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Transcript of Cpcr
Cardiopulmonary Resuscitation
Cardiac Arrest
Cardiac arrest is the cessation of all cardiac mechanical activity. It’s clinical diagnosis is confirmed by
UnresponsivenessAbsence of detectable pulseApnea (or agonal respirations )
The Cardiac Arrest Rhythms
The four cardiac arrest rhythms are
Asystole PEA ( Pulseless Electrical Activity ) Pulseless Ventricular Tachcardia (VT) Ventricular Fibrillation (VF)
International Guidelines for CPR 2005
International consensus on the art & science of CPR
Based on the most extensive evidence review of CPR
Recommendations designed to improve survival from sudden cardiac arrest (SCA)
Circulation Volume 112, Issue 24 Supplement; December 13, 2005
AHA Class of Recommendation Class I excellent evidence
Definitely recommended Class II a good to very good evidence
Acceptable and useful Class II b fair to good evidence
Acceptable and useful Indeterminate no harm and no benefit
Promising, evidence
lacking, immature Class III not acceptable, not useful,
May be harmful: no may be harmful
benefit documented
Chain Of Survival – 4 links
Call for help
Early CPR
Early Defibrillation
Early Advanced Care
BLS
1. Check Responsiveness
2. Call for help with AED defibrillator
3. Open the Airway
Head Tilt –Chin Lift Maneuver
3. Open The Airway
Jaw Thrust Maneuver
4. Check for Breathing
“ Look, Listen and Feel ”
5. Give 2 slow rescue breaths (over 1 second )
“The Chest Must Rise”
6. Check for Pulse (carotid pulse )
7.Start Chest Compressions (if pulse absent)
Site for chest compressions
Locate the margin of the ribs and follow upto xiphoid process
Place hand 2 finger spaces above the xiphoid process
Place other hand over hand on sternum
Chest Compressions A B
C D
“Push hard and Push fast” Minimise interruption of chest compression
• 100 /min.
• 30:2 ratio ( C:V )
• 5 cycles (2 minutes)
• 50% : 50 % ( C/R )
• 1 ½ -2 inches sternal depression
• Arms Straight, elbows locked,
shoulder over hands
• Complete recoil of chest
Attach defibrillator(AED) as soon as available and shock if indicated
D – Early Defibrillation Automated External Defibrillator
(AED)
Single greatest advance in CPR
The survival rate is 90% if the patient is defibrillated within 1 min. and only 10% if it is delayed till 10mins (Circulation 1984;69:943-8.)
Survival rate after cardiac arrest has been reported to go up from 30% to 49% (Ann Emerg Med 1996;28:480-5.)
Biphasic vs Monophasic Defibrillation
Advantages - greater efficacy - low energy produces same effect - less myocardial damage - less incidence of S-T changes ( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )
Energy - Monophasic 360 J - Biphasic 150/200 J
All AEDs are Biphasic
High first shock success of Biphasic defibrillation (84%-95%)
BLS Algorithm ( Primary ABCD )
Step 1. Assess Responsiveness
Step 2. Activate the EMS and call for the defibrillator
Step 3. Open the airway
Step 4. Assess Breathing (“ look, listen and feel ” )
Step 5. If Breathing is absent, give two slow rescue breaths
Step 6. Check for pulse (carotid pulsations)
Step 7. If pulse is absent initiate “ Chest Compressions ”
As soon as a defibrillator is available attach and defibrillate if indicated
ADVANCED LIFE SUPPORT
A - Airway
Definitive airway should be secured as soon as possible
Tracheal intubation using cricoid pressure (by trained
personnel only)
Laryngeal Mask Airway (LMA) and Esophageal–tracheal
Combitube are accepted alternatives for others
Cricothyrotomy to be performed in an emergency
B. Breathing - Confirm device placement
Primary Confirmation
Direct Visualisation of ETT passing through cords
Chest expansion
5 point auscultation - L and R anterior,
- L and R mid-axillary
- Over stomach
Still in doubt –repeat laryngoscopy
Further confirmation - Exhaled CO2 detector (ETCO2) - Oesophageal detector device
Inflate cuff and secure the tube
B. Breathing – Confirm effective oxygenation and
ventilation
No synchrony between ventilation and chest
compressions once definitive airway is secured
No longer 30 : 2 compression ventilation cycles
COMPRESSION @100/min
VENTILATION @ 6 – 8 breaths/min
C. Circulation
Identify the rhythm
Defibrillation /Pacing
Secure IV line-large easily accessible peripheral veins
Give rhythm appropriate medication
Recognition of Rhythm
Cardiac Arrest (lethal rhythms)
Shockable-VF,Pulseless VT
Non Shockable – Asystole.PEA
Non Cardiac Arrest (non lethal rhythm)
Rate too fast - >120/min
Rate too slow- <60/min
Defibrillation For shockable rhythms – VF / Pulseless VT
Monophasic or Biphasic defibrillators (Biphasic preferred) Monophasic 360 J ~ Biphasic 200 J
Steps of Defibrillation - Mains plugged in or on battery, On Defib mode
- ECG size/gain maximum - Set on leads: Only set on paddles if no leads - Select joules (200,300 & all others 360) - Charge, (“all clear”chant to count of 3 before discharge) - Discharge
Pacing
Disappointing results for asystole, PEA No benefit in post shock asystole
May be indicated for cardiac arrest with narrow QRS complexes
Not useful during terminal wide complex agonal rhythms
Extensive use in pre-arrest bradyarrhythmias Transcutaneous or transvenous
C-CirculationIV Access
Wide bore peripheral upper limb vein Push each bolus with 20cc fluid Raise extremity Urgent central/femoral line only if peripheral
access impossible or difficult & taking a long time to cannulate
C-Circulation Other Drug Delivery Routes
Tracheal - 2-3 times IV dose - Dilute in 10 ml saline - Preferably inject down a suction catheter which
is wedged deep into the bronchus - Rapid bagging
Intracardiac route - Not recommended - Dangerous
can result in refractory VF or convert to nonshockable rhythm
C - Circulation Rhythm appropriate medications
Epinephrine
Indicated in all cardiac arrest rhythms
i.e. VF, Pulse less VT, Asystole and PEA
IV dose is 1mg administered every 3-5 minutes
followed by 20 ml IV saline flush
Adrenaline causes intense cardio-cerebral sparing vasoconstriction CPR generates CO 25% of normal
Beneficial effects outweigh negative effects on the myocardium
Vasopressin Antidiuretic hormone and a powerful vasoconstrictor
when used in the higher doses.
Positive effects of epinephrine with lesser adverse
effects . Effect lasts for 20 minutes
Dose - 40 IU
Drug of choice for all 4 rhythms Pulseless VT , VF, Asystole and PEA
One dose of vasopressin may replace either the first or the second dose of epinephrine
Atropine
First drug of choice in symptomatic bradycardia (class I )
Second drug after epinephrine for asystole and
bradycardic PEA ( class II b ).
Dose is 1mg IV push, repeat every 3-5 minutes up to a
maximum dose of 0.04 mg /kg .
Amiodarone
Persistent or recurrent VF or VT ( class II b )
Dose is 300 mg IV push (150 mg may be repeated after
3-5 minutes ) may be followed by a 24 hour infusion of
1mg / minute for 6 hours and then 0.5 mg/minute for the
remaining 18 hours.
Amiodarone preferred over Lignocaine (class
indeterminate ) in the treatment of persistent or
recurrent VF /VT.
Sodium BicarbonateSpecific indications are as follows
class I if known pre-existing hyperkalemia class II a if known bicarbonate responsive acidosis -
TCA overdose class II b after prolonged resuscitation with
effective ventilation class III hypercarbic acidosis
The dose is 1 meq/kg bolus, repeat half this dose every
10 minutes thereafter
Calcium
Detrimental effect on ischaemic myocardiumImpairs cerebral recovery
NOT TO BE USED ROUTINELY
Indicated in PEA due to Hyperkalaemia Hypocalcaemia Ca channel blocker overdose
Magnesium sulphate
Shock refractory ventricular fibrillation in pr of possible hypomagnesemia
Torsades de pointes VT in pr of possible hypomagnesemia
Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2 min,can be repeated after 10 –15 min
D. Differential Diagnosis Review the most frequent causes ( the 5 H’s and 5 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Tamponade - cardiac
Hydrogen ions – acidosis Tension pneumothorax
Hyper / hypokalemia Thrombosis - coronary
Hypothermia Thrombosis - pulmonary
ACLS - Secondary ABCD Survey
A Airway : place airway device as soon as possible
B Breathing : confirm airway device placement by examination plus confirmation device
B Breathing : secure airway deviceB Breathing : confirm effective oxygenation & ventilation
C Circulation : identify rhythm – monitorC Circulation : Defibrillation/PacingC Circulation : establish IV accessC Circulation : give medications appropriate for rhythm and
condition
D Differential Diagnosis : search for and treat identified reversible causes
Monitoring the Victim - To assess effectiveness of rescue
efforts Monitor for signs of circulation and breathing
Check pulse during compression to assess
effectiveness of compression
To determine ROSC after 2 minutes of chest
compression check for pulse
ETCO2
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