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CARDIO PULMO (CEREBRAL) RESUSCITATION Jozef Firment Judita Capková Department of Anaesthesiology & Intensive Medicine 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 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 frequent causes of out-of-hospital cardiac arrest CA 3

Most common causes of cardiac arrest CA • 1. place IHD. . . Myocardial 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 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 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 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%) - • 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 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 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 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 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 The quality of cc is frequently suboptimal Effective chest compressions 14

Continous chest compression - only 15 Continous chest compression - only 15

Only 1 in 4 patients in CA recieves bystander CPR • transmission of infection: 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 Protective devices: 17

Continous chest compression - only • If layman is not able or is unwilling 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: - 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, 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 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 22

VENTILATION MANAGEMENT ALS –In-hospital CPR A and B: • Oral/nasal airway • Tracheal intubation 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 Laryngeal mask, laryngeal tube Oe-Trach Combitube Oe 90% Trach 24

Campbell B: O 2 l/min 13 adults: 15 - “ 4 children 5 20 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 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 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 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 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 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 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 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. 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% 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 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 Thoracocentesis 38

Needle pericardiocentesis Cardiac tamponade: - difficult to diagnose - penetrating chest trauma – is Needle pericardiocentesis Cardiac tamponade: - difficult to diagnose - penetrating chest trauma – is suggestive 39

Thrombosis pulmonary and coronary • thrombolysis • percutaneous coronary intervention -PCI 40 Thrombosis pulmonary and coronary • thrombolysis • percutaneous coronary intervention -PCI 40

DRUGS USED CPR 1. Adrenaline (EPINEPHRINE) 1 mg á 3’- 5 ’ (EVERY SECOND 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 + 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 EZ-IO AD Proximal Tibial Access Intraosseous Infusion System 43

Automatický intraoseálny injektor 44 Automatický intraoseálny injektor 44

Post – resuscitation care • Stable cardiac rhythm, normal haemodynamic function (thrombolysis, percutaneous coronary 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 • 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 Thank you! jcapkova@capko. sk 47

Open chest CPR • better coronary perfusion • Trauma, after cardiothoracic surgery, when chest 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 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 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 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) 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 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