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CARDIAC SURGERY
A D VA N C E D L I F E S U P P O R T
Resident questions for Thursday morning:
!
1. In a post cardiac surgery patient, high quality CPR is the first and most important step
in achieving a positive outcome? T/F
!
2. Define coronary perfusion pressure during cpr and explain its role in ROSC:
!
3. High quality CPR, when measured by a-line, is defined as a systolic BP of?
!
3. Re-sternotomy is indicated only in cases of tamponade? T/F
!
4. Define failure to rescue:
C A S E P R E S E N TA T I O N
63M
S/P CABG x 3 and MVR!
!
PMH: HTN, DM!
!
POD 1
Drips DC’d!
!
Swann Removed!
!
Out of Bed
C A S E P R E S E N TA T I O N
POD 2
Beta Blocker!
C A S E P R E S E N TA T I O N
POD 2
Beta Blocker!
!
Pleural Tube!
C A S E P R E S E N TA T I O N
POD 3
POD 4
Cordis Removed
C A S E P R E S E N TA T I O N
POD 5
C A S E P R E S E N TA T I O N
POD 5
No palpable pulse
Arterial Line: Non-pulsatile
FIRST STEP ?
CALS VS. ACLS
T H E Y ’ R E J U S T… . .
DIFFERENT
Cardiac Surgery Advanced
Advanced Cardiovascular
Life Life
Support Support
CALS
CALS
D I F F E R E N C E S
!
!
CALS
D I F F E R E N C E S
Monitoring
!
Personel / Location
!
Causes
!
CALS
D I F F E R E N C E S
!
• Tamponade
• Tension
• Hypovolemia
• Ischemia
• Arrhythmia
• 25-50% initial
Rhythm is vFib
C A S E P R E S E N TA T I O N
POD 5
CALS
CALS
!
E L E C T R I C I T Y
!
E L E C T R I C I T Y
!
CALS
90 BPM DDD pacing
CALS
E P I N E P H R I N E
Controversial
!
ROSC
• Generate coronary perfusion pressure (CPP)
• 15 mmHg
!
Buy time
A B D O M I N A L C P R
A B D O M I N A L C P R
WHY?
Release Tamponade
!
RE-STERNOTOMY
WHY?
Release Tamponade
!
Internal Defibrilation
• 20J
• Across ventricles
!
RE-STERNOTOMY
WHY?
Cardiac Massage
!
• Mean CPP Closed
Chest —> 7.3 mmHg
!
• Mean CPP Open
Chest —> 32 mmHg
!
• Goal = 15 mmHg
Why not do better than 46%?
RE-STERNOTOMY
WHO?
In CTICU
!
< 10 days post
!
Minimally invasive
or
Traditional Sternotomy
!
Within 10 minutes
NO ONE DIES WITH A
CLOSED CHEST
N O T O M Y
R E - S TER
S E Q U E N C E
• Prep +/-
• Scalpel
• Suction
• Retractor
• Look around
• Defibrillate
• Manual Compression
OPEN COMPRESSIONS
RIGHT HAND
BEHIND
AROUND APEX
!
LEFT HAND
F L AT O N
ANTERIOR
S U R FA C E
Volume & Mortality
Died
Complication
Survived
Failure to Rescue
• NYHA 4
!
Failure to Rescue
Complications
No#difference#
Fail To Rescue
Resident questions for Thursday morning:
!
1. In a post cardiac surgery patient, high quality CPR is the first and most important step
in achieving a positive outcome? T/F
!
2. Define coronary perfusion pressure during cpr and explain its role in ROSC:
!
3. High quality CPR, when measured by a-line, is defined as a systolic BP of?
!
3. Re-sternotomy is indicated only in cases of tamponade? T/F
!
4. Define failure to rescue:
THANK YOU