c) List the important differences in managing a cardiac arrest in a post-operative cardiac surgical
patient in ICU as compared to a non-cardiac surgical patient. (40% marks)
• Immediate VF or pacing (if indicated) before external cardiac massage – can delay ECM up to one minute to administer shock/pace
• No need for pulse check – observe monitored waveforms/ECG sufficient for diagnosis • Avoid adrenaline/vasopressin bolus
• Cease all infusions until reviewed
• If IABP in situ set to pressure trigger
• If PEA and paced, turn off pacemaker to exclude underlying VF
• Plan for emergency re-sternotomy, ideally within five minutes.
In short, the basic differences are:
- You do not use full dose adrenaline (rather, give smaller doses)
- You do three "stacked shocks"
- You try pacing in asystole if pacing wires are available; if they are already paced and in PEA, you turn off the pacing to "unmask" VF.
- These shocks and attempted pacing are all measures you take before starting CPR, which is a departure from the ACLS norms.
- If you can't control a shockable rhythm with three stacked shocks, you give amiodarone immediately rather than after three cycles.
- CPR is something you do while waiting to re-open the chest. After five minutes of unsuccessful resuscitation the chest should be re-opened.
- Non-surgical staff are encouraged to re-open the chest in an emergency
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