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CCARDIOARDIO - - PPULMOULMO - - ((CCEREBRAL)EREBRAL) RRESUSCITATIONESUSCITATION

Jozef Firment

Judita CapkováDepartment of

Anaesthesiology & Intensive MedicineŠafárik University Faculty of Medicine, Košice

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Basic life support A,B,C - to buy time for Advanced life support A,B,C,D,E –

to restore circulation

1961: Peter Safar

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Most frequent causes Most frequent causes of out-of-hospital cardiac of out-of-hospital cardiac

arrest CAarrest CA

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Most common causes of Most common causes of cardiac arrest CAcardiac arrest CA

• 1. place IHD...Myocardial infarction (80%)

Ventricular fibrilation

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Most common causes of Most common causes of cardiac arrest CAcardiac arrest CA

• 1. place IHD...Myocardial infarction

• Hypertension• Valvular disease,..

• • Trauma • Poisoning • Drowning

• Hypotermia...

Ventricular fibrilation

Electrical defibrillation –only effective treatment for VF

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Most common causes of Most common causes of cardiac arrest CAcardiac arrest CA

• 1. place IHD...Myocardial infarction (80%)

• Hypertension• Valvular disease,..

• • Trauma • Poisoning • Drowning

• Hypotermia...

Ventricular fibrilation

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Cause of CA inCause of CA in

• Trauma• Drowning

• Drug overdose Asphyxia• Children

Rescue breaths are critical for resuscitation

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• In- hospital arrests are due tu PEA or asystole (60-70%)

- early recognition of pp at risk may prevent arrest – „Medical Emergency Teams“

• Overall survival to hospital discharge is 10%

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THE CHAIN OF SURVIVALTHE CHAIN OF SURVIVAL

Early access

to emergency

services

EarlyBLSto

buytime

Earlydefibrillation

to reverseVF

Early advanced

care to

stabilise

up to 4 min up to 8 min

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Open Airway:Open Airway:

Cervical spine injuryCervical spine injury• Jaw thrust (no for lay rescuer) or chin lift

with manual inline stabilisation of head and neck by an assistant

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AGONAL BREATHINGAGONAL BREATHING

• Occurs shortly after the heart stops

in up to 40% of cardiac arrests

• Described as barely, heavy, noisy or gasping breathing

• Recognise as a sign of cardiac arrest

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EXTERNAL EXTERNAL CHEST CHEST

COMPRESSIONSCOMPRESSIONS

one rescuer 30:2

5-6 cm

f : 100-120/min.

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The quality of cc is frequently The quality of cc is frequently suboptimal suboptimal

Effective chest compressionsEffective chest compressions

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Continous chest compression - onlyContinous chest compression - only

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Only 1 in 4 patients in CA Only 1 in 4 patients in CA recieves bystander CPRrecieves bystander CPR

• transmission of infection: - tuberculosis, SARS, H1N1 –

small number, - HIV – never reported

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Protective devices:Protective devices:

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Continous chest compression - onlyContinous chest compression - only

• If layman is not able or is unwilling to perform mouth to mouth breathing

• Chest compressions f: 100/min without stopping

Basic life supportBasic life support C,A,BC,A,B

• Continue chest compressions and rescue breathing:

- victim starts breathing normally (signs of life)- Medical emergency service arrives

- you become exhausted

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Basic life support C,A,B Advanced life support

C, A, B, Drugs, ECG, Fibrilation treatment - defibrilation...

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In hospital CPR- In hospital CPR- Advanced life supportAdvanced life support One person starts 30:2

others call resuscitation team + defibrillator, r. equipments (airway, ambu bag, adrenalin,..)

only one person: leaves the patient, calls resuscitation

teamstarts 30:2

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A and B:A and B:• Oral/nasal airway

VENTILATION MANAGEMENT VENTILATION MANAGEMENT ALSALS –In-hospital CPR –In-hospital CPR

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A and B:A and B:• Oral/nasal airway• Tracheal intubation : f: 10/min , Fi02 = 1,0

(reservoir bag), VT(tidal volume) 6-7 ml/kg,(chest compressions and ventilations continue uninterupted)

VENTILATION MANAGEMENT VENTILATION MANAGEMENT ALSALS –In-hospital CPR –In-hospital CPR

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Oe Trach

90%

Laryngeal mask, laryngeal tube

Oe-Trach Combitube

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CampbellO2 FiO2 VT x fl/min %

adults: 13 85-100 1000 x 15 - “ - 4 >40 dttochildren 5 85-100 300 x 20 - “ - 2 >40 dtto

Inlet O2 10 - 13 l/min

BAG WITH OXYGEN SUPPLYBAG WITH OXYGEN SUPPLY

B:

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Advanced life supportAdvanced life supportSelf-inflating bag-mask + oropharyngeal airway : CC:V= 30:2

Hyperventilationreduces cerebral blood flow

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The quality of chest compressions is frequently suboptimal

team leader shouldchange CPR providers every 2 minutes (5x cc:v 30:2)

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Ventricular fibrillation Ventricular tachycardia

AsystoleElectro-mechanical disociation (EMD)Pulseless ventricular activity (PVA)

Hearth rhytms associated with CA:

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DEFIBRILLATIONDEFIBRILLATION• Paddle positions (sternum, apex),

no over the breast tissue• Self- adhesive pads (sparks!!)

- the best

• Biphasic defibrilators:1. 150-200J2. 150-360J,....

• CPR for 2 min (5 x 30:2)after shock

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DEFIBRILLATIONDEFIBRILLATION

• Check the rhythm(organised QRS complexes:regular + narrow- feeling for a pulse)

• After the third shock give:adrenalin 1mg every 3-5 min. ivamiodaron 300mg iv

• Time between CC and shock delivery < 5s – coronary perfusion pressure falls substantially

• Signs of life return :normal breathing,movement, coughing, puls

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A precordial thumpA precordial thump

• Generates a small electrical shock

• In witnessed and monitored VF/VT arrests if a defibrillator is not immediately available

•The ulnar edge of fist the lower half of sternum from a height of 20 cm

•Converting VT to sinus rhytm

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LIFE-THREATENING CARDIAC LIFE-THREATENING CARDIAC RHYTHM DISTURBANCESRHYTHM DISTURBANCES

Cardiac arrest (asystole)Fine VF will not be shocked successfully

Pulseless electrical activity (PEA, EMD)- myocardial contractions are too weak to produce pulse or blood pressure

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POTENTIALLY POTENTIALLY REVERSIBLE CAUSES REVERSIBLE CAUSES

((55 H H’s & ’s & 55 T’s T’s))::• Hypoxia• Hypovolemia• Hypothermia• Hyper/hypoK+and

metabolic disorders

• H+ ions (acidosis)

• Tension pneumothorax

• Tamponade• Toxic/therap.

disturbances• Thrombosis coronary• Thrombosis

pulmonary

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POTENTIALLY REVERSIBLE CAUSES POTENTIALLY REVERSIBLE CAUSES ((55 H H’s & ’s & 55 T’s T’s))::

• Hypoxia – ventilation with 100% oxygen• Hypovolemia (haemorrhage-trauma, GIT

bleeding,rupture of an aortic aneurysm- fluid ( saline or Hartman´s solution + urgent surgery)

• Hypothermia (in drowning incident)• Hyper/hypoK+and metabolic disorders

(detected by biochemical tests, renal failure)• H+ ions (acidosis) - bicarbonate

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POTENTIALLY REVERSIBLE POTENTIALLY REVERSIBLE CAUSES CAUSES

((55 H H’s & ’s & 55 T’s T’s))::• Tension pneumothorax- needle

thoracocentesis and chest drain• Tamponade – needle pericardiocentesis• Toxic substances – appropriate

antidotes • Thrombosis coronary - thrombolysis• Thrombosis pulmonary – trombolytic

drug

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ThoracocentesisThoracocentesis

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Needle pericardiocentesisNeedle pericardiocentesis

Cardiac tamponade:- difficult to diagnose

- penetrating chest trauma – is suggestive

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TThrombohrombosis pulmonary and sis pulmonary and coronarycoronary

• thrombolysis

• percutaneous coronary intervention -PCI

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DRUGS USED CPRDRUGS USED CPR1. Adrenaline (EPINEPHRINE)

1 mg á 3’- 5 ’(EVERY SECOND LOOP(5x CV 30:2) OF THE ALGORYTHM)alpha adrenergic actions cause vasoconstriction, increases myocardial and cerebral perfusion pressure

2. Bicarbonate 50ml 8,4%

-pH < 7.1, BE < -10-hyperkalaemia-tricyclic antidepressant overdose

&& equipment equipment• (defibrilator) • oxygen• Ambu bag• face mask• F1/1• infusion set• plastic IV cannula

3. 3. AmiodaroneAmiodarone 300 mg after a third unsuccessful defibrillation in VF/VT...150 mg (inf. 900mg/24h)lidocaine 1 mg/kg- alternative

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DRUG DELIVERY ROUTES DRUG DELIVERY ROUTES

• Intravenous (central, peripheral + 20 ml sol. F 1/1 + elevate 10-20 s)

• Intraosseal – effective concentrations of drugs is achieved very quickly

• Tracheal (2-3x more dose + 10 ml water) (adrenaline, lidocaine, atropine)

• NEVER IM nor SC !!!

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EZ-IO AD Proximal Tibial AccessEZ-IO AD Proximal Tibial AccessIntraosseous Infusion System

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Automatický intraoseálny injektor

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Post – resuscitation carePost – resuscitation care

• Stable cardiac rhythm, normal haemodynamic function (thrombolysis, percutaneous coronary intervention)

• Intubation, ventilation, sedation

• Therapeutical hypothermia

• Comatose adults after out-of-hospital VF cardiac arrest were cooled to 32-34 oC for 12-24 h.

• Improved neurological outcome

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• www.erc.edu• www.resus.org. uk

• Resuscitation (in october 2010) • http://www.lf.upjs.sk/kaim/pregradualne_vz

delavanie.html

47jcapkova@capko.sk

Thank you!Thank you!

Open chest CPROpen chest CPR

• better coronary perfusion

• Trauma, after cardiothoracic surgery, when chest or abdomen is already open

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PROTOCOL FOR CPCRPROTOCOL FOR CPCR INTERPRETATION INTERPRETATION

„Utstein in-hospital“„Utstein in-hospital“

TIME~ disaster call~ start CPCR~ emerg. team arrival ~ onset of circulation~ living out

+ provided activities...

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HODNOTENIE VÝSLEDKOVHODNOTENIE VÝSLEDKOVKPCRKPCR

• Kritériom krátkodobého výsledku KPCR je obnovenie krvného obehu

• Kritériom dlhodobého výsledku KPCR je návrat neurologických a psychických schopností pacienta

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Normal SR

Ectopic rhythm

Thrombus development

Acute MI

Rhythm disorders at AMI

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LIFE-THREATENING CARDIAC LIFE-THREATENING CARDIAC RHYTHM DISTURBANCESRHYTHM DISTURBANCES

1. Ventricular fibrillation,pulseless ventricular tachycardia

2. Cardiac arrest (asystole)

3. Pulseless electrical activity (PEA, EMD)

= circulatoty arrest

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• Európske guidelines týkajúce sa resuscitácie boli publikované Európskou radou pre resuscitáciu (ERC) v International Journal Resuscitation v novembri 2010.

• www. erc.edu, www.resus.org.uk

European resuscitation counscil