Emergencies General Part 3 : Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular CarePulseless Electrical Activity (PEA) Lack of pulse with persistent electrical activity Asystole Lack of all electrical activity on the cardiac monitor Determine cause of rhythm (hypoxemia, hyperkalemia, hemorrhage, metabolic acidosis, tension pneumothorax, cardiac tamponade, or toxins) Reversible causes of Asystole/PEA 5 Hs & 5 Ts: Hypovolemia, Hypoxia, Hydrogen Ions (Acidosis), Hypo/Hyperkalemia, Hypothermia Tension Pneumothorax, Tamponade (Cardiac), Toxins (narcotics, benzos), Thrombosis (Pulmonary or coronary), Trauma Treatment CPR, Epinephrine ± Vasopressin Fix cause No response to defibrillation Sudden Cardiac Arrest and Sudden Cardiac Death Sudden cessation of cardiac activity so that the victim becomes unresponsive, with no normal breathing and no signs of circulation Sudden Cardiac Arrest (SCA) used to signify an event that is reversed Sudden Cardiac Death (SCD) used to signify if the event leads to death Etiology HCM (36%) Coronary artery anomalies (17%) Possible HCM (8.2%) Myocarditis (5.9%) Arrhythmogenic RV cardiomyopathy (4.3%) Brugada Syndrome Autosomal Dominant disorder due to Sodium channel gene (SCN5A) mutation found in 25-30% Presentation Male, attacks occur at rest and during sleep 3rd /4th decades of life Polymorphic VT causing syncope Syncope and sudden cardiac death without structural heart disease EKG Type 1 (Typical): ≥2mm of coved ST elevation in the right precordial leads (V1-V3) with associated T-wave inversion and RBBB appearance Treatment Asymptomatic: Controversial Symptomatic: ICD Long QT (3.6%) MCC of SDA in the immediate post-infarction period with acute MI Immediate (<10min): Acute ischemia predisposes to Re-entrant ventricular arrhythmias (Ventricular fibrillation) Delayed (10-60min): Abnormal automaticity leads to arrhythmias Most important factor for survival out of the hospital SCA is elapsed time to effective resuscitation Includes adequate bystander CPR, prompt rhythm analysis, and defibrillation Defib possible: Vfib or Pulseless Vtach Defib not possible: Asystole, PEA Hallmark: Deeply inverted T waves in V2/V3 (Type B, 75%) or Biphasic T waves with initial positivity and terminal negativity in V2/V3 (Type A, 25%) PLUS: Isoelectric or minimally elevated ST segment, less than 1mm Preserved precordial R-wave progression and no precordial Q waves Recent history of angina EKG without pain Normal or slightly elevated cardiac markers Type A often evolve into Type B Symptoms Painless mild elevation in troponins Complications Highly specific for critical, proximal LAD stenosis Large anterior wall acute MI Treatment Admit to Telemetry is asymptomatic, ICU if symptomatic Cards consult for cath Cath w/Stents (refractory to medical management)