Sudden cardiac death urgent treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Sara Zand, M.D.[2]

Urgent Treatment

Medical Therapy

• The mainstay of therapy for patients with cardiac arrest is starting cardiopulmonary resuscitation with minimizing interruption in chest compression.

• The rhythm should be reassessed. If the rhythm is VF orpulseless VT, the shock should be delivered immediately.
• If the rhythm is asystole or pulseless electrical activity (PEA), CPR should be resumed.
• Advanced life support (ALS) should be kept with minimizing interruption in chest compression including:

• advanced airway
• Continuous chest compressions
• after placing an advanced airway
• capnography
• IV/IO access
• vasopressors, antiarrhythmics therapy
• Correcting reversible causes including hypoxia, hypovolemia,hypothermia, hyperkalemia, hypokalemia,acidosis, tension pneumothorax, tamponade, toxins (benzodiazepines, alcohol, opiates, tricyclics, barbiturates, betablockers, calcium channel blockers)

• The followings should be considered immediately in post cardiac arrest patients:

• 12–lead ECG
• Perfusion/reperfusion in patients with acute myocardial infarction
• Oxygenation and ventilation
• Temperature control
• Treatment of reversible causes

2017AHA/ACC/HRS Guideline for management of sudden cardiac arrest and ventricular arrhythmia

Recommendations for management of cardiac arrest

CPR (Class I, Level of Evidence A):

❑ CPR should be done according to basic and advanced cardiovascular life support algorithms

Amiodarone (Class I, Level of Evidence A) :

❑ In the recurrence of ventricular arrhythmia after maximum energy shock delivery and unstable hemodynamic, amiodarone should de infused

Direct current cardioversion : (Class I, Level of Evidence A)

❑ In ventricular arrhythmia and unstable hemodynamic, direct current cardioversion should be delivered

Revascularization:(Class I, Level of Evidence B)

❑ In patients with polymorphic VT and VF and evidence of acute STEMI in ECG, coronary angiography and emergency revascularization is advised

Wide QRS tachycardia: (Class I, Level of Evidence C)

❑ Wide QRS tachycardia should be considered as VT if the diagnosis is unclear

Intravenous procainamide (Class 2a, Level of Evidence A):

❑ In hemodynamically stable VT, intravenous procainamide is recommended

Intravenous lidocaine : (Class 2a, Level of Evidence B)

❑ Lidocaine is recommended in witness cardiac arrest due to polymorphic VT, VF unresponsed to CPR, defibrillation or vasopressor therapy

Intravenous betablocker : (Class 2a, Level of Evidence B)

❑ In polymorphic VT due to myocardial ischemia, intravenous betablocker maybe helpful

Intravenous Epinephrine : (Class 2b, Level of Evidence A)

❑ In cardiac arrest administration of 1 mg epinephrine every 3-5 minutes during CPR is recommended

Intravenous amiodarone : (Class 2b, Level of Evidence B)

❑ In hemodynamic stable VT, infusion amiodarone or sotalole maybe considered

High dose of intravenous epinephrine : (Class III , Level of Evidence A)

❑ In cardiac arrest, administration of high dose epinephrine>1 mg bolouses is not beneficial ❑ In refractory VF not related to torsades de pointes, administration of intravenous magnesium is not beneficial

Intravenous amiodarone : (Class III , Level of Evidence B)

❑In acute myocardial infarction, prophylactic administration of lidocaine or amiodarone for prevention of VT is harmful

Intravenous verapamil, diltiazem : (Class III , Level of Evidence C)

❑ In a wide QRS tachycardia with unknown origin, administration of verapamil and diltiazem is harmful

Sustained monomorphic VT

Hemodynamic stability

Stable

Unstable

12-Lead ECG, history, physical exam

Dirrect current cardioversion,ACLS

Notifying disease causing VT

Cardioversion(class1)

VT termination

Structural heart disease

Intravenous procainamide (class2a)

Yes, therapy of underlying heart disease

NO, cardioversion (class1)

NO, Ideopathic VT

Intravenous amiodarone or sotalole (class2b)

VT termination

Verapamil sensitive VT: Verapamil outflow tract VT: betablocker (class2a)

Effective

Non effective: cardioversion

Yes,therapy of underlying heart disease

NO, Sedation ,anesthesia, reassess antiarrhythmic therapy, repeating cardioversion

Therapy to prevent recurrence of VT

No VT termination

Catheter ablation (class1)

Catheter ablation (class1)

Verapamil , betablocker (class2a)

Intervention

Catheter ablation can only be performed for patients with sustained monomorphic ventricular tachycardia based on these characteristics:

• Incessant VT or electrical storm due to myocardial scar tissue
• Sustained VT and recurrent ICD shock in ischemic heart disease

2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and 2006 ACC/AHA/ESC Guidelines for Management of Patients With Cardiac Arrest (DO NOT EDIT)

Class III

"1. Adenosine should not be given for unstable or for irregular or polymorphic ventricular tachycardias, as it may cause degeneration of the arrhythmia to VF. (Level of Evidence: C)"

"1. Verapamil is contraindicated for wide complex tachycardias unless known to be of supraventricular origin. (Level of Evidence: B)"

"1. If one of these antiarrhythmic agents is given, a second agent should not be given without expert consultation. (Level of Evidence: B)"

Class IIa

" 1. Cardioversion with monophasic waveforms should begin at 200 J and increase in stepwise fashion if not successful. (Level of Evidence: B) "

" 2. If the etiology of the rhythm cannot be determined, the rate is regular, and the QRS is monomorphic, recent evidence suggests that IV adenosine is relatively safe for both treatment and diagnosis. (Level of Evidence: B) "

" 3. If IV antiarrhythmics are administered, procainamide can be considered. (Level of Evidence: B) "

" 4. If antiarrhythmic therapy is unsuccessful, cardioversion or expert consultation should be considered. (Level of Evidence: C) "

Class IIb

" 1. Monomorphic VT with a pulse responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J. If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion. (Level of Evidence: C) "

" 2. Precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia if a defibrillator is not immediately ready for use. (Level of Evidence: C) "

" 3. If IV antiarrhythmics are administered, amiodarone or sotalol can be considered. (Level of Evidence: B) "

Management of Cardiac Arrest (DO NOT EDIT)

Class I

"1 After establishing the presence of definite, suspected, or impending cardiac arrest, the first priority should be activation of a response team capable of identifying the specific mechanism and carrying out prompt intervention. (Level of Evidence: B) "

"2 Cardiopulmonary resuscitation (CPR) should be implemented immediately after contacting a response team. (Level of Evidence: A) "

"3 In an out-of-hospital setting, if an AED is available, it should be applied immediately and shock therapy administered according to the algorithms contained in the documents on CPR (334,335) developed by the AHA in association with the International Liaison Committee on Resuscitation (ILCOR) and/or the European Resuscitation Council (ERC). (Level of Evidence: C) "

"4 For victims with ventricular tachyarrhythmic mechanisms of cardiac arrest, when recurrences occur after a maximally defibrillating shock (generally 360 J for monophasic defibrillators), intravenous amiodarone should be the preferred antiarrhythmic drug for attempting a stable rhythm after further defibrillations. (Level of Evidence: B) "

"5 For recurrent ventricular tachyarrhythmias or nontachyarrhythmic mechanisms of cardiac arrest, it is recommended to follow the algorithms contained in the documents on CPR (334,335) developed by the AHA in association with ILCOR and/or the ERC. (Level of Evidence: C) "

"6 Reversible causes and factors contributing to cardiac arrest should be managed during advanced life support, including management of hypoxia, electrolyte disturbances, mechanical factors, and volume depletion. (Level of Evidence: C) "

Class IIa

"1 For response times greater than or equal to 5 min, a brief (less than 90 to 180 s) period of CPR is reasonable prior to attempting defibrillation. (Level of Evidence: B)"

Class IIb

"1 A single precordial thump may be considered by health care professional providers when responding to a witnessed cardiac arrest. (Level of Evidence: C)"

Management of Cardiac Arrest in Athletes (DO NOT EDIT)

Class I

"1 Preparticipation history and physical examination, including family history of premature or SCD and specific evidence of cardiovascular diseases such as cardiomyopathies and ion channel abnormalities, is recommended in athletes. (Level of Evidence: C)"

"2. Athletes presenting with rhythm disorders, structural heart disease, or other signs or symptoms suspicious for cardiovascular disorders should be evaluated as any other patient but with recognition of the potential uniqueness of their activity. (Level of Evidence: C)"

"3. Athletes presenting with syncope should be carefully evaluated to uncover underlying cardiovascular disease or rhythm disorder. (Level of Evidence: B)"

"4. Athletes with serious symptoms should cease competition while cardiovascular abnormalities are being fully evaluated. (Level of Evidence: C)"

Class IIb

"1. Twelve-lead ECG and possibly echocardiography may be considered as preparticipation screening for heart disorders in athletes. (Level of Evidence: B)"

References

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