Adult cardiopulmonary

resuscitationUD FM DAIC

English program practice

2018

www.erc.edu

www.reanimatio.com

Terminology

CPR – Cardiopulmonary Resuscitation

BLS – Basic Life Support CPR without the help of medical devices

EBLS – Extended Basic Life Support CPR with easy to use tools or devices (special

expertise not needed) (NPT / OPT, BVM + O2, automated defibrillator)

ALS – Advanced Life Support CPR with devices for the qualified personnel

ROSC – Return Of Spontaneous Circulation

Chain of survival

Response? (vocal and tactile stimulus)

Call for help!

Open the airway

Head tilt

Chin lift

Foreign body removal

Check vital signs

Breathing? (see / hear / feel!)

(Normal: RR≥2/10 sec, noticeable

chest/abdominal movement with

audible and sensible airflow without

pathological noises)

(Circulation / pulse?)

Monitor? (Pulse oxymetry /capnography

/ECG /IBPM)

Vital signs / open airways

CPR 30:2Until defibrillation /

monitoring is

available

Provide a patent airwayLook for vital signs

Call for paramedicsor Medical Emergency Team

Cardiac arrest

Calling the ambulance:

Your name

What has happened

Where did it happen

How to get there

Stay calm and follow

the advices

Chest compression Right („high quality”) technique:

Firm surface

Proper posture

Extended straight arms

Position of the hands: lower half of the sternum

Compression / ventilation rate

30:2 (adult)

15:2 (pediatric)

In the case of a primary cardiac cause COCPR (Compression Only CPR) is allowed in the first 3 minutes (?)

In the case of a secured patent airway (ETT) continuous compression without disruption

Depth:

Approx. 5, max. 6 cms (adult)

1/3rd of the chest (pediatric)

Frequency: 100-120 / min (metronome?)

Duty cycle 1:1; allow complete recoil

(Compression feedback devices?)

Avoid:

fatigue (→change)

> 5 (10) sec disruption (→planning)

Rescue breaths (BLS and EBLS)

Technique:

Mouth-to-mouth/ Mouth-to-nose

BVM (bag-valve mask) ventilation

NB: patent airway!

Head tilt + chin lift

jaw thrust (Esmarch-Heiberg)

NPT / OPT

Foreign body removal(→ FBAO protocol)

Normal blow in

Vt: approx. a normal breath intake (6-8 ml/ttkg)

Approx. 1 sec duration

30:2 (compressions:breaths)

Avoid:

Hyperventilation

→ hypocapnia → cerebral vasoconstriction → cerebral ischaemia

High pressures

→ abdominal insufflation → risk of aspiration

CPR 30:2Until AED or manual

defibrillator is applied

Rhythm

analysis

Shockable(VF/ pulseless VT)

Non-shockable(PEA/Asystole)

Patent airway

Vital signs

Call for

resuscitation

team

Ventricular Fibrillation

(VF)

Pulseless Ventricular

Tachycardia

(pulseless VT)

Rhythm

analysis

Shockable

(VF/ pulseless VT)

1 Shock150-360 J biphasic

or 360 J monophasic

Immediately resume

CPR 30:2

for 2 minutes

Shockable rhythm(VF)

Irregular wave

No recognizeable QRS complex

Ever changing frequency and amplitude

coarse / fine

NB: artefacts

movement

electric interference

Shockable rhythm(pulseless VT)

Monomorphic pulseless VT

widened QRS complex

high frequency

No QRS morphologic changes

Polimorphic pulselessVT

Torsades de pointes

(Precordial thump)

For immediate treatment of a witnessed VF/VT

Monitored patient

If defibrillation is not a prompt option

BUT: according to the 2015 ERC guidelines, it is NOT RECOMMENDED!

Defibrillators AED

Manual

Diagnostic / monitor function

ECG (monitor +/- 12 lead)

(+/- rhythm analysis)

NIBP

Pulse oxymetry

Capnography

Therapeutic options

Defibrillation

SCV (synchronized

cardioversion)

Transcutaneous pacing

Defibrillation energy

Factory recommendation / device learning

Monophasic: 1x360 J

Biphasic: 1x150-360 J (escalating)

If not sure, use the highest possible energy (don't waste time)!!!

(3 shock strategy?: witnessed VF/pulselessVT)

„Good” defibrillation

Efficient

Time !!!

Biphasic wave

Provide contact:

– Adhesive electrodes

– Defibrillator paddles

Contact gel or gel pad

Compression of the paddles

Shock during exhalation

(ventilated patients!)

Anterolat. vs. anteropost. vs. bilat.

position

Safe

Adhesive electrodes

Adequate communication

Correct manipulation (NB:

moving, contact, charging)

Avoidance of wet circumstances

O2 flow and NTTS removal from

defibrillation area

PM / ICD avoidance (>15 cm)

If VF/VT remains

Second shock and after:

150 - 360 J biphasic

360 J monophasic

Minimize the delay between the CPR

and a shock (< 10 s)

Adinistration of medication mustn’t

delay the shock

First 1 mg of Adrenaline + 300 mgs of

Amiodarone after the third shock

Repeat 1 mg Adrenaline if needed in

every 3-5 minutes

Repeat 150 mgs of Amiodarone if

needed once more

Third shock

Fourth shock

CPR for 2 minutes

Adrenaline 1mg iv.

+ Amiodarone 300 mgs iv.

Recheck:

if VF/VT remains

After the shock Immediately continue CPR for 2 minutes

Stop only if the patient shows clear vital signs (breaths,

coughs, opens his/her eyes, moves limbs, regains

consciousness)

After 2 minutes of CPR reassess ECG rhythm:

VT / pulseless VT: keep on with shockable algorithm

Any other electrical activities (compatible with circulation):

ROSC: continue with postresuscitation care

No signs of circulazion (PEA): swap to non-

shockable algorithm

Asystole: swap to non-shockable algorithm

Asystole (Asy)

Pulseless Electrical

Activity (PEA)

Rhythm

analysis

Non-shockable

(PEA/Asystole)

Immediately

resume

CPR 30:2

For 2 minutes

Non shockable rhythmAsystole

No ventricular activity (QRS)

Atrial activity is possible (P-wave asystole – PM indicated)

Rarely straight line (look out: electrical contact!)

Fine VF => treat as asystole

Asystole

During CPR:

Check ECG leads

Adrenaline 1 mg iv in every 3 – 5 minutes (Atropine 3 mg iv.)

Non-shockable rhythm(PEA)

Clinical signs of cardiac arrest with any

ECG pattern (VF excluded)

Pulseless Electrical Activity

During CPR:

Exclude / treat reversible causes

Adrenaline 1 mg iv in every 3-5 minutes

(Atropine 3 mg iv., in case of PEA with frequency below 60 / min)

During CPR:

• Maintain high quality chest compressions → change as frequently as needed

• Shortest possible disruption of CPR → planning

• Mechanical chest compression devices if available or needed. (CPR in or on the

way to the catheterization laboratory, fibrinolysis with CPR, hypothermic patient, etc)

• Ventilation with 100 % FiO2

• Route of administration (iv., io.)

• Adrenaline in every 3-5 minutes

• Advanced airway management

• Continuous compressions after securing airways

• Capnography (tube position? effectiveness? ROSC?)

• Reversible causes (4H/4T) and treatment

• Check devices, positions, functions regularly

Airway and ventilation Secured Airway:

ETT (gold standard)

LMA / iGel

LT

ETC, etc.

After a secured airway

Continuous chest compressions!

BVM/mechanical ventilation

FiO2: 100 % !!!

Avoid hyperventilation

Vt: 6-8 ml/bwkgs

RR: approx. 10/min

Mechanical chest

compression devices

LUCAS AutoPulse Weil SCC

Route of administration

Peripheral?

Veins on the upper limbs

external jugular vein

Central?

Femoral vein

Internal jugular vein

Subclavian vein

Route of administration

Intraosseous route !!! (EZ IO, BIG, NIO, Fast I.)

ALS medicines

4H Hypoxia (asphyxia)

Hypovolemia (absolute, eg. bleeding / relative, eg. anaphylaxis)

Hypo/hyperkalemia & metabolic changes (acidosis, hypoglycaemia)

Hypo/hyperthermia

4T Thrombosis (ACS, PE)

Tension PTX

Tamponade (cardiac)

Toxin / Tablets (side effects)

Dg: Heteroanamnesis

Medical documentations

Physical examination

Blood gas analysis

Emergency Ultrasound (EUS)

THINK!!!

Potentially reversible causes

After ROSC (postresuscitation care)

ABCDE approach

Advanced monitoring - ECG, BGA, laboratory tests

Imaging (X-Ray, US, CT – HRCT; skull, thorax, abdomen)

Consider coronarography +/- PCI

Causal (4H-4T) treatment ASAP

Supportive therapy: provide tissue oxygenation

Augmentation of the cardiac function (DO2)

O2, NIV, invasive ventilation (normoxia, normocapnia)

Katecholamines, PDE inhibitor drugs, Ca-sensitizers

IABP, ECMO (failing all else)

Decreasing metabolic demand (VO2)

Mechanical ventilation

Analgo-sedation, seizure prophylaxis

(Neuromuscular blockade???)

Targeted Temperature Management (TTM) → 32-36 ⁰C, avoid fever

Any

questions ?

Thank you for your attention