17 Cpr

1.Cardiopulmonary Resuscitation Chai-yanfen Department of Emergency Medicine, Tianjin Medical University General Hospital

At the end of the course the student will be able to

1.Define the sudden cardiac arrest, the clinical death and biologic death. CPR defination

2.Master the cardiopulmonary cerebral resuscitation skill, procedure and the method of BLS.

3.Know the complication of CPR.

4.Know the chain of survival.

General consideration

CPR Steps

Complication of CPR

Monitoring during CPR

Terminating Resuscitation

General consideration

CPR definition

The History of CPR

The Goals of CPR

4.Anatomy and function of the circulatorysystem

5.Death concepts

6.Epidemiology of Sudden cardiac death

7.The chain of survival

8. Do Not Attempt Resuscitation ,DNAR

The termcardiopulmonary resuscitationmeans: the revival or return to function of the heart and lungs.

CPR is a technique through mechanical, physiologic and pharmacologic methods to resuscitatethe patients in sudden unexpected death resulting from reversible disease.

There are three goals of resuscitaition:

The history of CPR and cerebrial arrest prophylaxis begins in ancient times.

5000 -first artificial mouth to mouth ventilationin3000 BC

1780 first attempt of newborn resuscitation by blowing

1874 first experimental direct cardiac massage

1901 first successful direct cardiac massage in man

1946 first experimental indirect cardiacmassage and defibrillation

1960 indirect cardiac massage

1980 development of cardiopulmonary resuscitation due to the works of Peter Safar

There were no immediately applicable effective emergency resuscitation techniques available before 1950s.

Modern respiratory resuscitation was pioneeredin 1950s

safar: opening airway 1958,

Elam:mouth to mouth breath,),

Modern circulatory resuscitation in the 1960s Kouwenhoven :external cardiac compression,1960 ,

Therapeuticall promising reseach on brain resuscitationbegan in 1970.

The circulatory system is similar to a city water system:

The heartfunctionsas a pump

The blood vesselsas a network pipes

The bloodas fluid

After blood picks up oxygen in the lungs ,it goes to the heart ,which pumps the oxygenated blood to rest of the body.

The cells of the body absorb oxygen and nutrients from the blood and produce waste products(including carbon dioxide),that blood carries back to the lungs.In lungs ,the blood exchanges the carbon dioxide for more oxygen .Then the oxygenated blood returns to the heart to be pumped out again.

If the heart stop contracting,and no blood is pumped through the blood vessels.Without a supply of blood, the cells of the body will die because they cannot get any oxygen and nutrients and they cannot eliminate waste products.

Death is a physiologic and biologic process ,it just occurs after cardiac arrest.

Clinical Death

Biologic death

Suddencardiac death

Clinical Death has been defined by Negovsky as the period of respiratory,circulatory,and brain arrest during which initiation of resuscitation can lead to recovery with prearrest central nervous system function.Clinical Death is a reversible state

The duration of clinical deathdepends on the length of timeofthe cerebral cortex survives in the absence of circulation and respiration.

Under normal temperature ,from clinical death to biologic death ,the period does not exceed 3-6min.

Biologic deathwhich sets in after clinical death,is anirreversiblestate of cellular destruction.

Sudden cardiac death (also called sudden arrest) is death resulting from an abrupt loss of heart function (cardiac arrest). The victim may or may not have diagnosed heart disease. The time and mode of death areunexpected . It occurs within minutes to 1 hour after symptoms appear. The most common cause ofcardiac arrest is coronary heart disease.

Sudden cardiac death is the clinical death,Thisis a reversiblecondition.In most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation.

Cardiac

Ischemic heart disease (myocardial infarction, stenocardia)

Arrhythmias of different origin and character

Electrolytic disorders

Valvular disease

Cardiac tamponade

Pulmonary artery thromboembolism

Ruptured aneurysm of aorta

Extracardiac

airway obstruction

acute respiratory failure

Reflective cardiac arrest

embolisms of different origin

drug overdose

Electrocution(

poisoning

Ventricular fibrillation

pulseless Ventricular

tachycardia

Asystole

Electric mechanical activity dissociation

Cardiac arrest accounts for between 250 000-350 000 death each year inUSA.

Expert estimate that the overall survival rate may be beween 3% -5%,in many large urban areas maybe less than 2%.

In China, cardiac arrest approximately is 1 000 000 Mortality of cardiac arrest is 95%-98% in USA and 98%-99% inChina .

Delay Initiation of CPRare the most common cause oflowrates of survival from out-of-hospital cardiac arrest.

Sudden cardiac arrest is reversible,in most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation.

Early Accessto Medical Care (calling 911 in USA ,and calling 120 in Chinaimmediately)

Early CPR(within 4 min after cardiac arrest)

Early Defibrillation(for an out of hospital sudden cardiac death within 5min,for a in hospital victims within 3minIn guidelins 2000 )

Early Advanced Care (including intubation and IV medication)should be initiated within 8min of arrest.

No CPR 0%-2% survive Delayed defibrillation

Early CPR 2%-8% survive Delayed defibrillation

Early CPR20%surviveEarly defibrillation

Early CPR30% survive Very early defibrillationEarly ACLS

Resuscitation success is dependent on each link in the chain. Early defibrillation has emerged as a single element of ALS that appears to have the greatest impact on ultimate survival.When defibrillation alone is added to the BLS regimen,survival increases from 6% to 25% for prehospital VF.

Sudden death is unique.Time constraints are extreme. If resuscitative interventions are not begun within 5-7min,there is little likelihood of sucessful resuscitation and functional survival.Few attempts at resuscitation succeed after 10 minutes.

Whosecollapse is witnessed by a bystander,

Whoreceive cardiopulmonary resuscitation (CPR) within 4 to 5 minutes, and

Whoreceive advanced cardiac life support (ACLS), e.g., defibrillation, intubation, drug therapy, within the first 10 minutes.

Decapition the head is separated from the rest of body.When this occurs,there no chance of saving the patient.

Rigor morits This is the temporary stiffening of muscles that occurs several hours after death. The presence of this stiffening indicate the patient dead and cannot be resuscitated .

Evidence of tissue decompositon Tissure decomposition or actual flesh decay occurs after a person has been dead for more than a day.

Dependent livdity It is the red or purple color that appears on the parts of the patiens body that are closest to the ground.It is caused by blood seeping into the tissure on the dependent,or lower, part of the persions body. It occurs after a persion has been dead for several hours

Gerneral consideration

CPR Steps

Complication of CPR

CPRsteps

Basic Life Support, BLS

Advanced Life Support, ALS

BLS is the application of artificial ventilation and circulation without special equipment or drugs to prevent brain damage.

Revives heart (cardio) and lung(pulmonary) functioning

Use when there is no breathing and no pulse

Provides O2 to the brain until ALS arrives

Effective CPR provides 1/4 to 1/3 normal blood flow

Rescue breaths contain 16% oxygen (21%in air)

recognition of cardiac arrest

A- airway control

B-breathing support

C-circulation support

CALL Check the victim for

unresponsiveness

2. BLOW Tilt the head back and listen for breathing ..

3. PUMPIf the victim is still not breathing normally, coughing or moving, begin chest compressions.

Sudden cardiac death can be confirmed by the absence of detectable pulse,unresponsiveness,and apnea or gasping .

Responsiveness

Tap shoulder and shout Are you ok?

Loss of conscious

Absence of pulse on carotid arteries

Respiration arrest cardiac arrest

E nlargement of pupils

follwing cardiac arrest :

loss on consciousness at about 10-15 seconds

Electro-encephalogram becomes falt after 30 sec

respiration arrestmay be in 30 seconds after cardiac arrest

pupils dilate fully after 60seconds

Braindamage takes place wthin 4 to 6 minutesafter cardiac arrest.

irreversible cerebral cortical damage occurring within 8-10 min after cardiac arrest.

In an unconscious patient,airway obstruction is most commonly due to relaxation of the muscles of the tongue allowing it to rest against the posterior pharyngeal wall.

The several simple airway maneuver toensure open airway by preventing the falling back of tongue.

Head-tilt/chin-liftis usually the first maneuver , if no concern cervical spine injury . This is done by placing one hand on the forehead ,and placing the tips of fingers of other hand under the bony part of the chin.life the chin foreward,bring the entire lower jaw with it ,helping to tilt the head back.

Jaw-thrust

This is the safest method for opening the airway if there is the possibility of cervical spine injury.this is done by playing placing the fingers behind the angle of the jaw and bring the head foreward.

Cleaning the secration of airway tract or foreign body(such as gastric contents regurgitation blood clotting or denture in the mouth inspired into the airway)

After opening the airway you shouldquickly take 3~5s Check For Breathing

listeningfor sounds of breathing, placing your ear over the patients nose and mouth

* Pinch the nose- prevent air escape

* take a deep breath

*Seal the mouth with yours

*give two breaths (1 second or longer)

Vent rate of 12 to 20 minute

If the first two dont go in, re-tilt and give two more breaths (if breaths still do not go in, suspect choking)

* Cant open mouth

*Cant make a good seal

*Severely injured mouth

*Stomach distension

mouth-to-nose ventilation may be more effective .

After tracheotomy ,

the stoma becomes the patient s airway..

To prevent transmission of disease from the victim to rescuer,a bag valve mask or other suitable device should be used in place of mouth-to-mouth technique.

Both mouth to mouth and mouth to nose ventilation can provide large volumes the concentration of oxygen delivered to the patient is 16%~17% may produce an alveolar partial pressure of oxygen of 80mmHg,more than enough to patients life.

With mouth to mask ventilation connected to high flow oxygen the concentration of oxygen is 55%

Oncethe airway has been established and the lungs ventilated If there is not carotid pulse ECC should be started.

* The rescuer position- bedside the victims chest.

* Locate proper hand position for chest compressions

* Place heel of one hand on the lower half of the sternum .

* The fingers interlocked

* Keeping the arms straght (will reduce fatigue)

* Compression rate 100/min

* Depth of compressions: 1 .5 to 2 inches(4-5cm)

After 30 chest compressions give:2 slow breaths ( Ratio of compression-to-ventilations30:2)

Continue until help arrives or victim recovers

If the victim starts moving: check breathing

Blood circulation is restored due to the change in intra thoracic pressure and jugular and subclavian vein valves

During the chest compression blood is directed from the pulmonary circulation to the systemic circulation. Cardiac valves function as in normal cardiac cycle .

The effects of ECC can be check in several ways :

With each compression,an arterial pulse should appear.The carotid artery pulse is more meaningful than either the radial artery or femoral artery pulse.

The ECG also responds to the ECC,Various types of electrocardiographic artifacts may appear with each compression. Occasionally,each ECC cause a recognizable QSR complex and T wave to appear.

The reaction of the pupils ,if present,is a good indicator of cerebral circulation

ALSrefers to used special equipment to manage airway,breathing and circulation and provide definitive care,including defibrillation and pharmacotherapy of dysrhythimas and acid- base disturbance.

ALSmay be applied by trained individuals operating withinan emergency medical services system in the community,in transport, and in the hospital setting.

Artificial airway

D- defibrillation

E-electrocardiaogram

F -fluid and drugs

1 Oropharyngeal airway has two major purpose.The first is to keep the tongue from blocking the upper airway.The second is to make suctioning the airway.This should be inserted in unconscious patients, and is often used inconunction with BVMventilation

2 Nasopharyngeal airway

often used for a conscious patient who is not able to maintain an airway.This airway is usually well tolerated and is not a likely a the oropharygeal airway to cause vomiting.

3. Endotracheal intubation

Is the definitive technique for airway management in ALS. It should be performed as soon as possible in all patients for whom CPR .especially in the patientwho cannot be rapidly resuscitated .It is a mandatory skill for any physician who cares for critically ill patients.

Note :The resuscitative efforts should not be interrupted by more than 30s with each attempt.

The Advantages Endotracheal intubation

Itcan completely controls and protects the airway,

It delivers better minute volume.

It maybe left in place for a long time ,if necessary.

It prevents gastric distention,and less regurgitation ,so it prevents aspiration of stomach contents.

It allows for direct access to suctioning of trachea.

It allows for administration of certain medication

Bag-valve-mask manual ventilation

This techniquemaybe used after cardiac arrest immediately.

If the bag connected to a gas reservoir,It can deliver 21%~ 100%oxygen . This deviceshould be used with oropharyngeal or nosopharyngealairway or endotracheal intubation .

Mechanicalventilation

Early mechanical ventilators were not adequate for the management of cardiac arrest . High pressure ventilation via endotracheal tube results in severe arterial respiratory alkalemia during CPR.

At present ,the safest approach is manual ventilation guided by arterial blood gases analysis .

Chest compression during ALS are performed in the same manner as in BLS.

Newer techniques include the use of compression-decompression devices and abdominal counterpulsation compression-decompression device. These mechanical devices were used,have result in improved rates of return of spontaneous circulation but not in improved ultimate survial.

Automated extral chest compression-decompresion devices

Defibrillation is the defnitive treatment for the vast majority of cardiac arrests.It should be delivered as early as posible.

At least 50% of patient in cardiac arrest are in VF when the first ECG.

In early 1970s blinddefibrillation was recommended as soon as a defibrillator was available.

However, current defibrillators with quick-look paddles enable visualization of the rhythm disturbance upon arrival the defibrillator.As soon as ventricular fibrillation is documented,defibrillation as described below should be perform.

Precordial thump If an electrical defibrillator is not immediately available,a precordial thump should be employed.A sharp blow with the outside of a fist is delivered to the sternum from height of 8-12in (25 30cm).

If this successfully results in sinus rhythm, a bolus of lidocaine should be given.If VF persists, proceed to BLS and to defibrillation as soon as the defibrillator is available.

Electrical defibrillation: passing an electrical current through a fibrillating heart, and causing synchronous depolarization the disorganized contracting myofibrils at once ,and allowing for uniform repolarization and subsequent organized cardiac electromechanical activity.

Automated external defibrillators(AED)

AED with a large pads.This machine can recognize VF and deliver direct current(DC) countershock with better than 85% sensivity and with 100%specificity.Defibrillation success rate appears equal traditional handheld defibrillator. The potential impact of using this technology widely in public setting such as office building,stadiums( ,factorices airport railway stations,and rural areas served by volunteer rescue personnel.

While awaiting arrival of a defibrillator, effective BLS must be maitained.

If you do not know the duration of arrest ,first you should perform BLS for 2 min,then perform electrical defibrillation.

perform BLS untill the equipment and personnel arrive.

Assess the patients pulse and ECG.

choice asynchronous mode

Seletion of proper enery level

Adequate contact (Apply electrode gel or saline-soaked44 gauze pads) between paddles and skin

Proper position of the paddles

ventricular tachycardia

bradyarrythmia including electromechanical dissociation and asystole

supraventricular arrhythmia accompanied with tachycardia

supraventricular arrhythmia with normal blood pressure and pulse rate

If several shocks fail to stop VF , optimal chest compression,oxygen and intermittent positive-pressure ventilation, epineprine, lidocaine, and sodium bicarbonate should be given in this sequence. If this measure is unsuccessful, bretylium is indicated.Patients have occasionllay recovered after more than 1 hour of external CPR with multiple defibrillation attempts

Peripherial veins :usually recommed median cubital vein( particularly during the arrest situationwhen access to the neck and chest is restricted by BLS procedure. when these route are being used,IV medication should be administered rapidly by bolus injection and following by a 20ml fluid bolus injection and elevate the extremity.

Central venous offers more secure route for drugadministrationinternal jugularor subclavian are preferable because of proximity to the heart but their placement should not be allowed delay defibrillation attempts or interfere with BLS. femoral vein cannulation is difficult to achieve during CPR.

If intravenous lines cannot be established quickly some drugs such as epinephrine lidocaine atropine can be administered byendotracheal and intracardiacroutes.

Endotracheal routerequires a higher dose to achievinganequivalent blood level .It is suggestedthat 2.5 times the IV dose be administered.Delivery of the drug to the circulation is facilitated by dilutingthe drug to a 10ml volume ,delivering it though a catheter positioned to the tip of the endotracheal tube.

Intracardiac injectionshould be avoided and is indicated only if intravenous and endotracheal routes are not available.

The roles of fluid and drug therapy are

Increase central volume rising the perfusion presure of myocardium and brain.

Treat arrhythmias and preventrecurrent cardiac arrest.

Correctacidosis and hypoxia

Correct the causes of cardiac arrest.

To maintainthe IV access and increased central volume are often required during CPR.The standard fluid infusion for ALS should benormal salineorlactated Ringers solution , rather than dextrose in water ,because glucose mayexacerbate anoxic injury to the brain.

During CPR ,only a few drugs have proved useful.I introduceepinephrine, Vasopresine, Amiodarone lidocaine,atropine , magneium ,andsodium bicarbonate.

It can help convert fine VF into coarse VF which is moresusceptible to stop by electrical shock .

Indication :include all forms cardiac arrest. It is recommeded in VF/VT cardiac arrest if there is no ROSC(return ofspontaneous circulation) after first three defibrillation.It is recommended in EMD and asystole after initiation of CPR

The standard adultdoseis 1mg IV bolus and repeated every 3~5min until return of spontaneous circulation

Actions:is a endogenouspeptide hormone .It produces vasoconstriction in non vital tissues whle perserving blood flow to the coronary and cerebral circulations

In some cases 40 U can replace adrenaline ( Epinephrine)

Actions: Lidocaine is a class IB agent that depresses myocardial excitability by blocking sodium channels without extending action potential duration.

Indication : The drug is indicated in Ventricularectopy, ventricular tachycardia and ventricular fibrillation that has recurred after a successful defibrillation or that has been refractory to defibrillation. Prophylactic lidocaine therapeutic dose is deemphasized.

Dose: The recommened dose is 1.5mg/kg bolus repeated in 5~10 min for total dose of 3mg/kg .

Actions: Amiodarone is classIII agent that has some classI activity weak non-competitive -blocking effects.It lowers the defibrillation threshold and has potent antifibrillatory effect.its broad spectrum of antidysrhythmic effects make it a potentially useful agent.

Indication and dose:can be considered if multiple electrialshocks and epinephrine have failed to revert VF/VT.Theinitial doseis 5mg/kggiven as a slow intravenous infusion over 5-15min.This may be repeated if indicated

Actions: Atropineantagonizes parasympathetic nervous effects on the heart by blocking cholinergicreceptors,leading to increased sinoatrial and atrioventricular automaticity and rate on conduction.

Indication and dose: It is retained as pharmacotherapy for symptomatic bradycardia. It is given in dosages of 0.5~1.0mg every 3~5min, The total dose of atropine is 0.04mg/kg(3mg)

Class Irecommendation (definitely helpful): symptomatic sinus bradycardia

Class IIrecommendation (acceptable, or possibly helpful):atrioventricular block AVB at the nodal level, or in asystole.

Class IIIrecommendation (not indicated, maybe harmful) :In Mobitz AVB or CHB.

Acidosisis often present in victims of cardiaorespiratory arrest,particulary if the arrest condition has persisted for more a few minurtes.

There two components contributing to the acid load.

Respiratory acidosis:result from failure carbon dioxide eliminition, carbon dioxide(CO 2 ) production continues , but it can not be remove because pulmonary and heart failure during CPR, the PaCO 2rise.

Metabolic acidosis:develops prolongedtissue hypoperfusion and conversion to anaerobic forms of metabolism.

Actions: Sodium bicarbonate (NaHCO 3 )is an alkalinizing agent,that theoretically reverse the metabolic acidosis associated with profound ischemia.However,provided CPR is effective, acidosis does not develop rapidly or severely in otherwise healthy individuals duringduring cardiac arrest.

Indication and dose:Itis unneccessary in brief resuscitation when the patient have been previously well.It can be considered if cardiac arrest exceeds 10-15mintures duration.It should be considered when cardiac arrest occurs in a patient with aprexisting profound acidosisor in special conditions,such ashyperkalaemia andtricyclie antidepressant overdose .

Note:If alveolar ventilation is not adquate,the CO 2 released from the NaHCO 3, ,and correction of the acidosis will not be attained, and may result inincreased central venous and tissue PaCO 2level .Tissue acidosis may worsen following NaHCO 3,administration.

* Sodium bicarbonate administration is not indicated for hypoxic lactic acidosis.

The initial dose should be 1mmol/kg

CPR Steps

Complication of CPR

The complication of CPR

The complication of CPR are legion,but unavoidable complications are acceptable compared with an otherwise certain death .

fractures of ribs, sternum or spine;

laceration of lungs or liver or other abdominal organs;

pulmonary or cerebral fat embolism;

laceration or rupture of heart;

herniation of the heart through the pericardium;

cardiac tamponade;

hemothorax or pneumothorax .

Complication of artificial ventilation:

These complications are more likely to occur when ventilation pressure exceeded the opening pressure of the lower esophagealsphincter .In mouth-to-mouthe ventilation,1.5~2.0seconds shouled be allowed for air delivery to the lungss to prevent airway pressure from exceeding 20~25cmH 2 O.Breathing rapidly without allowing full exhalation should be avoided for same reason.

pulmonary edema

gastrointestinal hemorrhage

pneumonia

recurrent cardiopulmonary arrest.

Anoxic brain injurycan occur in a resuscitated victim who suffered prolonged hypoxia .It is the most common cause of death in resuscitated patients

CPR Steps

Complication of CPR

ECG monitoring is essential during resuscitation, both as a diagnostic tool and as a guide to the most effective therapy.Initially,the quick look paddles should be used.if available,the standardECG machine or monitoring unit with a display screen should be attached as soon as possible.

Blood pressue Intra- arterial pressure monitoring provides an accurate and continuous measure of SBP DBP and MAP.Continous intra-arterial monitoring during CPR allows for rational titration of vasoconstrictor therapy and accurate assessment of the hemodynamic effectiveness of spontaneous rhythms

Endotracheal CO 2monitoring provide a noninvasive measure of pulmonary perfusion (CO).Which also has been shown to correlate with coronary perfusion pressure.Patients who have undergoing 10~15 min of ECC with accompanying ALS ,and have an endotracheal CO2 above 10-15mmHg are unlikely to survive.

Laboratory investigationwill guide ongoing therapy.The most useful initial measurements include arterial blood gas,the hematocrit,serum glucose, sodium, potassium, calcium.if abnormalities are noted,they may be treated, and the succes of such treatment maybe monitored by repeated measurement.

CPR Steps

Complication of CPR

When Can I Stop CPR?

Victim revives

Trained help arrives

The rescuerToo exhausted to continue

Unsafe scene

Physician directed (do not resuscitate orders)

Cardiac arrest of longer than 30 minutes

(controversial)

Recovery from cardiac arrest depends on time to CPR and rhythm-specific intervention. Resuscitationand long-term outcome in normothermic patients with arrest times of 20 min or more are very poor.

The decision to terminate unsusccesful resuscitative efforts is always a difficute one,particulary if the patient is a child or a young adult.

17 Cpr

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