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Cardiopulmonary ressuscitation
Dr Guillaume Thiery,Medical ICU
Klinicki Centar Univerziteta SarajevoSt Louis Hospita, Paris
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
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