Cardiopulmonary ressuscitation

Dr Guillaume Thiery,Medical ICU

Klinicki Centar Univerziteta SarajevoSt Louis Hospita, Paris

Out-of-hospital cardiopulmonary arrest by aetiology

Importance of each link

Stiell et al. NEJM, 2004

Why is it every time I press on his chest he

opens his eyes, and every time I stop to

breathe for him he goes back to sleep?"

Discharged alive:

Compression + mouth to mouth 29/278 (10,4%)

Compression alone 35/240 (14,6%)

Why is it every time I press on his chest he

opens his eyes, and every time I stop to

breathe for him he goes back to sleep?"

Cardio Pulmonary Ressuscitation

Cardio Cerebral Ressuscitation

Why is it every time I press on his chest he

opens his eyes, and every time I stop to

breathe for him he goes back to sleep?"

Cardio Pulmonary Ressuscitation

2006

• Overall survival increased from 19% to 57%

• Survival neurologically intact increased from 15% to 48%

2009

• Overall survival increased from 22% to 44%• 88% of these survivors were discharged with good

neurological outcome

Cardio Cerebral Ressuscitation

• Reduce or avoid positive pressure ventilation,• Airway management is limited to a pharyngal

devince (airway) and O2 supplementation,• Avoid or delay intubation (3 cycles of 2 min)• No more than 10 sec without compression,

3 rules of airway management

• Head tilt (hyperextention) and chin lift• Pharyngeal device (airway)• O2 non mask with reserve 15 L/min

3 rules of airway management

• Head tilt (hyperextention) and chin lift • Pharyngeal device (airway)• O2 non mask with reserve 15 L/min

3 rules of airway management

• Head tilt (hyperextention) and chin lift • Pharyngeal device (airway)• O2 non mask with reserve 15 L/min

2004

Deleterious effect of hyperventilation

Mean Intrathoracic pressure

Coronary Perfusion Pressure

The 4th rule of airway management

• If Positive Pressure Ventilation, by mask of intubation:

Maximun 12/min

Cardio Cerebral Ressuscitation

ALL TO IMPROVE COMPRESSIONS

• Mandatory pre-shock compression during 2 min,

• 100 compressions/minute,

• 2 min of compression after each shock before pulse check

• No more than 10 sec without compression,

• Reduce or avoid positive pressure ventilation,

• Airway management is limited to a pharyngal device (airway) and O2 supplementation,

• Avoid or delay intubation (3 cycles of 2 min),

• When intubated, maximun resp frequency 12/min.

Clincal case

• Patients 45 years old presents in the ER for chest pain

• 10 after arrival, – Acute chest pain– Unresponsive

What would you do first?

• Chest compressions 100/min• Mask ventilation 12/min + oxygen• Rapid intubation• Rapid defibrillation

– Maximum joules – One time– Resume ventilation and compressions during 2 min

• +/- drugs: adrenalin• Check pulse after 2 min of compressions/ventilation• New defibrillation after 2 min if not Return of Spontaneous

Circulation.

What could have been done differently?

• Chest compressions 100/min• Mask ventilation 12/min + oxygen• Rapid intubation• Rapid defibrillation

– Maximum joules – One time– Resume ventilation and compressions during 2 min

• +/- drugs: adrenalin• Check pulse after 2 min of compressions/ventilation• New defibrillation after 2 min if not Return of Spontaneous

Circulation.• Etc…

What could have been done differently?

• Chest compressions 100/min• Head tilt and Chin lift• Pharyngeal device (airway) placement• Oxygen mask 15L/min• Rapid defibrillation

– Maximum joules – One time– Resume ventilation and compressions during 2 min

• +/- drugs: adrenalin• Check pulse after 2 min of compressions/ventilation• New defibrillation after 2 min if not Return of Spontaneous

Circulation.

Case (suite)

• Patients gets return to spontaneous circulation • But remains unconscious

Case (suite)

• If the patient has this ECG

Therapeutic hypothermia

• Goal: temp 32 – 34°C during 12 to 18h after return of spontaneous circulation,

• External cooling:– Axillar and Femoral ice

– Blowing cold air

• Internal cooling: – Infusion of 30 ml/kg of cold NaCl 4°C

Therapeutic hypothermia

Therapeutic hypothermia

Experience in the medical ICU in KCU Sarajevo (Jedinica Internisticke Intenzivne Terapije)

• 5 patients admitted in the ICU for cardiac arrest remaining unconscious after successfull ressuscitation

• VT/VF initial or after adrenalin• All myocardial infarction• Mean age 59

Median Min-maxTime from end CPR to temp < 36°C

6,2h 0 – 7h

Time < 36°C 5 5 – 20hTime < 34°C 5 0 – 17h Nadir temperature 33,2°C 32,5° - 35°C

Characteristic of the hypothermia

Median Min-max

Minium glycemia 5,5 4,4 – 15,8

Maximum glycemia 10,7 7,2 – 27,7

Mininum K 3 2,5 – 4,6

Maximum K 4,6 3,7 – 6,4

CK 2400 1300 - 11300

Complications

Shock state 2/5

ARDS 1/5

DIC 1/5

Acute renal failure 2/5

Seizures of myoclonies 2/5

Complications

Survival 4/5

Neurological intact 3/5

Duration of MV Median 8 days (min 1 - max 40)

Lenght of stay in the ICU Medial 14 dayx (min 1 – max 47)

Outcome