optimal anticoagulation and antiplatelet regimens along with adjunctive therapies like manual thrombectomy can improve outcomes of primary PCI.
This document provides guidelines for post-cardiac arrest care. It recommends:
1) Performing emergency coronary angiography for OHCA patients with suspected cardiac cause and ST elevation on ECG.
2) Maintaining blood pressure above 90 mmHg systolic or 65 mmHg mean and immediately correcting any hypotension.
3) Inducing therapeutic hypothermia between 32-36°C for at least 24 hours in comatose cardiac arrest patients to minimize brain injury.
Atrial tachycardias can originate from different sites in the atria and have various mechanisms. Common sites include the right atrial appendage, coronary sinus ostium, and crista terminalis. Mechanisms include focal automaticity, triggered activity, microreentry, and macroreentry. Macroreentry is the most common mechanism and can involve single or double loop circuits around anatomical barriers or scar tissue. Diagnosis involves electrocardiographic localization of the origin and electrophysiological testing including pacing maneuvers to evaluate for entrainment. Catheter ablation is often curative by targeting the arrhythmia origin site or critical portions of reentrant circuits.
In critical moments where every second counts, the knowledge and skills to perform Adult Cardio Pulmonary Resuscitation (CPR) can make the difference between life and irreversible damage. This comprehensive presentation, titled "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)," available on SlideShare, delves into the intricacies of adult CPR, offering a well-rounded overview of Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and the crucial post-CPR procedures.
The presentation is meticulously designed to cater to healthcare professionals, first responders, and individuals seeking a comprehensive understanding of adult CPR techniques. Starting with the fundamental principles of BLS, the slides explore step-by-step instructions for delivering effective chest compressions and rescue breaths. The integration of up-to-date guidelines ensures that viewers are equipped with the most accurate and evidence-based practices.
Transitioning into the realm of ACLS, the presentation delves into the advanced interventions necessary for managing cardiac arrest situations. Topics such as defibrillation, drug administration, and airway management are covered in depth, empowering viewers to make informed decisions and take appropriate actions during critical moments.
Furthermore, the post-CPR segment of the presentation highlights the essential steps to follow once successful resuscitation has occurred. From monitoring vital signs to providing appropriate care, this section addresses the critical period following CPR and emphasizes the significance of ongoing support and medical attention.
The presentation employs a blend of engaging visuals, explanatory diagrams, and succinct textual content to facilitate a holistic learning experience. Whether you're a medical professional aiming to refresh your skills, a student delving into life-saving techniques, or an individual concerned with being prepared for emergencies, this slide deck offers an invaluable resource for acquiring and reinforcing essential knowledge.
In summary, "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)" is a comprehensive SlideShare presentation that meticulously covers the entire spectrum of adult CPR, ranging from Basic Life Support and Advanced Cardiovascular Life Support techniques to vital post-CPR considerations. By exploring this presentation, you'll be better equipped to respond effectively to cardiac emergencies and contribute to saving lives within your community.
This document discusses pacemakers and their management during anesthesia. It begins by describing the components of the heart's conducting system and types of pacemakers. It then discusses indications for pacemakers and implantable cardioverter defibrillators. The key points regarding anesthetic management are to have the device interrogated preoperatively, monitor it closely intraoperatively, and avoid potential electromagnetic interference from devices like electrocautery or defibrillation. Regional anesthesia is usually safe but general anesthesia requires avoiding drugs that could interfere with pacemaker function.
Follow up and management of pacemaker programming anddrskd6
Pacemaker components include the battery, pacing impedance, pulse generator, and modes and mode switching. Pacing impedance refers to opposition to current flow and varies between 250-1200 ohms. The pulse generator includes output, sensing, and timing circuits. Capture threshold is the minimum energy for depolarization. Pacemaker follow up includes electrical testing and management of complications like pocket hematomas, infections, and device malfunctions such as failure to capture or output.
Noninvasive ventilation (NIV) delivers ventilatory support without an invasive airway. It works by reducing inspiratory muscle work and avoiding fatigue. NIV improves lung compliance and gas exchange while allowing oral intake and speech. The main advantages of NIV are that it is noninvasive and avoids complications of intubation. Potential disadvantages include slower correction of abnormalities and issues with masks like leaks or skin damage. NIV can be administered in emergency departments or wards by trained staff and is used to treat conditions like COPD exacerbations, cardiogenic pulmonary edema, and post-extubation respiratory failure.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
This document summarizes the results of the CARE-HF trial, which investigated the effects of cardiac resynchronization therapy (CRT) in patients with heart failure. The trial found that CRT significantly reduced the risks of death and hospitalization compared to medical therapy alone. For every 9 patients treated with CRT, 1 death and 3 hospitalizations were prevented. The results provide strong evidence that CRT can improve outcomes for appropriately selected heart failure patients.
BLS(basic life support) & ACLS with PALS by Dr. ShailendraShailendra Satpute
This document provides information on Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS). It defines cardiac arrest, outlines its causes and types including ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity. It describes the signs and symptoms of cardiac arrest. It also summarizes the steps of BLS including chest compressions, airway management, rescue breathing, and defibrillation. Advanced techniques like intubation, use of laryngeal mask airways, endotracheal tubes, and automated external defibrillators are also outlined.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
Cardiac Resynchronization Therapy and ICDsAhmed Mahmood
Cardiac resynchronization therapy (CRT) uses an implanted device to resynchronize heart ventricle contractions, improving heart pumping efficiency. CRT-Ds additionally treat abnormal heart rhythms. CRT benefits include improved hemodynamics, reduced heart remodeling, and reduced hospitalizations and mortality. CRT is indicated for patients with left ventricular dysfunction, heart failure symptoms, and prolonged QRS duration, especially over 150ms with left bundle branch block. Randomized trials show CRT effectiveness includes these benefits compared to conventional therapy.
This document summarizes guidelines for emergency medicine training in resuscitation. It discusses adult cardiopulmonary resuscitation, including a focus on high-quality chest compressions. It also reviews the treatment of cardiac arrest, including defibrillation and drug therapy. Additional sections cover bradycardia, tachycardia, cardiac rhythms like atrial fibrillation and flutter, and management approaches.
Weaning and Extubation: A Pediatric Prespective Dr.Mahmoud Abbas
This document discusses weaning and extubation in pediatrics. It defines weaning as transitioning from ventilatory support to spontaneous breathing, and extubation as separating a patient from their ventilator. Successful weaning and extubation means maintaining effective gas exchange without mechanical support. Factors that indicate readiness for weaning include improving underlying conditions, adequate gas exchange, no undue burden on respiratory muscles, and the ability to sustain spontaneous ventilation as support decreases. Spontaneous breathing trials can assess readiness for extubation. Protocols for weaning and criteria for extubation can help optimize outcomes in pediatrics.
This document provides information on anesthesia for coronary artery bypass grafting procedures that are performed either on pump or off pump. It discusses the history of CABG, indications for the procedure, types of CABG, components and management of cardiopulmonary bypass, and the physiological effects of bypass. Key points include the components of the bypass circuit including the oxygenator, pump, and cannulation sites, anticoagulation with heparin and reversal with protamine, and weaning from bypass by assessing temperature, hemoglobin, infusion support, electrolytes, and cardiac contractility.
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
This document provides an overview of trans-catheter aortic valve implantation (TAVI). It discusses the indications for TAVI including symptomatic severe aortic stenosis in high-risk surgical patients. The pre-procedural workup involves imaging to assess anatomy and risk. The procedure involves accessing the femoral or other arteries and deploying a balloon-expandable or self-expanding bioprosthetic valve. Complications include conduction abnormalities, paravalvular regurgitation, and hypotension. Two clinical cases are presented of high-risk patients undergoing TAVI.
Cardiac arrest is the cessation of functional cardiac contraction and is the final common pathway in death from any pathology.
In the clinical context, cardiac arrest refers to the sudden loss of cardiac output that prompts an emergency response.
Pathogenesis, prognosis and management of in-hospital and out-of-hospital cardiac arrest are subtly different; however, the basic principles of cardiopulmonary resuscitation (CPR) are to maintain forward flow of oxygenated blood, correct the causative factor and restore spontaneous circulation.
This document discusses cardioversion, which is a medical procedure used to restore a normal heart rhythm. It defines cardioversion and describes the different types (electrical and chemical). It outlines recommendations for pharmacological and electrical cardioversion of atrial fibrillation, including appropriate medications, energy requirements, and anticoagulation strategies before and after the procedure. The document provides details on preparing for and performing a cardioversion, and discusses differences between cardioversion and defibrillation.
Cardiac arrhythmias occur frequently in ICU patients, with the most common being sinus tachycardia. Arrhythmias are often seen in patients with structural heart disease and can be exacerbated by critical illness. Management involves treating any imbalances that may be triggering the arrhythmia as well as directed medical therapy. Arrhythmias in the ICU represent a major source of morbidity and increased length of stay.
Sudden cardiac arrest (SCA)&Sudden cardiac death (SCD)Abdullah Ansari
INTRODUCTION
SCD : Definition
Epidemiology
Etiology
THE INITIAL ASSESSMENT
BASIC LIFE SUPPORT
CPR Steps
SELF-ASSESSMENT FOR BLS
ADVANCED CARDIAC LIFE SUPPORT
PRINCIPLES OF EARLY DEFIBRILLATION
AUTOMATED EXTERNAL DEFIBRILLATOR
SELF-ASSESSMENT FOR ACLS
The document discusses new trends in cardiac arrest management based on research findings. It finds that survival is directly related to how quickly a patient receives treatment. Research showed that chest compressions were only being performed 52% of the time, and when they were being done, 28% were too slow and 40% were not deep enough. It also found ventilations were being done too quickly 60% of the time. The document recommends a "pit crew" approach where rescuers are assigned specific roles like compressions, airway management, and operating the AED to improve coordination during resuscitation efforts. Managing cardiac arrest on scene for 30 minutes before transporting is also discussed as improving outcomes based on studies.
Primary PCI involves performing urgent angioplasty and potentially stenting of the culprit artery in STEMI patients, with the goal of reopening the blocked vessel within 90 minutes of first medical contact. It is the preferred reperfusion strategy when it can be performed promptly by an experienced team. Factors such as patient age, time to treatment, comorbidities, and initial flow in the artery help determine whether primary PCI or thrombolysis is most appropriate. Optimal anticoagulation and antiplatelet regimens along with adjunctive therapies like manual thrombectomy can improve outcomes of primary PCI.
This document provides guidelines for post-cardiac arrest care. It recommends:
1) Performing emergency coronary angiography for OHCA patients with suspected cardiac cause and ST elevation on ECG.
2) Maintaining blood pressure above 90 mmHg systolic or 65 mmHg mean and immediately correcting any hypotension.
3) Inducing therapeutic hypothermia between 32-36°C for at least 24 hours in comatose cardiac arrest patients to minimize brain injury.
Atrial tachycardias can originate from different sites in the atria and have various mechanisms. Common sites include the right atrial appendage, coronary sinus ostium, and crista terminalis. Mechanisms include focal automaticity, triggered activity, microreentry, and macroreentry. Macroreentry is the most common mechanism and can involve single or double loop circuits around anatomical barriers or scar tissue. Diagnosis involves electrocardiographic localization of the origin and electrophysiological testing including pacing maneuvers to evaluate for entrainment. Catheter ablation is often curative by targeting the arrhythmia origin site or critical portions of reentrant circuits.
In critical moments where every second counts, the knowledge and skills to perform Adult Cardio Pulmonary Resuscitation (CPR) can make the difference between life and irreversible damage. This comprehensive presentation, titled "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)," available on SlideShare, delves into the intricacies of adult CPR, offering a well-rounded overview of Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and the crucial post-CPR procedures.
The presentation is meticulously designed to cater to healthcare professionals, first responders, and individuals seeking a comprehensive understanding of adult CPR techniques. Starting with the fundamental principles of BLS, the slides explore step-by-step instructions for delivering effective chest compressions and rescue breaths. The integration of up-to-date guidelines ensures that viewers are equipped with the most accurate and evidence-based practices.
Transitioning into the realm of ACLS, the presentation delves into the advanced interventions necessary for managing cardiac arrest situations. Topics such as defibrillation, drug administration, and airway management are covered in depth, empowering viewers to make informed decisions and take appropriate actions during critical moments.
Furthermore, the post-CPR segment of the presentation highlights the essential steps to follow once successful resuscitation has occurred. From monitoring vital signs to providing appropriate care, this section addresses the critical period following CPR and emphasizes the significance of ongoing support and medical attention.
The presentation employs a blend of engaging visuals, explanatory diagrams, and succinct textual content to facilitate a holistic learning experience. Whether you're a medical professional aiming to refresh your skills, a student delving into life-saving techniques, or an individual concerned with being prepared for emergencies, this slide deck offers an invaluable resource for acquiring and reinforcing essential knowledge.
In summary, "Adult CPR Techniques: A Comprehensive Guide (BLS-ACLS-Post CPR)" is a comprehensive SlideShare presentation that meticulously covers the entire spectrum of adult CPR, ranging from Basic Life Support and Advanced Cardiovascular Life Support techniques to vital post-CPR considerations. By exploring this presentation, you'll be better equipped to respond effectively to cardiac emergencies and contribute to saving lives within your community.
This document discusses pacemakers and their management during anesthesia. It begins by describing the components of the heart's conducting system and types of pacemakers. It then discusses indications for pacemakers and implantable cardioverter defibrillators. The key points regarding anesthetic management are to have the device interrogated preoperatively, monitor it closely intraoperatively, and avoid potential electromagnetic interference from devices like electrocautery or defibrillation. Regional anesthesia is usually safe but general anesthesia requires avoiding drugs that could interfere with pacemaker function.
Follow up and management of pacemaker programming anddrskd6
Pacemaker components include the battery, pacing impedance, pulse generator, and modes and mode switching. Pacing impedance refers to opposition to current flow and varies between 250-1200 ohms. The pulse generator includes output, sensing, and timing circuits. Capture threshold is the minimum energy for depolarization. Pacemaker follow up includes electrical testing and management of complications like pocket hematomas, infections, and device malfunctions such as failure to capture or output.
Noninvasive ventilation (NIV) delivers ventilatory support without an invasive airway. It works by reducing inspiratory muscle work and avoiding fatigue. NIV improves lung compliance and gas exchange while allowing oral intake and speech. The main advantages of NIV are that it is noninvasive and avoids complications of intubation. Potential disadvantages include slower correction of abnormalities and issues with masks like leaks or skin damage. NIV can be administered in emergency departments or wards by trained staff and is used to treat conditions like COPD exacerbations, cardiogenic pulmonary edema, and post-extubation respiratory failure.
The document provides an overview of transcatheter aortic valve implantation (TAVI), including a brief history of its development, descriptions of the Edwards Sapien valve and delivery systems, approaches for TAVI, and complications. It also discusses patient screening and risk stratification, as well as newer valve devices that are being developed.
This document summarizes the results of the CARE-HF trial, which investigated the effects of cardiac resynchronization therapy (CRT) in patients with heart failure. The trial found that CRT significantly reduced the risks of death and hospitalization compared to medical therapy alone. For every 9 patients treated with CRT, 1 death and 3 hospitalizations were prevented. The results provide strong evidence that CRT can improve outcomes for appropriately selected heart failure patients.
BLS(basic life support) & ACLS with PALS by Dr. ShailendraShailendra Satpute
This document provides information on Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS). It defines cardiac arrest, outlines its causes and types including ventricular fibrillation, pulseless ventricular tachycardia, asystole, and pulseless electrical activity. It describes the signs and symptoms of cardiac arrest. It also summarizes the steps of BLS including chest compressions, airway management, rescue breathing, and defibrillation. Advanced techniques like intubation, use of laryngeal mask airways, endotracheal tubes, and automated external defibrillators are also outlined.
This document discusses the management of atrial fibrillation. It provides information on the causes, consequences, classification, and epidemiology of AF. It describes the acute management of AF including assessing hemodynamic status, starting anticoagulation, and deciding between rate and rhythm control strategies. Methods for rhythm control include electrical cardioversion and pharmacological cardioversion with drugs like amiodarone, ibutilide, flecainide, and propafenone. Rate control strategies use drugs like digoxin, beta blockers, calcium channel blockers, and amiodarone. The document also discusses anticoagulation for thromboembolism prevention and newer oral anticoagulants.
Cardiac Resynchronization Therapy and ICDsAhmed Mahmood
Cardiac resynchronization therapy (CRT) uses an implanted device to resynchronize heart ventricle contractions, improving heart pumping efficiency. CRT-Ds additionally treat abnormal heart rhythms. CRT benefits include improved hemodynamics, reduced heart remodeling, and reduced hospitalizations and mortality. CRT is indicated for patients with left ventricular dysfunction, heart failure symptoms, and prolonged QRS duration, especially over 150ms with left bundle branch block. Randomized trials show CRT effectiveness includes these benefits compared to conventional therapy.
This document summarizes guidelines for emergency medicine training in resuscitation. It discusses adult cardiopulmonary resuscitation, including a focus on high-quality chest compressions. It also reviews the treatment of cardiac arrest, including defibrillation and drug therapy. Additional sections cover bradycardia, tachycardia, cardiac rhythms like atrial fibrillation and flutter, and management approaches.
Weaning and Extubation: A Pediatric Prespective Dr.Mahmoud Abbas
This document discusses weaning and extubation in pediatrics. It defines weaning as transitioning from ventilatory support to spontaneous breathing, and extubation as separating a patient from their ventilator. Successful weaning and extubation means maintaining effective gas exchange without mechanical support. Factors that indicate readiness for weaning include improving underlying conditions, adequate gas exchange, no undue burden on respiratory muscles, and the ability to sustain spontaneous ventilation as support decreases. Spontaneous breathing trials can assess readiness for extubation. Protocols for weaning and criteria for extubation can help optimize outcomes in pediatrics.
This document provides information on anesthesia for coronary artery bypass grafting procedures that are performed either on pump or off pump. It discusses the history of CABG, indications for the procedure, types of CABG, components and management of cardiopulmonary bypass, and the physiological effects of bypass. Key points include the components of the bypass circuit including the oxygenator, pump, and cannulation sites, anticoagulation with heparin and reversal with protamine, and weaning from bypass by assessing temperature, hemoglobin, infusion support, electrolytes, and cardiac contractility.
Fluid responsiveness in critically ill patientsUbaidur Rahaman
This document discusses fluid responsiveness in critically ill patients. It begins by defining fluid responsiveness as an increase in cardiac index after fluid infusion. It then describes three scenarios involving fluid resuscitation: patients with acute blood or fluid loss requiring immediate resuscitation, patients with suspected septic shock where early goal-directed therapy with fluids is important, and ICU patients who have already received fluids and their fluid responsiveness needs to be assessed. The document discusses various methods of assessing preload and preload dependence, including filling pressures, volumes, respiratory variations in inferior vena cava diameter, inspiratory drops in right atrial pressure, and predicting responsiveness through respiratory variations in parameters related to cardiac index. It emphasizes that preload alone
This document provides an overview of trans-catheter aortic valve implantation (TAVI). It discusses the indications for TAVI including symptomatic severe aortic stenosis in high-risk surgical patients. The pre-procedural workup involves imaging to assess anatomy and risk. The procedure involves accessing the femoral or other arteries and deploying a balloon-expandable or self-expanding bioprosthetic valve. Complications include conduction abnormalities, paravalvular regurgitation, and hypotension. Two clinical cases are presented of high-risk patients undergoing TAVI.
Cardiac arrest is the cessation of functional cardiac contraction and is the final common pathway in death from any pathology.
In the clinical context, cardiac arrest refers to the sudden loss of cardiac output that prompts an emergency response.
Pathogenesis, prognosis and management of in-hospital and out-of-hospital cardiac arrest are subtly different; however, the basic principles of cardiopulmonary resuscitation (CPR) are to maintain forward flow of oxygenated blood, correct the causative factor and restore spontaneous circulation.
This document discusses cardioversion, which is a medical procedure used to restore a normal heart rhythm. It defines cardioversion and describes the different types (electrical and chemical). It outlines recommendations for pharmacological and electrical cardioversion of atrial fibrillation, including appropriate medications, energy requirements, and anticoagulation strategies before and after the procedure. The document provides details on preparing for and performing a cardioversion, and discusses differences between cardioversion and defibrillation.
1. Cardiorespiratory arrest is the sudden, unexpected cessation of respiration and functional circulation. CPCR may be successful if performed within 4-6 minutes before biological death of vital tissues develops.
2. CPCR involves circulating oxygenated blood to vital organs like the heart and brain. It aims to restore breathing, circulation, and cerebral functions in those experiencing sudden failure of these systems.
3. Defibrillation is required for ventricular fibrillation, while continued CPR is important for asystole and PEA. Drugs like adrenaline, amiodarone, and atropine may be used if initial shocks and CPR fail to restore a perfusing rhythm.
This document provides an overview of a seminar on advanced cardiovascular life support (ACLS) algorithms and interventions for cardiac arrest. The seminar will cover rhythms that can cause cardiac arrest, monitoring during CPR, establishing vascular access, advanced airways, medications for arrest rhythms, and interventions not recommended for routine use. Key points include: the importance of high-quality CPR and timely defibrillation to increase return of spontaneous circulation and survival; using vasopressors, amiodarone, or lidocaine for refractory rhythms; monitoring end-tidal CO2, coronary perfusion pressure, and central venous oxygen saturation to guide CPR quality; and avoiding routines use of atropine, calcium,
This document provides information about Advanced Cardiac Life Support (ACLS). It begins by defining ACLS as a set of clinical interventions for urgently treating cardiac arrest and other life-threatening emergencies, as well as the knowledge and skills to perform those interventions. The document then discusses the American Heart Association protocols that are considered the gold standard for ACLS and how ACLS builds upon the foundation of basic life support. It also reviews the adult and pediatric chains of survival and components of high-quality CPR in BLS before providing details on ACLS interventions like defibrillation, airway management, ventilation, pharmacotherapy, synchronized cardioversion, and post-cardiac arrest care.
1) Atrial fibrillation is the most common cardiac arrhythmia characterized by irregular electrical activity in the atria. It increases in prevalence with age and can cause complications like heart failure, stroke, and systemic embolism.
2) Management of atrial fibrillation involves rate or rhythm control as well as long-term anticoagulation to prevent thromboembolism depending on stroke risk factors. The CHA2DS2-VASc score is used to assess this risk.
3) While antiarrhythmic drugs and cardioversion can restore normal sinus rhythm, rate control is preferred for many patients. Newer anticoagulants like dabigatran and rivar
1. The document discusses advanced cardiac life support (ACLS) guidelines for treating cardiac arrest. It outlines the chain of survival and emphasizes high-quality CPR, defibrillation, airway management, monitoring during CPR, and drug therapy.
2. Key ACLS interventions include chest compressions, rescue breathing, defibrillation, and vasopressor administration to treat cardiac rhythms like ventricular fibrillation.
3. The document also reviews special considerations for cardiac arrest associated with pregnancy and post-cardiac arrest care.
This document provides information on cardiopulmonary resuscitation (CPR) and cardiac arrest. It discusses the cardiac arrest rhythms of asystole, pulseless electrical activity, pulseless ventricular tachycardia, and ventricular fibrillation. It outlines the international guidelines for CPR, including recommendations to improve survival from sudden cardiac arrest. The four links in the chain of survival for cardiac arrest are early CPR, early defibrillation, early advanced care, and early access to emergency medical services. Basic life support procedures like checking responsiveness, calling for help, opening the airway, providing rescue breaths, and chest compressions are described. Advanced life support builds upon these with securing the airway, confirming device
The document summarizes updates from the 2015 CPR and ECC guidelines developed by the International Liaison Committee on Resuscitation (ILCOR). Key changes included emphasizing high-quality chest compressions, use of automated external defibrillators, and early defibrillation for cardiac arrest. The guidelines were informed by reviews of over 250 studies and recommendations were made using the GRADE methodology. Updates were provided for defibrillation, airway management, drug administration including epinephrine timing, and post-cardiac arrest care such as targeted temperature management.
Atrial fibrillation is the most common arrhythmia and increases mortality risk. It is classified as paroxysmal, persistent, or permanent based on duration. The CHA2DS2-VASc score is used to assess stroke risk and determine need for anticoagulation. Treatment focuses on rate control with medications like calcium channel blockers or cardioversion for hemodynamic instability. Anticoagulation is recommended for CHA2DS2-VASc score over 2 to prevent stroke.
Advanced cardiac life support (ACLS) refers to interventions for urgent treatment of cardiac arrest and other life-threatening emergencies, as well as the knowledge and skills to deploy those interventions. ACLS protocols from the American Heart Association are considered the gold standard and get reviewed every 5 years. BLS with high-quality CPR forms the critical foundation for ACLS. For shockable rhythms like ventricular fibrillation, the ACLS treatment involves defibrillation, CPR, and administration of drugs like epinephrine and amiodarone. For non-shockable rhythms like asystole, ACLS focuses on identifying and treating reversible causes through CPR and medications while preparing for transport to a hospital.
Advanced cardiac life support (ACLS) refers to interventions for urgent treatment of cardiac arrest and other life-threatening emergencies, as well as the knowledge and skills to deploy those interventions. ACLS protocols from the American Heart Association are considered the gold standard and get reviewed every 5 years. BLS with high-quality CPR forms the critical foundation for ACLS. For shockable rhythms like ventricular fibrillation, the ACLS treatment involves defibrillation, CPR, and administration of drugs like epinephrine and amiodarone. For non-shockable rhythms like asystole, ACLS focuses on identifying and treating reversible causes through CPR and medications while providing post-cardiac arrest care.
This document provides guidelines for managing pediatric cardiac arrest. It defines cardiac arrest and describes the main causes as respiratory failure, shock, or arrhythmia. Hypoxic/asphyxial arrest from respiratory failure or shock is more common than sudden cardiac arrest from arrhythmias. The treatment for cardiac arrest includes high-quality CPR, identifying and treating reversible causes, defibrillation if needed, advanced airway, medications like epinephrine, and post-cardiac arrest care. Special considerations are discussed for traumatic arrest, drowning, anaphylaxis, poisoning, and patients with congenital heart disease. Extracorporeal CPR may be considered for in-hospital arrests with existing ECMO capabilities.
This document summarizes guidelines for the initial management of atrial fibrillation encountered in primary care settings. It discusses the following key points:
- The initial goals of treatment are controlling the ventricular rate to under 100 beats per minute using drugs like beta blockers, calcium channel blockers, or digoxin. This is generally the first step before considering restoring normal sinus rhythm.
- For rate control, drugs like diltiazem can be given intravenously following the "rule of 15" to rapidly control the heart rate. Verapamil is also effective.
- If atrial fibrillation does not resolve spontaneously, medical or electrical cardioversion may be considered to restore normal rhythm, starting ant
1. Rate control is the initial approach for elderly patients with minor AF symptoms, while rhythm control may be considered for symptomatic patients despite rate control.
2. Catheter ablation is recommended for symptomatic patients where medical therapy fails, and can be considered as initial therapy in some selected patients.
3. Anticoagulation is recommended for AF patients based on their stroke risk profile according to CHA2DS2-VASc score. Warfarin requires careful management during pregnancy.
This document summarizes updates to the Advanced Life Support guidelines from 2015 to 2020. Key changes include:
- Lignocaine dosage recommendations for IV/IO administration were updated.
- Emphasis on early adrenaline administration for non-shockable and shockable rhythms.
- Double sequential defibrillation is not recommended.
- Standard adrenaline dosing remains 1mg every 3-5 minutes but high dose is not routinely advised.
- Amiodarone and lidocaine can be considered for refractory ventricular fibrillation/pulseless ventricular tachycardia.
Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.
PVCs are common, occurring in 40-75% of the general population on Holter monitoring. While traditionally thought to be benign without structural heart disease, they represent an increased risk of sudden death in patients with conditions like ischemic heart disease. The frequency and complexity of PVCs is associated with increased mortality in these patients. Implantable cardioverter defibrillators are indicated for those with nonsustained ventricular tachycardia due to prior myocardial infarction and left ventricular ejection fraction ≤40% who are inducible for sustained ventricular arrhythmias on electrophysiological study. However, for patients with congestive heart failure, PVCs do not provide significant prognostic value beyond clinical variables. The concept of PVC-induced
The document discusses strategies for preventing thromboembolism in patients with atrial fibrillation. It describes various risk scoring systems used to estimate stroke risk, such as CHADS2 and CHA2DS2-VASc. It recommends oral anticoagulation for patients with a CHADS2 score of 2 or higher. While aspirin provides some protection, oral anticoagulants like warfarin are more effective at reducing stroke risk. Newer oral anticoagulants also provide benefit compared to warfarin. For patients who cannot take oral anticoagulants, aspirin plus clopidogrel may be considered despite higher bleeding risks.
Assessment of prosthetic valve functionSwapnil Garde
This document discusses the assessment of prosthetic valve function through various imaging modalities. It begins with an introduction to prosthetic valves and outlines topics to be covered, including classification of valve types. Evaluation methods like chest x-ray, fluoroscopy, echocardiography, and CT are described. Parameters assessed on each modality and guidelines for evaluation are provided. Complications of prosthetic valves and 3D imaging advances are also mentioned.
The document discusses various techniques for assessing myocardial viability, including stress echocardiography, single photon emission computed tomography (SPECT), positron emission tomography (PET), and cardiac magnetic resonance imaging (MRI). Stress echocardiography evaluates contractile reserve through techniques like dobutamine stress echocardiography. SPECT assesses viability by detecting thallium or technetium uptake, which relies on intact cell membranes. PET detects FDG uptake indicating active glucose metabolism. MRI evaluates viability through detection of late gadolinium enhancement, indicating scar tissue, and can also assess contractile reserve with stress MRI. A combined approach utilizing multiple techniques can provide complementary information on viability.
This document provides an overview of approaches to chronic total occlusion percutaneous coronary intervention (CTO PCI). It defines CTOs and discusses their prevalence. Key points include:
- Success rates for CTO PCI are over 90% currently due to improved techniques and tools.
- Imaging like angiography, CT angiography, and IVUS help plan procedures by assessing lesion characteristics and collateral circulation.
- The retrograde approach and antegrade dissection and re-entry are common techniques in addition to the standard antegrade wire escalation method.
- Scoring systems like the J-CTO and W-CTO scores can predict difficulty and likelihood of success to help determine approach.
- Careful planning including
Antithrombotic therapy in patients with atrialSwapnil Garde
- The optimal antithrombotic treatment for patients with atrial fibrillation undergoing percutaneous coronary intervention poses challenges due to the need to balance risks of bleeding and thrombosis.
- New clinical trials have found that using a non-vitamin K oral anticoagulant (NOAC) along with a single antiplatelet drug reduces bleeding risks compared to the standard triple therapy of oral anticoagulant, aspirin, and clopidogrel, without increasing thrombotic risks.
- This expert consensus recommends generally using an NOAC over a vitamin K antagonist, along with single antiplatelet therapy, based on the trial results showing better safety outcomes with lower bleeding.
Debate of opening non infarct related arteriesSwapnil Garde
This document discusses the debate around opening non-infarct related arteries (non-IRA) during primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). It provides background on the higher mortality and reinfarction rates seen in patients with multi-vessel disease. It also summarizes several trials that have compared culprit-only PCI versus complete revascularization, with some trials like PRAMI and CvLPRIT finding lower event rates with complete revascularization, while others like CULPRIT-SHOCK found lower mortality and renal failure with culprit-only PCI in cardiogenic shock patients. The optimal strategy for managing non-IRA lesions during primary PCI for STEMI remains debated.
This document summarizes information about patent foramen ovale (PFO) closure procedures. It begins by describing a PFO and conditions it can be associated with like cryptogenic stroke. It then discusses devices used for closure like the Amplatzer PFO Occluder and the procedure. Risks include air embolism or device migration. The document also reviews trials that have evaluated PFO closure for stroke prevention. While some trials were negative, a meta-analysis showed a trend favoring closure, particularly in high-risk groups. Ongoing trials aim to provide more clarity around PFO closure benefits.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
2. Definition
• “ Abrupt cessation of cardiac mechanical function,
which may be reversible with prompt intervention
but will lead to death in its absence”
Sudden Cardiac Death
Sudden, irreversible cessation of all biologic functions
5. Presentation
Differences in Clinical Status Immediately before Death in Patients Dying Primarily of
Arrhythmia versus Circulatory Failure
Clinical Status Immediately
Before Death
Arrhythmic Deaths (n = 82) Circulatory Failure Deaths (n
= 59)
Comatose 0/82 (0%) 56/59 (95%)
Standing or actively moving 39/82 (48%) 0/59 (0%)
Terminal arrhythmia
Ventricular fibrillation 15/18 (83%) 3/9 (33%)
Asystole 3/18 (17%) 6/9 (67%)
Duration of terminal illness
<1 h 53/82 (65%) 4/59 (7%)
>24 h 17/82 (21%) 48/59 (81%)
Nature of terminal illness
Acute cardiac events 80/82 (98%) 8/59 (14%)
Noncardiac events 1/82 (1%) 51/59 (86%)
6. • One minute into persistent VF, coronary blood
flow (myocardial perfusion) declines to zero,
and by 4 minutes, carotid blood flow (cerebral
perfusion) is also nil.
• After about 12 minutes, defibrillation for VF is
rarely effective in the absence of chest
compressions.
7. • Although VF in an adult is persuasively
associated with CAD, PEA, and asystole usually
are not. The exception is when they are seen
in the terminal phase of VF arrests.
8. • One has to consider secondary causes of
cardiac arrest when PEA is otherwise the
primary rhythm.
9. • Recognition of Life Extinct (ROLE) guidelines in
England and Wales deem 20 minutes of
asystole, despite advanced resuscitative
measures, as grounds for termination of
resuscitative efforts.
• Even after successful ROSC, more than 60% of
patients do not survive to hospital discharge.
10. Predictors of poor outcomes for
OHCA include
(1) advanced age;
(2) severe comorbidities, including cancer or
stroke;
(3) preexisting cardiac disease or left ventricular
systolic dysfunction;
(4) CPR greater than 5minutes duration;
(5) development of sepsis;
(6) recurrence of arrhythmias;
(7) PEA or asystole on presentation;
(8) persistent coma; and
(9) unwitnessed arrest or lack of bystander CPR
13. • The previous sequence of the “ABC” of basic
life support—airway, breathing,compression—
has been changed to “CAB”—compression,
airway, breathing—based on the recognition
that compression alone is the better strategy
because it minimizes interruptions in
perfusion and avoids excessive ventilation
14. 2000 Guidelines 2005 Guidelines
1 Alerting EMS (only
children)
Phone EMS first and then do
CPR
CPR for 2 min and then call
EMS
2 Unwitnessed adult Shock first 200 CC, then shock
3 Rescue breath Take a deep breath Take a normal breath
4 Rescue breath duration 1–2 s <1 s
5 Ventilation rate 12-15/min 8-10/min
6 CC Ratio 15:2 30:2
7 Two-person CPR Switch when fatigued Every 2 min or 5 cycles (150
CC)
8 Defibrillation Three shocks without CC One shock followed by CC
9 Defibrillation energy Three monophasic stacked 360 J monophasic or 150-
200 J biphasic
10 Postdefibrillation Pulse and rhythm analyses Immediate CC
11 Intubated patients Pause CPR to give breaths Give breaths during CC
12 Drug delivery Drug–CPR–shock Drugs not to interrupt CC
13 High-dose epinephrine May be used Not recommended
15. • For single responders to victims from infancy
(excluding newborns) through adulthood and
for adults responded to by two rescuers, a
compression-ventilation ratio of 30:2 is now
recommended.
16.
17. • Of the factors identified as being responsible
for forward flow with chest compression,
perhaps the most important is the
duration between the onset of VF arrest and
initiation of chest compressions. Other
important factors are the technique used for
chest compressions and the patient's chest wall
configuration.
• It is important to remember that even with
optimal chest compressions, total coronary
flow is only around 20% to 40% of pre-
arrest values
18. Management of Cardiac Arrest
• Defibrillation Strategies for Ventricular Fibrillation or Pulseless
Ventricular Tachycardia: Waveform Energy and First-Shock Success.
• Defibrillation Strategies for Ventricular Fibrillation or Pulseless
Ventricular Tachycardia: Energy Dose for Subsequent Shocks.
• Defibrillation Strategies for Ventricular Fibrillation or Pulseless
Ventricular Tachycardia: Single Shocks Versus Stacked Shocks.
• Antiarrhythmic Drugs During and Immediately After Cardiac Arrest.
• Vasopressors in Cardiac Arrest.
• Steroids.
• Prognostication During CPR.
• Overview of Extracorporeal CPR.
19.
20.
21. ADJUNTS TO CPR:
1. OXYGEN SUPPORT
• When supplementary oxygen is available, it
may be reasonable to use the maximal feasible
inspired oxygen concentration during CPR
(Class IIb, LOE C-EO).
22. 2. Physiologic parameters of
monitoring
• Although no clinical study has examined whether
titrating resuscitative efforts to physiologic
parameters during CPR improves outcome, it may
be reasonable to use physiologic parameters
(quantitative waveform capnography, arterial
relaxation diastolic pressure, arterial pressure
monitoring, and central venous oxygen saturation)
when feasible to monitor and optimize CPR
quality, guide vasopressor therapy, and detect
ROSC (Class IIb, LOE C-EO).
23. 3.Ultrasound During Cardiac Arrest
• Ultrasound (cardiac or noncardiac) may be
considered during the management of cardiac
arrest, although its usefulness has not been well
established (Class IIb, LOE C-EO).
• If a qualified sonographer is present and use of
ultrasound does not interfere with the standard
cardiac arrest treatment protocol, then ultrasound
may be considered as an adjunct to standard
patient evaluation (Class IIb, LOE C-EO).
24. Defibrillation Shock
• All published studies support the effectiveness
(consistently in the range of 85%–98%) of biphasic
shocks using 200 J or less for the first shock.
• Defibrillators using the RLB waveform typically
deliver more shock energy than selected, based on
patient impedance.
• For the RLB, a selected energy dose of 120 J
typically provides nearly 150 J for most patients.
25. • Defibrillators (using BTE, RLB, or monophasic
waveforms) are recommended to treat atrial and
ventricular arrhythmias (Class I, LOE B-NR).
26. • Based on their greater success in arrhythmia
termination, defibrillators using biphasic waveforms
(BTE or RLB) are preferred to monophasic defibrillators
for treatment of both atrial and ventricular arrhythmias
(Class IIa, LOE B-R).
• In the absence of conclusive evidence that 1 biphasic
waveform is superior to another in termination of VF, it
is reasonable to use the manufacturer’s recommended
energy dose for the first shock. If this is not known,
defibrillation at the maximal dose may be considered
(Class IIb, LOE C-LD).
27. Defibrillation Strategies for Ventricular Fibrillation
or Pulseless Ventricular Tachycardia: Energy Dose
for Subsequent Shocks
• It is reasonable that selection of fixed versus
escalating energy for subsequent shocks be based
on the specific manufacturer’s instructions (Class
IIa, LOE C-LD).
• If using a manual defibrillator capable of escalating
energies, higher energy for second and subsequent
shocks may be considered (Class IIb, LOE C-LD).
28. Defibrillation Strategies for Ventricular Fibrillation
or Pulseless Ventricular Tachycardia: Single Shocks
Versus Stacked Shocks
• A single-shock strategy (as opposed to stacked
shocks) is reasonable for defibrillation (Class IIa, LOE
B-NR).
29. Antiarrhythmic Drugs During and Immediately
After Cardiac Arrest
• Antiarrhythmic Drugs During and Immediately After
Cardiac Arrest: Antiarrhythmic Therapy for Refractory
VF/pVT Arrest
the principal objective of antiarrhythmic drug therapy in
shock-refractory VF/Pvt is to facilitate the restoration and
maintenance of a spontaneous perfusing rhythm in concert
with the shock termination of VF.
Amiodarone may be considered for VF/pVT that is
unresponsive to CPR, defibrillation, and a vasopressor
therapy (Class IIb, LOE B-R).
Lidocaine may be considered as an alternative to
amiodarone for VF/pVT that is unresponsive to CPR,
defibrillation, and vasopressor therapy (Class IIb, LOE C-LD).
30. The routine use of magnesium for VF/pVT is
not recommended in adult patients (Class
III: No Benefit, LOE B-R).
No antiarrhythmic drug has yet been shown
to increase survival or neurologic outcome
after cardiac arrest due toVF/pVT.
31. Antiarrhythmic Drugs After
Resuscitation
• There is inadequate evidence to support the
routine use of a β-blocker and lidocaine after
cardiac arrest.
• However, the initiation or continuation of an oral
or intravenous β-blocker may be considered early
after hospitalization from cardiac arrest due to
VF/pVT (Class IIb, LOE C-LD).
32. Steroids
• In IHCA, the combination of intra-arrest
vasopressin, epinephrine, and methylprednisolone
and post-arrest hydrocortisone as described by
Mentzelopoulos et al may be considered; however,
further studies are needed before recommending
the routine use of this therapeutic strategy (Class
IIb,LOE C-LD).
• For patients with OHCA, use of steroids during CPR
is of uncertain benefit (Class IIb, LOE C-LD).
33. Cardiac Arrest During
Percutaneous Coronary Intervention
• Cardiac arrest during PCI is rare, occurring in approximately
1.3% of catheterization procedures.
• Cardiac arrest during PCI is present in both elective and
emergency procedures.
• cardiac arrest during PCI have superior outcomes to
patients in cardiac arrest that occurs in other settings
• Rapid defibrillation (within 1 minute) is associated with
survival to hospital discharge rates as high as 100% in this
population.
34. • The combination of ECPR and IABP has been associated
with increased survival when compared with IABP alone for patients
who present with cardiogenic shock, including those who have a
cardiac arrest while undergoing PCI.
35. Vasopressors in Cardiac arrest
• Standard-dose epinephrine (1 mg every 3 to 5
minutes) may be reasonable for patients in
cardiac arrest (Class IIb, LOE B-R).
• Vasopressin offers no advantage as a substitute
for epinephrine or in combination with
epinephrine in cardiac arrest (Class IIb, LOE
B-R). The removal of vasopressin has been
noted in the Adult Cardiac Arrest Algorithm
36.
37. Recommendations
• Institutional guidelines should include the selection of
appropriate candidates for use of mechanical support
devices to ensure that these devices are used as a bridge to
recovery, surgery or transplant, or other device (Class I, LOE
C-EO).
• It may be reasonable to use mechanical CPR devices to
provide chest compressions to patients in cardiac arrest
during PCI (Class IIb, LOE C-EO).
• It may be reasonable to use ECPR as a rescue treatment
when initial therapy is failing for cardiac arrest that occurs
during PCI (Class IIb, LOE C-LD).
38. Special Circumstances of Resuscitation
1. Cardiac arrest associated with pregnancy .
2. Pulmonary embolism (PE).
3. Cardiac arrest during PCI.
39. PREGNANCY
• Survival of the mother has been reported up to 15
minutes after the onset of maternal cardiac arrest.
Neonatal survival has been documented with PMCD
performed up to 30 minutes after the onset of
maternal cardiac arrest.
• In general, aortocaval compression can occur for
singleton pregnancies at approximately 20 weeks of
gestational age.
• Manual left lateral uterine displacement (LUD)
effectively relieves aortocaval pressure in patients
with hypotension
40.
41. CAUSES
• The most common causes of maternal cardiac
arrest are
1. Hemorrhage
2. Cardiovascular diseases (including myocardial
infarction, aortic dissection, and myocarditis)
3. Amniotic fluid embolism
4. Sepsis
5. Aspiration pneumonitis,
6. Eclampsia.
7. Important iatrogenic causes ofmaternal cardiac
arrest include hypermagnesemia from
magnesium sulfate administration and
anesthetic complications.
42. 2015 Recommendations—New and
Updated
• BLS Modification: Relief of Aortocaval Compression
• Priorities for the pregnant woman in cardiac arrest
are provision of high-quality CPR and relief of
aortocaval compression (Class I, LOE C-LD).
• If the fundus height is at or above the level of the
umbilicus, manual LUD can be beneficial in relieving
aortocaval compression during chest
compressions(Class IIa, LOE C-LD).
43. ALS Modification: Emergency Cesarean
Delivery In Cardiac Arrest
• Because immediate ROSC cannot always be achieved, local resources for a
PMCD should be summoned as soon as cardiac arrest is recognized in a
woman in the second half of pregnancy (Class I, LOE C-LD).
• Care teams that may be called upon to manage these situations should
develop and practice standard institutional responses to allow for smooth
delivery of resuscitative care (Class I, LOE C-EO).
• During cardiac arrest, if the pregnant woman with a fundus height at or
above the umbilicus has not achieved ROSC with usual resuscitation
measures plus manual LUD, it is advisable to prepare to evacuate the
uterus while resuscitation continues (Class I, LOE C-LD).
• PMCD should be considered at 4 minutes after onset of maternal cardiac
arrest or resuscitative efforts (for the unwitnessed arrest) if there is no
ROSC (Class IIa, LOE C-EO).
44. PULMONARY EMBOLISM
• Pulseless electrical activity is the presenting
rhythm in 36% to 53% of PE-related cardiac
arrests, while primary shockable rhythms are
uncommon.
• Current advanced treatment options include
systemic thrombolysis, surgical or percutaneous
mechanical embolectomy, and extracorporeal
cardiopulmonary resuscitation (ECPR).
• Systemic thrombolysis is associated with ROSC
45. • accelerated emergency thrombolysis dosing
regimens for fulminant PE include alteplase
50 mg intravenous (IV) bolus with an option
for repeat bolus in 15 minutes, or single-dose
weight-based tenecteplase; thrombolytics are
administered with or followed by systemic
anticoagulation.
46. 2015 Recommendations
• Confirmed Pulmonary Embolism
• In patients with confirmed PE as the precipitant of
cardiac arrest, thrombolysis, surgical embolectomy,
and mechanical embolectomy are reasonable
emergency treatment options (Class IIa, LOE C-LD).
• Thrombolysis can be beneficial even when chest
compressions have been provided (Class IIa, LOE C-
LD).
47. Post–Cardiac Arrest Care
2015 American Heart Association
Guidelines Update for
Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care
48. Hemodynamic Goals
• Avoiding and immediately correcting hypotension
(systolic blood pressure less than 90 mm Hg,
MAP less than 65 mm Hg) during post-
resuscitation care may be reasonable (Class IIb,
LOE C-LD).
• In the absence of evidence for specific targets,
the writing group made no recommendations to
target any hemodynamic goals other than those
that would be used for other critically ill patients.
49. Targeted Temperature Management
• Induced Hypothermia
• AHA recommends that comatose (ie, lack of
meaningful response to verbal commands) adult
patients with ROSC after cardiac arrest to be
considered for TTM(Class I, LOE B-R for VF/pVT
OHCA;Class I, LOE C-EO for non-VF/pVT (ie,
“nonshockable”) and in-hospital cardiac arrest).
• AHA recommends selecting and maintaining a
constant temperature between 32ºC and 36ºC
during TTM (Class I, LOE B-R).
50. • It is reasonable that TTM be maintained for at
least 24 hours after achieving target
temperature (Class IIa, LOE C-EO).
51. COOLING METHODS
• Cooling methods include the following:
1. Surface cooling with ice packs.
2. Surface cooling with blankets or surface heat
exchange device and ice.
3. Surface cooling helmet.
4. Internal cooling methods using catheter based
technology.
5. Internal cooling methods using infusion of cold
fluids.
52. • Of note, there are essentially no patients for
whom temperature control somewhere in the range
between 32oC and 36oC is contraindicated.
• Higher temperatures might be preferred in patients
for whom lower temperatures convey some risk (eg,
bleeding), and lower temperatures might be
preferred when patients have clinical features that
are worsened at higher temperatures (eg, seizures,
cerebral edema).
53. Hypothermia in the Prehospital
Setting
• AHA recommends against the routine
prehospital cooling of patients after ROSC
with rapid infusion of cold intravenous fluids
(Class III: No Benefit, LOE A).
54. Avoidance of Hyperthermia
• It may be reasonable to actively prevent fever
in comatose patients after TTM (Class IIb, LOE
C-LD).
55. Oxygenation
• 2015 Recommendations
• To avoid hypoxia in adults with ROSC after
cardiac arrest, it is reasonable to use the
highest available oxygen concentration until
the arterial oxyhemoglobin saturation or the
partial pressure of arterial oxygen can be
measured (Class IIa, LOE C-EO).
56. Glucose Control
• The benefit of any specific target range of glucose
management is uncertain in adults with ROSC after
cardiac arrest (Class IIb, LOE B-R).
57. Prognostication Time
• The earliest time for prognostication using clinical
examination in patients treated with TTM, where
sedation or paralysis could be a confounder, may be
72 hours after return to normothermia (Class IIb,
LOE C-EO).
• We recommend the earliest time to prognosticate a
poor neurologic outcome using clinical examination
in patients not treated with TTM is 72 hours after
cardiac arrest (Class I, LOE B-NR).
58. • Major management categories:
1. Primary Cardiac Arrest in patients with
AMI
2. Secondary Cardiac arrest in patients with
AMI
3. Due to non-cardiac diseases.
4. Survival after out of hospital cardiac
arrest.
59. • For successfully resuscitated patients, whether
OHCA or IHCA, post cardiac arrest care
includes admission to ICU and continous
monitoring for a minimum of 48-72 hrs.
61. Acute Cardiovascular Interventions
• Coronary angiography should be performed emergently (rather than
later in the hospital stay or not at all) for OHCA patients with
suspected cardiac etiology of arrest and ST elevation on ECG
(ClassI, LOE B-NR).
• Emergency coronary angiography is reasonable for select (eg,
electrically or hemodynamically unstable) adult patients who are
comatoseafter OHCA of suspected cardiac origin but without
ST elevation on ECG (Class IIa, LOE B-NR).
• Coronary angiography is reasonable in post–cardiac arrest patients
for whom coronary angiography is indicated regardless of whether
the patient is comatose or awake (Class IIa,LOE C-LD).
63. Beta Blockers
• Universally applicable and better established
for prevention of SCD.
• The Metoprolol CR/XL Randomized
Intervention Trial in Congestive Heart Failure
(MERIT-HF) demonstrated a 34% decrease in
the all-cause mortality rate, 38% decrease in
the cardiovascular mortality rate, and a 41%
decrease in the sudden death rate.
64. • Beta Blockers are effective in the setting of
ventricular arrhythmias provoked by a high
sympathetic tone, as in patients with
congenital long-QT syndrome, arrhythmogenic
right ventricular dysplasia, or CHF.
• Importantly, the beneficial effects of Beta-
blockers on cardiac mortality are most
pronounced in patients who are at higher risk
for sudden cardiac death, such as those with
CHF, atrial and ventricular arrhythmias, post-
myocardial infarction, and diabetes
65. ACE INHIBITORS
• Although data from individual trials has
conflicted on this issue, a meta-analysis
including more than 15,000 post–myocardial
infarction patients reported a 20% reduction in
sudden cardiac death in ACE-inhibitor treated
subjects
66. • Whether these results also pertain to
angiotensin receptor blockers is not known.
• The protection afforded by ACE inhibitors may
extend to patients with vascular disease in
general.
67. STATINS
• Reports suggest that, in addition to preventing
vascular events, statins reduce SCD and
appropriate shocks in patients with ICDs.
[Chiu JH, Abdelhadi RH, Chung MK, et al. Effect of statin therapy on risk of ventricular arrhythmia
among patients with coronary artery disease and an implantable cardioverter-defibrillator.
Am J Cardiol. 2005;95(4):490-491. [PMID: 15695135]
• A report from the MADIT II trial found that time-
dependent exposure to statins was associated with a
nearly 30% reduction in appropriate ICD therapy for
VT/VF or cardiac death, after adjustment for other
factors
68. AMIODARONE
• Amiodarone was shown to significantly reduce SCD
rates among post–myocardial infarction and heart
failure patients in several placebo-controlled
randomized studies, but its effects on total
mortality are questionable, with some individual
trials showing improved survival, but others not.
• Unlike with other antiarrhythmic drugs, no study
showed increased mortality with amiodarone in
these populations.
69. • Amiodarone is the drug of choice(DOC) when
antiarrhythmic drug treatment is required in
patients with left ventricular dysfunction and
congestive heart failure.
70. • In contrast to the oral version, relatively
strong evidence supports the use of
intravenous amiodarone for out-of-hospital
cardiac arrest and recurrent unstable
ventricular arrhythmias.
71. Implantable Defibrillators
• Primary prevention of Sudden Cardiac arrest in
Patients with Advanced Heart Disease.
• Secondary prevention Of Sudden Cardiac
Death after Survival Of Cardiac Arrest.
75. SURGICAL INTERVENTION
• REVASCULARIZATION
• There is a reduced prevalence of SCD after CABG,and attempts
should be made to identify and revascularize ischemic myocardium
in order to mitigate arrhythmic risk.
• Among the 13,476 patients in the Coronary Artery Surgical Study
(CASS) registry, all of whom had significant coronary artery disease,
operable vessels, and no significant valvular disease, the mean
incidence of SCD during the 4.6-year average follow-up was 5.2% in
patients treated medically and 1.8% in those treated surgically. The
beneficial effect of CABG was even more pronounced in the
subgroup of patients with reduced left ventricular ejection fraction
and multivessel disease.
• The protective effect of CABG against recurrent cardiac arrest
appears to be best in patients with reversible ischemia as the major
pathophysiologic factor in SCD.
76. Antiarrhythmia Surgery
• Electrophysiologically guided subendocardial
resection and cryoablation are potentially curative
surgical options in patients with recurrent
monomorphic VT in whom areas of slow conduction
around myocardial scars are critical for sustaining VT.
• Long-term follow-up of this operative technique has
yielded a clinical success rate of nearly 90% in
eliminating the presenting rhythm in patients who
survive surgery.
• The best candidates for electrophysiologically guided
subendocardial resection are patients who require
coronary revascularization and have a well-defined left
ventricular aneurysm.
77. Catheter Ablation Therapy
• Catheter ablation of arrhythmias has emerged as a
curative approach for many supraventricular
arrhythmias and a few specific forms of VT.
• The role of catheter ablation in the prevention of
SCD is less well established, but this therapy form
has been successfully used in selected cases.
• Radiofrequency catheter ablation can potentially
prevent SCD in patients with documented and
inducible bundle-branch reentrant VT as
the only mechanism of cardiac arrest.
• But high rates of recurrent VT after apparently
successful VT ablations suggest that few of these
patients can safely be managed without ICDS.
78. The 2016 American Heart Association (AHA)/American College of Cardiology
(ACC) Clinical Performance and Quality Measures for Prevention of Sudden
Cardiac Death (SCD) propose 10 key measures in the domains of preventative
cardiology, resuscitation/emergency cardiovascular care, heart failure/general
cardiology, and electrophysiology:
1. Smoking cessation intervention in patients who suffered sudden cardiac
arrest (SCA), have ventricular arrhythmias, or are at risk for SCD.
2. Screening for family history of SCD.
3. Screening for asymptomatic left ventricular dysfunction among individuals
who have a strong family history of cardiomyopathy and SCD.
4. Referring for cardiopulmonary resuscitation (CPR) and automatic external
defibrillator (AED) education those family members of patients who are
hospitalized with known cardiovascular conditions that increase the risk of
SCA (any acute myocardial infarction, known heart failure [HF], or
cardiomyopathy).
5. Use of an implantable cardioverter-defibrillator (ICD) for prevention of
SCD in patients with HF and reduced ejection fraction (HFrEF) who have an
anticipated survival of >1 year.
79. 6. Use of guideline-directed medical therapy: angiotensin-converting
enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) or
angiotensin-receptor/neprilysin inhibitor (ARNI), and beta-blocker,
and aldosterone receptor antagonist) for prevention of SCD in
patients with HFrEF.
7. Use of guideline-directed medical therapy (ACE-I or ARB or ARNI,
and beta-blocker, and aldosterone receptor antagonist) for the
prevention of SCD in patients with myocardial infarction and
reduced EF.
8. Documenting the absence of reversible causes for cardiac arrest
and/or sustained ventricular tachycardia before a secondary-
prevention ICD is placed.
9. Counseling eligible patients about an ICD.
10. Counseling first-degree relatives of survivors of SCA associated
with an inheritable condition.