Rosens 9 Adult Resus

Front 1

What clinically feasible interventions have actually been shown to consistently improve survival from cardiac arrest?

Back 1

- Early CPR
- Early defibrillation
- CPR before defibrillation after prolonged arrest
- Prolonged hypothermia induced after return of spontaneous circulation*********

Front 2

Define sudden unexpected death.

Back 2

- Death within 24 hours of symptom onset in a previously functional individual

Front 3

What is the basic pathophysiologic cascade of cardiac arrest (focus at the cellular level)?

Back 3

- Tissue hypoxia
- Cessation of aerobic metabolism
- Transition to anaerobic metabolism
- Depletion of ATP
- Failure of maintenance of cellular ionic gradients
- Intracellular Ca overload
- Generation of free radicals
- Mitochondrial dysfunction
- Altered gene expression
- Activation of catabolic enzymes (phospholipases, endonucleases, proteases)
- Activation of inflammation

Front 4

What percent of baseline cardiac output can be generated by standard chest compressions?

Back 4

- 30% *Decreases with time to initiation and duration

Front 5

How do chest compression result in circulation of blood?

Back 5

- “Cardiac compression model”
o Heart is squeezed between sternum and thoracic spine
o Generating a pressure gradient between the ventricle and great vessels
o Heart valves prevent retrograde flow
• Likely minor role


- “Thoracic pump model”
o Chest compression causes an increase in intrathoracic pressure which creates a pressure gradient between intrathoracic vascular bed and extrathoracic arterial bed
• Likely major role

Front 6

Define postresuscitation syndrome.

Back 6

- Multiorgan injury and failure occurring after severe global ischemia

Front 7

What is the term for reversible postarrest myocardial dysfunction?

Back 7

cardiac stunning

Front 8

Provide a DDx for nontraumatic cardiac arrest (table 7.1).
**THINK Hs and Ts and derive DDx from that

Back 8

Front 9

How does electrocution cause cardiac arrest?

Back 9

- Primary dysrhythmia or apnea

Front 10

List indicators of inadequate blood flow during cardiopulmonary resuscitation (table 7.3).

Back 10

Front 11

What is a minimum coronary perfusion pressure that must be generated in order to achieve ROSC in initial attempts at defibrillation have failed?

Back 11

- Coronary perfusion pressure>15mmHg

Front 12

How is coronary perfusion pressure measured (and calculated)?

Back 12

How is coronary perfusion pressure measured (and calculated)?
- Arterial diastolic pressure (measured by intraarterial catheter) – central venous pressure (measures by central line at the right atrium)
- EDP - LVEDP

Front 13

Is there an arterial pressure measure that also predicts ROSC?

Back 13

- Arterial diastolic pressure >40mmHg predicts ROSC

Front 14

What are the benefits of PetCO2 in a patient in cardiac arrest?

Back 14

What are the benefits of PetCO2 in a patient in cardiac arrest?
- Reliable indicator of cardiac output during CPR
o Target PetCO2>10mmHg (prior to vasopressor administration)
- Determining pseudo-EMD (higher PetCO2) vs. true EMD (Lower PetCO2
- Detecting success of resuscitation measures
- Confirm intubation of the trachea

EMD - electromyocardial dissociation - pseudo is when still have some contraction but no pulse

Front 15

What is the differential diagnosis of undetectable PetCO2 in an arrest patient?

Back 15

- Failure to intubate the trachea
- Massive PE
- Inadequate chest compressions

Front 16

What ScVO2 should be target during arrest to determine adequacy of chest compressions?

Back 16

>40%

Front 17

Provide an algorithm for treatment of cardiac arrest. (fig 7.4)

Back 17

Front 18

When should CPR be considered prior to defibrillation (even if immediately available)?

Back 18

- Duration of untreated cardiac arrest is prolonged >4-5 minutes a brief period of CPR (90-180 seconds) before defibrillation has been shown to improve likelihood of ROSC and survival

Front 19

Discuss the evidence for chest compression before defibrillation

Back 19

Cobb 1998 JAMA - retrospective +
Wik 2003 JAMA - only vfib >5min +
Jacobs 2005 Emerg med Oz -

2005 ILCOR guidelines - bystander defib, EMS >5min 2 min before/multiple people 1 cpm 1 get defib ready

Front 20

Who should receive immediate angioplasty post ROSC?

Back 20

- Evidence of acute myocardial ischemia and
o Thrombolytic exclusion criteria
o Drug resistant hypertension
o Cardiogenic shock
- +/- Patients with high risk for occult critical coronary stenosis

Front 21

In what patients post ROSC should transcutaneous pads be placed and transvenous pacing be considered?

Back 21

- New LBBB
- RBBB with LAFB or LPFB
- Second degree type II block
- Third-degree block

Front 22

Explain the significance of the oxygen delivery (DO2)/Oxygen consumption (VO2) curve post ROSC.

Back 22

- Oxygen extraction ratio increases and mixed venous oxygen saturation decreases in response to decreased oxygen delivery
- Below the critical DO2, VO2 become delivery dependent
- Anaerobic metabolism and lactate production result (dysoxia)

Front 23

Provide a goal-directed guide to the post resuscitation care of the cardiac arrest patient.

Back 23

Front 24

What are complications of standard CPR?

Back 24

- Aspiration (hypoxia, pneumonia, ARDS)
- Hepatic trauma (exsanguinations)
- Gastroespohageal trauma (fatal mediastinitis or hemorrhage)
- Cardiac trauma (cardiac contusion, hemopericardium, pericardial effusions)
- Bone trauma (sternal and rib fractures, hemothrorax, and bone marrow emboli)

Front 25

What are alternative methods of chest compression?

Back 25

- Interposed abdominal compressions
- Active comporession-decompression
- Vest (circumferential) compressions
- Open-chest cardiac massage
- Cardiopulmonary bypass
- Cough cardiopulmonary resusciatation

Front 26

.What medications can be delivered via the ETT?

Back 26

- Epinephrine
- Atropine
- Lidocaine

Front 27

Generally how are meds given via by the ETT?

Back 27

- 2.5 times standard IV dose
- Diluted to 10cc in NS or sterile water
- Via catheter placed through ETT
- Followed by 4-5 rapid PPVs
- NAVEL

Front 28

What is the mechanism of epinephrine in arrest?

Back 28

- Alpha stimulation
- Increased PVR
- Shunting of blood to cerebral and coronary circulations
- Improved coronary perfusion pressure and cerebral perfusion pressure
- +/- B1 agonism increasing myocardial contractility

Front 29

What is vassopressin?

Back 29

- Vasoactive peptide hormone
- Normally released form pituitary gland in response to hypovolemia or hypotension
- Potent vasoconstrictor (via G-protien mediated second messenger increases in ctytosolic CA and increased smooth muscle contraction)

Front 30

What is the evidence for vasopressin?

Back 30

lindner 97 Lancet - >epi
Stiel 2001- inp - no diff
Wenzel 2004 - faso better but screwy analysis

Front 31

What is the evidence for amiodarone?

Back 31

- Improved survival to hospital, but not discharge in persistent VF

Kudenchuk 1999 NEJM -impr to hosp
Dorian 2002 NEJM - amio>lido surv hosp adm

Front 32

What Vaughab-Williams class is amiodarone?

Back 32

3

Front 33

What is the dose of amiodarone for persistent VF?

Back 33

- 300mg IV bolus (may give additional 150mg at 30min)
- Post resuscitation
o 1mg/min for 6 hours (360mg)
o 0.5mg/min over 18 hours (540mg)
- Breakthrough VF or VT
o Bolus 150mg

Front 34

What is the dose of MGSO4?
List indications for MGSO4.

Back 34

- 2 g in 100 cc 5%dextrose over 1-2 minutes
- Torsades de points
- Hypomagnasemia

Front 35

List indications for NAHCO3.

Back 35

- Hyperkalemia (known or suspected)
- TCAs
- Preexisting metabolic academia