CARDIO PULMO (CEREBRAL) RESUSCITATION Jozef Firment Judita Capková Department of Anaesthesiology & Intensive Medicine Šafárik University Faculty of Medicine, Košice 1
F Basic life support A, B, C - to buy time for F Advanced life support A, B, C, D, E – to restore circulation 1961: Peter Safar 2
Most frequent causes of out-of-hospital cardiac arrest CA 3
Most common causes of cardiac arrest CA • 1. place IHD. . . Myocardial infarction (80%) Ventricular fibrilation 4
Most common causes of cardiac arrest CA • 1. place IHD. . . Myocardial infarction • Hypertension Electrical defibrillation – • Valvular disease, . . only effective treatment for VF • • Trauma • Poisoning • Drowning Ventricular fibrilation • Hypotermia. . . 5
Most common causes of cardiac arrest CA • 1. place IHD. . . Myocardial infarction (80%) • Hypertension • Valvular disease, . . • • Trauma • Poisoning • Drowning Ventricular fibrilation • Hypotermia. . . 6
Cause of CA in • Trauma • Drowning • Drug overdose • Children Asphyxia Rescue breaths are critical for resuscitation 7
• 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% 8
THE CHAIN OF SURVIVAL up to 4 min Early access to emergency services up to 8 min Early BLS to buy time Early defibrillation to reverse VF Early advanced care to stabilise 9
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Open Airway: Cervical spine injury • Jaw thrust (no for lay rescuer) or chin lift with manual inline stabilisation of head and neck by an assistant 11
AGONAL 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 12
EXTERNAL CHEST COMPRESSIONS one rescuer 30: 2 f : 100 -120/min. 5 -6 cm 13
The quality of cc is frequently suboptimal Effective chest compressions 14
Continous chest compression - only 15
Only 1 in 4 patients in CA recieves bystander CPR • transmission of infection: - tuberculosis, SARS, H 1 N 1 – small number, - HIV – never reported 16
Protective devices: 17
Continous chest compression - only • If layman is not able or is unwilling to perform mouth to mouth breathing • Chest compressions f: 100/min without stopping 18
Basic life support C, A, B • Continue chest compressions and rescue breathing: - victim starts breathing normally (signs of life) - Medical emergency service arrives - you become exhausted 19
F Basic life support C, A, B F Advanced life support C, A, B, Drugs, ECG, Fibrilation treatment - defibrilation. . . 20
In hospital CPR- Advanced life support F One person starts 30: 2 others call resuscitation team + defibrillator, r. equipments (airway, ambu bag, adrenalin, . . ) F only one person: leaves the patient, calls resuscitation team starts 30: 2 21
VENTILATION MANAGEMENT ALS –In-hospital CPR A and B: • Oral/nasal airway 22
VENTILATION MANAGEMENT ALS –In-hospital CPR A and B: • Oral/nasal airway • Tracheal intubation : f: 10/min , Fi 02 = 1, 0 (reservoir bag), VT(tidal volume) 6 -7 ml/kg, (chest compressions and ventilations continue uninterupted) 23
Laryngeal mask, laryngeal tube Oe-Trach Combitube Oe 90% Trach 24
Campbell B: O 2 l/min 13 adults: 15 - “ 4 children 5 20 - “ - 2 BAG WITH OXYGEN SUPPLY Fi. O 2 % 85 -100 VT x f >40 85 -100 dtto 300 x >40 dtto 1000 x Inlet O 2 10 - 13 l/min 25
Advanced life support Self-inflating bag-mask + oropharyngeal airway : CC: V= 30: 2 Hyperventilation reduces cerebral blood flow 26
The quality of chest compressions is frequently suboptimal team leader should change CPR providers every 2 minutes (5 x cc: v 30: 2) 27
Hearth rhytms associated with CA: Ventricular fibrillation Asystole Ventricular tachycardia Electro-mechanical disociation (EMD) Pulseless ventricular activity (PVA) 28
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DEFIBRILLATION • Paddle positions (sternum, apex), no over the breast tissue • Self- adhesive pads (sparks!!) - the best • Biphasic defibrilators: 1. 150 -200 J 2. 150 -360 J, . . • CPR for 2 min (5 x 30: 2) after shock 30
DEFIBRILLATION • Check the rhythm (organised QRS complexes: regular + narrow- feeling for a pulse) • After the third shock give: adrenalin 1 mg every 3 -5 min. iv amiodaron 300 mg iv • Time between CC and shock delivery < 5 s – coronary perfusion pressure falls substantially • Signs of life return : normal breathing, movement, coughing, puls 31
A 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 32
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LIFE-THREATENING CARDIAC RHYTHM 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 34
POTENTIALLY REVERSIBLE CAUSES (5 H’s & 5 T’s): • • Hypoxia Hypovolemia Hypothermia Hyper/hypo. K+and metabolic disorders • H+ ions (acidosis) • Tension pneumothorax • Tamponade • Toxic/therap. disturbances • Thrombosis coronary • Thrombosis pulmonary 35
POTENTIALLY REVERSIBLE CAUSES (5 H’s & 5 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/hypo. K+and metabolic disorders (detected by biochemical tests, renal failure) • H+ ions (acidosis) - bicarbonate 36
POTENTIALLY REVERSIBLE CAUSES • • • (5 H’s & 5 T’s): Tension pneumothorax- needle thoracocentesis and chest drain Tamponade – needle pericardiocentesis Toxic substances – appropriate antidotes Thrombosis coronary - thrombolysis Thrombosis pulmonary – trombolytic drug 37
Thoracocentesis 38
Needle pericardiocentesis Cardiac tamponade: - difficult to diagnose - penetrating chest trauma – is suggestive 39
Thrombosis pulmonary and coronary • thrombolysis • percutaneous coronary intervention -PCI 40
DRUGS USED CPR 1. Adrenaline (EPINEPHRINE) 1 mg á 3’- 5 ’ (EVERY SECOND LOOP(5 x CV 30: 2) OF THE ALGORYTHM) alpha adrenergic actions cause vasoconstriction, increases myocardial and cerebral perfusion pressure 2. Bicarbonate 50 ml 8, 4% -p. H < 7. 1, BE < -10 -hyperkalaemia -tricyclic antidepressant overdose & equipment • (defibrilator) • oxygen • Ambu bag • face mask • F 1/1 • infusion set • plastic IV cannula 3. Amiodarone 300 mg after a third unsuccessful Amiodarone defibrillation in VF/VT. . . 150 mg (inf. 900 mg/24 h) lidocaine 1 mg/kg- alternative 41
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 -3 x more dose + 10 ml water) (adrenaline, lidocaine, atropine) • NEVER IM nor SC !!! 42
EZ-IO AD Proximal Tibial Access Intraosseous Infusion System 43
Automatický intraoseálny injektor 44
Post – 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 o. C for 12 -24 h. • Improved neurological outcome 45
• www. erc. edu • www. resus. org. uk • Resuscitation (in october 2010) • http: //www. lf. upjs. sk/kaim/pregradualne _vzdelavanie. html 46
Thank you! jcapkova@capko. sk 47
Open chest CPR • better coronary perfusion • Trauma, after cardiothoracic surgery, when chest or abdomen is already open
PROTOCOL FOR CPCR INTERPRETATION „Utstein in-hospital“ TIME ~ ~ ~ disaster call start CPCR emerg. team arrival onset of circulation living out + provided activities. . . 49
HODNOTENIE VÝSLEDKOV KPCR • Kritériom krátkodobého výsledku KPCR je obnovenie krvného obehu • Kritériom dlhodobého výsledku KPCR je návrat neurologických a psychických schopností pacienta 50
Ectopic rhythm Normal SR 1 2 5 Rhythm disorders at AMI 3 Thrombus development 4 Acute MI 51
LIFE-THREATENING CARDIAC RHYTHM DISTURBANCES 1. Ventricular fibrillation, pulseless ventricular tachycardia 2. Cardiac arrest (asystole) 3. Pulseless electrical activity (PEA, EMD) = circulatoty arrest 52
European resuscitation counscil • 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 53
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