Part 12: Cardiac Arrest in Special Situations2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular CareTerry L. Vanden Hoek, Ketua; Laurie J. Morrison; Michael Shuster; Michael Donnino; Elizabeth Sinz; Eric J. Lavonas;
Farida M. Jeejeebhoy; Andrea Gabrielli
Presented by:Susi Muharni RismaRaihanun Nisa Dinur
Cut ChairaniMaulina Fusya
Supervisor:dr. Yusmalinda, Sp.An
IntroductionThis journal discuss 15 spesific cardiac arrest situations such as:
Asthma Anaphylaxis Pregnancy Morbid obesity Pulmonary embolism Electrolyte imbalance Ingestion of toxic
substances Trauma
Accidental hypothermia
Avalanche Drowning Electric
shock/lightning strikes Percutaneous
coronary intervention (PCI)
Cardiac tamponade cardiac surgery.
Pathophysiology
•Bronchoconstriction•Airway inflammation•Mucous plugging
Clinical aspect
•Wheezing
Cardiac Arrest Associated with Asthma
Primary Therapy• Oxygen• Inhaled β2-
Agonists (Albuterol,Levalbuterol)
• Corticosteroids (Methylprednisolone, Dexamethasone)
Adjunctive Therapy• Anticholinergics• Magnesium Sulfate• Epinephrine or
Terbutaline• Ketamine• Heliox• Methylxanthines• Leukotriene
Antagonists• Inhaled Anesthetics
Assisted Ventilation• Noninvasive
Positive-Pressure Ventilation
• Endotracheal Intubation with Mechanical Ventilation
Management of Asthma
•Hypersensitivity reaction
•Tachycardia•Faintness cutaneous•Flushing•Urticaria•Pruritus•Stridor, wheezing•Cardiovascular colaps
• Airway• Fluid resuscitation• Vasopressor • Antihistamin• Extracorporeal
support of circulation
• Airway• Circulation
(Epinephrine IM 0,2-0,5 mg)
Definition Signs & Symptomps
ACLS Modifications
BLS Modifications
Cardiac Arrest Associatedwith Anaphylaxis
Place the patient in the full left lateral position
Give 100% oxygen
Establish intravenous access above the diaphragm
Asses for hypotension
Consider reversible causes of critical illness and treat conditions that may contribute to clinical deterioration as early as possible.
Cardiac Arrest Associated with Pregnancy
• Positioning (left-lateral tilt position)
• Airway (bag-mask ventilation,suctioning)
• Breathing (oxygenation, ventilation,monitor oxygen saturation)
• Circulation (Chest compressions)
• Defibrillation (AED)
•Airway (ETT or supraglottic airway, bag-mask ventilation)
•Circulation•Defibrillation
BLS Modification ACLS Modification
Masalah pada ibu hamil
Penyakit jantung
Infark miokard
Aterosklerotik
Penyakit jantung bawaan
Keracunan magnesium sulfat
Kelainan jantung
Neurologis
gastrointestinal
Preeklampsia/ eklampsia
kegagalan organ bahkan sistem
Edema pulmonal/ Emboli cairan
ketuban
Henti Jantung pada Ibu yang Tidak Segera Membaik dengan BLS dan ACLS
Seksio sesaria darurat< 5 menit• Jika uterus gravid
di atas umbilikus> kompresi aortocaval> mengganggu hemodinamik
Pertimbangkan histerektomi
Hipotermia terapeutik sebagai perawatan post henti jantung
Henti Jantung pada Ibu yang Tidak Segera Membaik dengan BLS dan ACLS
Tidak ada modifikasi BLS standar atau perawatan ACLS yang terbukti berkhasiat, meskipun teknik mungkin perlu disesuaikan dengan fisik pasien.
Cardiac Arrest in the Morbidly Obese
Ekokardiografi darurat untuk diagnosa emboli pulmonal
Modifikasi ACLS
• Fibrinolitik• Trombektomi mekanik perkutan
• Embolektomi bedah
Emboli Pulmonal
Cardiac Arrest Associated with Pulmonary Embolism
Kalium
• Hiperkalemia• Hipokalemia
(pemberian bolus kalium)
Sodium (Na)
• tidak menyebabkan henti jantung
Magnesium (Mg)
• Hipermagnesemia(>2,2 mEq/L)
• Hipomagnesemia (<1,3 mEq/L)
Kalsium
• Diduga akibat penggunaan kalsium klorida atau kalsium glukonat
Cardiac Arrest Associated with Life Threatening Electrolyte Disturbances
-> Calcium gluconate [10%] 15-30 mL IV 2-5 minutes
->Bolus MgSO4 IV 1-2 gr
Electrolyte Disturbanc
e
Use of calcium chloride [10%] 5-10 mL or calcium gluconate [10%] 15-30 mL IV over 2-5 minutes is suspected as the cause of cardiac arrest
Definisi• konsentrasi
kalium serum > 6.5 mmol/L
Etiologi:• gagal ginjal, • Obat-obatan
Klinis
• flaccid paralysis, paresthesia, depresi refleks tendon dalam, atau kesulitan pernapasan
• EKG: T memuncak, gelombang P yang rata atau tidak ada, interval PR memanjang, kompleks QRS melebar, gelombang S dalam, dan penggabungan gelombang S dan T
akibat• aritmia• henti jantung
Hyperkalemia
Menstabilkan membran sel miokard:
• Kalsium klorida (10%): 5 -10 mL (500 sampai 1000 mg) IV lebih dari 2-5 menit atau kalsium glukonat (10%): 15-30 mL IV lebih dari 2-5 menit
Pergeseran kalium ke dalam sel:
• Natrium bikarbonat: 50 mEq IV lebih dari 5 menit• Glukosa ditambah insulin: campurkan 25 g (50 mL D50) glukosa dan 10 U
insulin reguler dan memberikan IV selama 15 -30 menit• Nebulasi albuterol: 10 -20 mg nebulized lebih dari 15 menit
Meningkatkan ekskresi kalium:
• Diuresis: furosemide 40 -80 mg IV• Kayexalate: 15 -50 g ditambah sorbitol per lisan atau rektum• Dialisis
ACLS Modifications in Management of SevereCardiotoxicity or Cardiac Arrest Due to
Hyperkalemia
Cardiac Arrest Associated WithToxic Ingestions
Alters the function of a
cellular receptor,
ion channel, organelle, or
chemical pathway
Respiratory depressionHypotension
Alteration of cardiac
conduction
Single dose activated charcoal can be
administered within 1 hour of poisoning
Multiple dose activated charcoal for patient who have ingested a
life threatening amount of specific toxins (carbamazepine, dapson, phenobarbital,quinine
or theophylin)
Charcoal should not be administered for ingestion
of caustic substances, metals or hydrocarbon
Opioid Toxicity• Naloxone administration should begin
with a low dose (0.04 to 0.4 mg)
Benzodiazepines • Flumazenil
β-Blockers• High-dose insulin, or IV calcium
salts.
Glucagon• Dopamine alone or in combination
with isoproterenol
Calcium Channel Blockers • Insulin high dose
Digoxin• One vial of antidigoxin Fab is
standardized to neutralize 0.5 mg of digoxin
Cocaine• 1 mL/kg of sodium bicarbonate
solution (8.4%, 1 mEq/mL) IV as a bolus.
Cyclic Antidepressants• Sodium bicarbonate boluses of 1
mL/kg• Vasopressor
Local Anesthetic Toxicity
• Consider 1.5 mL/kg of 20% long-chain fatty acid emulsion as an initial bolus epeated every 5 minutes until cardiovascular stability is restored
Hyperbaric Oxygen• A treatment regimen of 100% oxygen
and hydroxocobalamin, with or without sodium thiosulfate
Toxidromes
Cardiac Arrest AssociatedWith Trauma
Modifikasi BLS
Multisystem trauma: jaw thrust should be used instead of a head tilt– chin lift to stablish a
patent airway
Ventilation should be providedwith a barrier device, a pocket mask
Stop any visible hemorrhage using direct compression and appropriate dressings
CPR and defibrillation as indicated
Cardiac Arrest in Accidental Hypothermia
Patients with mild hypothermia (34°C [93.2°F]),moderate (30°C to 34°C [86°F to 93.2°F]), severe hypothermia (30°C [86°F])
Focus on interventions that prevent further loss of heat and begin to rewarm the victim immediatelyvasopresor (epinefrine or vasopresin)
Cardiac Arrest in Avalanche Victims
Causes ofavalanche-
related death
Caridac Arrest in Drowning
Recovery
From the
Water
Airway
Breathing
Circulation
The routine use of abdominal thrusts or the Heimlich maneuver for drowningvictims is not recommended
If vomiting occurs, turn the victim to the side and remove the vomitus using your finger, a cloth, or suction
Cardiac Arrest Associated withElectric Shock and Lightning Strikes
Electrical Shock
•Tetanic skeletal muscle contractions•Ventrikel fibrilation
Lightining Strikes
•Simultaneously depolarizing the entire myocardium•Respiratory arrest (thoracic muscle spasm and suppression of the respiratory center)•Producing extensive catecholamine release (hypertension, tachycardia)•Brain hemorrhages, edema, and small-vessel and neuronal injury•Hypoxic encephalopathy
Standard BLS resuscitation care -> early intubation should be performed for patients with evidence of extensive burns -> Fluid administration should be
adequate
Cardiac Arrest duringPercutaneous Coronary Intervention
Mechanical CPR During PCI
Cough CPR
Intracoronary Verapamil
Emergency
Cardiopulmona
ry Bypass
Rapid diagnosis and drainage of the pericardial fluid are required to avoid cardiovascular collapse. Pericardiocentesis guided by echocardiography is a safe and effective method of relieving tamponade in a nonarrest setting
Cardiac Arrest caused byCardiac Tamponade
Cardiac surgery
Ventricular
fibrillation,
hypovolemia
, cardia
c tamponade,
or tensio
n pneu
mothorax
Resternotom
y and internal
cardiac
compression
Extracorporeal
membrane
oxygenation and cardiopulmonary bypass
+ Pharmacological Interven
tion (epinephrine and antiarrhythmics)
Cardiac Arrest followingCardiac Surgery
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