Download CARDIOPULMONARY RESUSCITATION

CARDIOPULMONARY
RESUSCITATION
CARDIAC ARREST
Abrupt loss of consciousness caused by lack of
adequate cerebral blood flow due to failure of
cardiac pump function.
Survival depends on
• The setting in which arrest occurs
• Electrical mechanisms
• Underlying clinical status
Electrical mechanisms
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•
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Ventricular fibrillation
Pulseless VT
Asystole
Pulseless electrical activity
PHASES OF VF
ELECTRICAL (0-4 min)
o adequate myocardial ATP store
o defibrillation alone restore perfusing
o rhythm(without chest compressions)
o duration of this phase can be prolonged
by bystander CPR.
Circulatory phase(4-10 min)
 depletion of ATP store, lactic acidosis
 defibrillation without chest compression
rarely successful, may result in PEA
 ECG fine fibrillatory wave.
Metabolic phase(>10 min)
 terminal phase
 irreversible damage
 less chance of successful defibrillation
 mild therapeutic hypothermia delay the
onset.
Pulseless electrical activity
H “S
• Hypoxia
• Hypovolemia
• Hydrogen ion(acidosis)
• Hypo/hyperkalemia
• Hypothermia.
T”S
• Toxins
• Tamponade
• Tension pneumothorax
• Thrombosis(pulmonary)
• Thrombosis(coronary)
Asystole
• No cardiac electrical and mechanical activity
of heart.
• Terminal rhythm in non intervened PEA or VF
• Same causes of PEA can also sometimes
present initially as asystole
AHA 2010 GUIDELINE
• Recognition of SCA based on
unresponsiveness and absence of normal
breathing( ie the victim is not breathing
or gasping)
• Look ,listen, and feel removed
• ABC Sequence
CAB
• Encourage hands only CPR
• Continue effective chest compressions/CPR
until return of spontaneous circulation
(ROSC) or termination of resuscitative efforts
• Continued de-emphasis on pulse check
Ensure high-quality CPR
• compressions of adequate rate and depth
• Allowing full chest recoil between
compressions
• Minimizing interruptions in chest
compressions
• Avoiding excessive ventilation
Chain
Chainof
ofSurvival
Survival
Immediate recognition and activation, early CPR, rapid defibrillation, effective
advanced life support and integrated post-cardiac arrest care.
ADULT BLS SEQUENCE
 Recognition of SCA
unresponsive
no breathing or only gasping
 Pulse checknot recommended for lay rescuer
Healthcare provider –not more than 10 sec
 Early CPR
Early CPR
Chest Compressions
Chest compressions consist of forceful rhythmic applications
of pressure over the lower half of the sternum.
These compressions create blood flow by increasing
intrathoracic pressure and directly compressing the heart.
This generates blood flow and oxygen delivery to the
myocardium and brain.
Effective chest compressions
“push hard and push fast”
rate of at least
100 compressions per minute
compression depth of at least 2
inches/5 cm.
Allow complete recoil of the chest after each compression, to
allow the heart to fill completely before the next compression
Minimizing interruptions in compressions
A compression-ventilation ratio of 30:2 is recommended
HANDS ONLY CPR
• Initially during SCA with VF rescue breath are
not important
• Oxygen level remains adequate.
• Gasping and passive chest recoil allow gas
exchange.
• Improves survival in OHCA
Airway Control and Ventilation
• During low blood flow states such as CPR,
oxygen delivery to the heart and brain is
limited by blood flow rather than by arterial
oxygen content.
• Advanced airway placement in cardiac arrest
should not delay initial CPR and defibrillation
• Empirical use of 100% inspired oxygen during
CPR optimizes arterial oxyhemoglobin content
and in turn oxygen delivery.
Airway and Ventilations
• Opening the airway (with a head tilt–chin lift
or jaw thrust) followed by rescue breaths
• Untrained rescuer will provide Hands-Only
(compression-only) CPR and the lone rescuer
who is able, should open the airway and give
rescue breaths with chest compressions.
• Ventilations should be provided if the victim
has a high likelihood of an asphyxial cause of
the arrest.
Rescue Breaths
• by mouth-to-mouth or bag-mask
• Deliver each rescue breath over 1 second
• Give a sufficient tidal volume to produce
visible chest rise.
• Use a compression to ventilation ratio of 30:2
Mouth-to-Mouth Rescue Breathing
• Open the victim’s airway, pinch the victim’s
nose
• Create an airtight mouth-to-mouth seal.
• Give 1 breath over 1 second, take a “regular”
(not a deep) breath
• A second rescue breath over next 1 second
Ventilation With Bag and Mask
• With room air or oxygen.
• Positive-pressure ventilation without an
advanced airway
• Produce gastric inflation and its complications
• To deliver approximately 600mL tidal volume.
• Squeezing a 1-L adult bag about two thirds of
its volume or a 2-L adult bag about one third.
• Cycles of 30compressions and 2 breaths.
• Delivers ventilations during pauses in
compressions and each breath over 1 second.
• Can use supplementary oxygen
(O2concentration 40%, at a minimum flow
rate of 10 to 12 L/min) when available.
• When an advanced airway (ie, endotracheal tube,
combitube,or laryngeal mask airway [LMA]) is in
place during 2-person CPR,
• give 1 breath every 6 to 8 seconds without
attempting to synchronize breaths between
compressions
• This will result in delivery of 8 to 10
breaths/minute
• There should be no pause in chest compressions
for delivery of ventilations
Cricoid Pressure
• Applying pressure to the victim’s cricoid
cartilage to push the trachea posteriorly and
compress the esophagus against the cervical
vertebrae
• Used in a few special circumstances (eg, to aid
in viewing the vocal cords during tracheal
intubation,
• The routine use of cricoid pressure in adult
cardiac arrest is not recommended
• During CPR cardiac output is 25% to 33% of
normal
• Oxygen uptake from the lungs and CO2
delivery to the lungs are also reduced
• low minute ventilation (lower than normal
tidal volume and respiratory rate) can
maintain effective oxygenation and ventilation
• Excessive ventilation is unnecessary and can
cause gastric inflation and its resultant,
regurgitation and aspiration
• Excessive ventilation can be harmful because it
increases
Intrathoracic pressure
decreases venous return to the heart
diminishes cardiac output
• Rescuers should avoid excessive ventilation (too
many breaths or too large a volume) during CPR
Universal Adult Basic Life Support
(BLS) Algorithm
Adult Advanced Cardiovascular Life
Support
• Advanced cardiovascular life support (ACLS)
includes interventions to treat cardiac arrest, and
improve outcomes of patients who achieve return
of spontaneous circulation (ROSC).
• Includes:
-airway management,
-ventilation support, and
-Rhythm based management of cardiac arrest
Advanced airways
Advantages
• Improved ventillation and oxygenation
• Eliminate pauses in chest compressions
• 1 breath every 6-8 sec(8-10 breath/min)
• Reduce risk of aspiration
Supraglotic airways
• Laryngeal mask airways
regurgitation less
when ET is difficult
neck injury
positioning of patient is difficult for ET
Provides equivalent ventillation comp. ET.
• Esophageal tracheal tube
• Laryngeal tube
DEFIBRILLATION
Initial shock
• 360j for monophasic , same dose for
subsequent shocks
• 120-200j for biphasic defibrillator, subsequent
dose same or higher.
• If VF recurs use previously successful energy
level
Medication for arrest rhythms
Vasopressors
• Epinephrine 1 mg IV/IO every 3-5 min
• Alpha-adrenergic receptor stimulation
produces vasoconstriction.
• Increases coronary perfusion pressure,
• Cerebral perfusion pressure.
Vasopressin
• Non adrenergic
• Coronary vasoconstrictor
• Dose:40 units IV/IO
ANTI ARRYTHMICS
AMIODARONE
• For VF/Pulseless VT unresponsive to CPR,
defibrillation ,vasopressor
• Initial 300mg IV/IO can be followed by 150mg
Lidocaine
• if amiodarone not available
• initial dose 1 to 1.5 mg/kg IV
• addl. Dose 0.5 to 0.75 mg/kg if not responding
Magnesium sulphate
• Used in torsades de pointes
• Dose 1-2gm diluted in 5% D
Post - cardiac arrest care
Objective
• Optimise cardio pulmonary function
• Try to identify precipitating causes
• Control body temperature to optimise
• Neurological recovery
• Identify and treat ACS
Induced hypothermia
• In comatose (lack of meaningful response to
verbal commands) adult patients
• With ROSC after out of hospital VF arrest
(class 1)
• In hospital arrest with any rhythm (class2 b)
• Cooled to 32-340C for 12 -24 hrs
• Inhibitory effect on adverse enzymatic and
chemical reactions initiated by ischemia
• Inhibits the release of glutamic and dopamine
• Induces brain derived neurotropic factors
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Cooling blanket
Ice packs
Direct immersion in ice water
IV ice-cold fluids (500 ml to 30 ml/kg NS or
Ringer’s lactate)
• Monitor with esophageal thermometer
or bladder catheters in nonanuric patients
THANK U
THANK U
1.current recommendation for compression
ventilation ratio
a) 15:2
b) 30:2
c) 15:1
d) 1:5
2.initial dose of amiodarone in ACLS
a)300 mg bolus
b)150 mg bolus
c)450 mg
d)200 mg
3) Therapeutic hypothermia
a)32-34
b)30-32
c)27-30
d)35
4)1st shock for VF with monophasic defibrillator
is
a)300 j
b)360 j
c)250 j
d)200 j
5)Breath/min with advanced airway in CPR is
a)8-10
b)5
c)7
d)2
6)Max .rate of defibrillation success is in which
phase of VT
a)Circulatory phase
b)Electrical phase
c)Metabolic phase
d)Equal in all phase
7) rate of chest compression /min at least
A)60
b)80
c)100
d)120
8)drug not used routinely in adult ACLS
a)Epinephrine
b)Amiodarone
c)Vasopressin
d)atropine
9)depth of chest compression
A)3 cm
b)5 cm
c)4 cm
d)6 cm
10)not a part of BLS
A)Chest compression
b)Bag and mask ventillation
c)Manual defibrillation
d)AED