What are reversible causes of CPR?
Hypoxia Hypovolaemia Hypo/hyperkalaemia Toxins Thrombosis (cardiac or pulmonary) Cardiac tamponade Tension pneumothorax
What are the first stages of action on discovering adult cardiac arrest, before an ECG establishes rhythm ?
- confirm cardiac arrest by monitoring pulse and breathing activity simultaneously
- call resus team (2222 at St. George’s)
- start CPR - uninterrupted chest compressions and apply defib pads - one under RIGHT clavicle and other in V6
- stop chest compressions to confirm rhythm on ECG
What are the 2 shockable rhythms?
VF / VT
What are the steps of action if VT/VF is confirmed?
- resume CPR while designated person selects shock energy
- charge defib and ensure all stand clear
- restart CPR using 30:2 ratio and continue for 2 mins then reassess rhythm - if organised electrical activity is seen, look for ROSC: central pulse, end-tidal CO2 trace - start post-resus care
- if still VT/VF, repeat shock and 2 mins CPR at 30:2, reassess and repeat if still VT/VF
- after 3rd shock resume CPR for 2 mins and give adrenaline 1mg IV and amiodarone 300mg IV
- continue 2 mins CPR - assess- shock sequence if still in VT/VF, giving further 1mg adrenaline IV after alternate shocks (every 3-5 mins)
- if asystole seen, switch to non-shockable course of action
What are the 2 non-shockable rhythms?
Asystole and PEA
What is PEA?
Pulseless electrical activity - no palpable pulse even though there is electrical rhythm expected to produce cardiac output - survival is unlikely unless a reversible cause is found
What is the course of action if PEA is discovered?
- CPR 30:2 and 1mg adrenaline IV as soon as access is achieved
- achieve secure airway and do continuous chest compressions
- look for and correct reversible causes
- reassess after 2 mins - if still no pulse or chance in ECG, continue CPR and recheck after 2 mins, giving 1mg adrenaline in alternate cycles
- if rhythm becomes VT/VF, switch to shockable protocol
- if pulse detected, start post-resus care
What is the course of action for asystole?
• CPR 30:2 and adrenaline 1mg IV as soon as you have access
• secure airway and continue uninterrupted chest compressions
• look for and correct reversible causes
(ARE THERE P WAVES? May respond to pacing)
• reassess after 2 mins and continue CPR if still PEA or asystole, giving adrenaline 1mg IV at alternate cycles
• if VT/VF, change to shockable rhythm plan
When does hypertension require hospital admission?
- when there is evidence of a rapid rise in blood pressure
- when BP is significantly raised, eg to a systolic BP >220mmHg and/or diastolic BP >120mmHg
- if there is evidence of severe or life-threatening end organ damage (eg hypertensive encephalopathy, intra-cranial haemorrhage, aortic dissection, acute coronary syndromes, acute LV failure with pulmonary oedema, pre-eclampsia/eclampsia)
What is malignant hypertension?
Syndrome characterised by severely elevated BP with retinopathy (retinal haemorrhages, exudates or papilloedema), visual impairment, nephropathy AKI +/- hypertensive encephalopathy and microangiopathic haemolytic anaemia
• send patient to HDU or ITU and seek advice from blood pressure unit
What is the aim of treatment of a hypertensive emergency?
To lower blood pressure in a rapid (2-4 hours) but controlled manner to safe levels of 160mmHg systolic 100mmHg diastolic (NOT ‘normal’ levels) - maximum initial BP drop should not exceed 25% of starting value - too rapid a fall could cause stroke/MI or acute renal failure
What is the drug of choice for most hypertensive emergencies?
SNP - sodium nitroprusside - arteriolar and venous dilator with immediate onset and short duration of action - beware associated with cyanide toxicity (clinical deterioration, altered mental status and lactic acidosis) - caution use in pre-eclampsia - only give in HDU/ITU with continuous intra-arterial blood pressure monitoring
When is labetalol used?
It is a combined alpha and beta blocker which can be used in most hypertensive emergencies or urgencies - logical for use in patients with IHD, aortic dissection or stroke (plus high BP in pregnancy as it is safe) - give by slow IV injection or infusion - beware postural hypotension
When might GTN be used?
GTN is a venodilator (slight arteriolar dilator) with quick onset of action but tolerance builds quickly - used in acute LV failure, acute pulmonary oedema, and ACS - beware BP response to GTN is not as predictable as with SNP
What else could be used in hypertensive emergencies in pregnancy?
Hydralazine- arteriolar dilator - given by slow IV injection or infusion - not to be given to pts with IHD or aortic dissection
What would you give to a phaeochromocytoma patient in hypertensive emergency?
Phentolamine- short acting alpha blocker
What must you exclude in a patient with severe hypertension and chest back or abdo pain? What is initial treatment in this presentation?
Aortic dissection - initial treatment is IV beta blocker eg labetalol plus a vasodilator such as SNP or dihydropyridine CCB - aim for systolic BP <120mmHg if tolerated
How should a patient with a hypertensive urgency be managed?
Admit to a medical bed and slowly reduce BP to systolic 160-180mmHg and diastolic 100-110mmHg with oral agents if possible - if patient is known hypertensive and non compliant with normal meds, resume normal regimen - for compliant patients, increase doses or add new drugs
• nifedipine SR/MR 10mg and again 2 hours later if needed - maintenance up to 20mg 3 times a day
• add beta blocker as second line (esp with co existing IHD or resting tachycardia)
• ACE inhibitors but use with caution and consult blood pressure unit
What is the follow up management after initial decrease in BP in patients with a hypertensive emergency or urgency ?
Monitor renal function as it can deteriorate when BP is reduced quickly
Gradually reduce BP to normal levels over the subsequent few weeks
Refer patients with severe hypertension to blood pressure unit for investigations into secondary causes of hypertension
What are some causes of secondary hypertension?
- renal artery stenosis
- phaeochromocytoma
- primary hyperaldosteronism
- adrenal pathology
- renal disease
What are the important things to remember DURING CPR?
- ensure good quality compressions
- minimise interruptions to compressions
- give oxygen
- consider advance airway - anaesthetics involvement
- get vascular access
- adrenaline every 3-5 mins
- look for and correct reversible causes
