approach to cardiac arrest

Cardiac-Arrest

The standard approach to the cardiac arrest patient is to try to recall the “Hs and Ts,” a terrible mnemonic to remember in high-stress situations, and a classic example of a shotgun approach to diagnosis and treatment. Recently the article A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity helped to stratify PEA arrest into wide complex (metabolic) and narrow complex (structural), which builds an understanding of underlying causes and stratifies treatment. We can go one step further, putting this into the expanded ABCs to provide an integrated approach to causes and treatment of arrest, using rhythm and POCUS to guide diagnosis and treatment.

 

First consider the causes of arrest

A: airway obstruction

B: CHEST: anything causing hypoxia

  • Collapse lung + tension is most acute and reversible

C: CARDIOVASCULAR:

  • rhythm: Cardiac arrhythmia: VT/VF
  • pump: Around heart (tamponade), RV strain (PE), Dysfunction LV (massive MI), Incompetent valve, Outflow dissect
  • volume: Volume depletion, Abdominal bleed (GI, intraperitoneal) Soft tissue bleed (AAA, retroperitoneal, pelvic), Child-bearing (ectopic)
  • tone: Urticaria (anaphylaxis) Lactate (septic) Adrenal crisis Rx: distributive shock

E: ENDO: Electrolyte (hypoglycemia, hypo/hyperkalemia), Normothermia (hypothermia), Determine acid-base (acidosis)

I: INTOX: eg sodium channel blocker (wide complex), beta blocker/CCB (brady)

 

Putting this into practice, you can rapidly run through the expanded ABCs with a focus on resuscitation and reversible causes

A: BVM all patients +/- LMA

  • intubate to remove foreign body

B: oxygen all patients

  • needle thoracostomy if unilateral loss breath sound/lung slide (unless right mainsteam intubation)

C: early rhythm check, CPR and fluids to all patients

  • rhythm: Cardiac arrhythmia: identify shockable rhythm, stratify PEA
    • VT/VF –> shock +/- amio
    • PEA narrow complex –> obstructive
    • PEA wide complex –> metabolic/toxic
  • pump: CPR + cardiac POCUS identify primary cardiac cause
    • Around heart: pericardial tamponade –> pericardiocentesis
    • RV dilation –> thrombolysis
    • Dysfunctional LV –> cath if ROSC
    • Incompetent valve –> surgery if ROSC
    • Outflow dissection –> surgery if ROSC
  • volume: IV/IO NS + abdominal POCUS to identify hemorrhage
    • Volume depletion –> NS
    • Abdominal bleed: free fluid –> RBC + surgery
    • Soft tissue bleed: AAA –> RBC + surgery
    • Child-bearing ectopic: pregnant + free fluid –> RBC + surgery
  • tone: epi to all patients + consider distributive shock
    • Urticaria: anaphylaxis –> epi, steroids
    • Lactate –> pressor, antibiotics, source control
    • Adrenal crisis –> pressors, steroids
    • Rx distributive shock –> pressors, reverse (eg Ca, glucagon)

E: check glucose, consider electrolytes

  • give calcium/bicarb if wide complex, eg renal patient
  • warm if hypothermic, cool if ROSC without RONF

I:

  • consider toxic if unusual rhythm (brady, wide complex)

arrest

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