CARDIOPULMONARY RESUSCITATION

CARDIOPULMONARY RESUSCITATIONWiwi JayaSMF Anesthesiology & Intensive TreatmentRS Saiful Anwar Malang - East Java1CARDIAC ARRESTAbrupt loss of consciousness caused by lack of adequate cerebral blood flow due to failure of cardiac pump function.

2CARDIAC ARRESTSurvival depends onThe setting in which arrest occursElectrical mechanismsUnderlying clinical status

3Ventricular fibrillationPulseless VTAsystolePulseless electrical activity

Electrical mechanisms4PHASES OF VFELECTRICAL (0-4 min) adequate myocardial ATP store defibrillation alone restore perfusing rhythm(without chest compressions) duration of this phase can be prolonged by bystander CPR.

5PHASES OF VFCirculatory phase(4-10 min) depletion of ATP store, lactic acidosis defibrillation without chest compression rarely successful, may result in PEA ECG fine fibrillatory wave.6PHASES OF VFMetabolic phase(>10 min)terminal phaseirreversible damageless chance of successful defibrillationmild therapeutic hypothermia delay the onset.7Pulseless electrical activityH SHypoxiaHypovolemiaHydrogen ion(acidosis)Hypo/hyperkalemiaHypothermia.TSToxins TamponadeTension pneumothoraxThrombosis(pulmonary)Thrombosis(coronary)8AsystoleNo cardiac electrical and mechanical activity of heart.Terminal rhythm in non intervened PEA or VFSame causes of PEA can also sometimes present initially as asystole9AHA 2010 GUIDELINERecognition of SCA based on unresponsiveness and absence of normal breathing( ie the victim is not breathing or gasping)Look ,listen, and feel removedABC Sequence CABEncourage hands only CPR

10AHA 2010 GUIDELINEContinue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts Continued de-emphasis on pulse check11AHA 2010 GUIDELINEEnsure high-quality CPRcompressions of adequate rate and depthAllowing full chest recoil between compressionsMinimizing interruptions in chest compressions Avoiding excessive ventilation

12Chain of Survival

Immediate recognition and activation, early CPR, rapid defibrillation, effective advanced life support and integrated post-cardiac arrest care.Chain of Survival13ADULT BLS SEQUENCERecognition of SCA unresponsive no breathing or only gasping Pulse check- not recommended for lay rescuer Healthcare provider not more than 10 secEarly CPR

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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.15Effective chest compressions push hard and push fastAllow complete recoil of the chest after each compression, to allow the heart to fill completely before the next compression

Minimizing interruptions in compressions

rate of at least100 compressions per minutecompression depth of at least 2 inches/5 cm. A compression-ventilation ratio of 30:2 is recommended16HANDS ONLY CPRInitially during SCA with VF rescue breath are not importantOxygen level remains adequate.Gasping and passive chest recoil allow gas exchange.Improves survival in OHCA17During 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 defibrillationEmpirical use of 100% inspired oxygen during CPR optimizes arterial oxyhemoglobin content and in turn oxygen delivery.

Airway Control and Ventilation 18Opening the airway (with a head tiltchin lift or jaw thrust) followed by rescue breathsUntrained 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.

Airway and Ventilations19Rescue Breaths

by mouth-to-mouth or bag-maskDeliver 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

20Mouth-to-Mouth Rescue Breathing

Open the victims airway, pinch the victims noseCreate an airtight mouth-to-mouth seal.Give 1 breath over 1 second, take a regular (not a deep) breathA second rescue breath over next 1 second 21Ventilation With Bag and Mask

With room air or oxygen.Positive-pressure ventilation without an advanced airwayProduce gastric inflation and its complicationsTo 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.

22Ventilation With Bag & MaskCycles 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.

23VentilationWhen 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 compressionsThis will result in delivery of 8 to 10 breaths/minuteThere should be no pause in chest compressions for delivery of ventilations

24Cricoid Pressure

Applying pressure to the victims cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebraeUsed 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

25During CPR cardiac output is 25% to 33% of normalOxygen uptake from the lungs and CO2 delivery to the lungs are also reducedlow minute ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation26Excessive 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 outputRescuers should avoid excessive ventilation (too many breaths or too large a volume) during CPR

27Universal Adult Basic Life Support (BLS) Algorithm

28Advanced 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 arrestAdult Advanced Cardiovascular Life Support29Advanced 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 30Supraglotic airwaysLaryngeal mask airways regurgitation less when ET is difficult neck injury positioning of patient is difficult for ET Provides equivalent ventillation comp. ET.Esophageal tracheal tubeLaryngeal tube31

32DEFIBRILLATIONInitial shock360j for monophasic , same dose for subsequent shocks120-200j for biphasic defibrillator, subsequent dose same or higher.If VF recurs use previously successful energy level 33

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35Medication for arrest rhythmsVasopressorsEpinephrine 1 mg IV/IO every 3-5 minAlpha-adrenergic receptor stimulation produces vasoconstriction.Increases coronary perfusion pressure,Cerebral perfusion pressure.36VasopressinNon adrenergic Coronary vasoconstrictorDose:40 units IV/IO37ANTI ARRYTHMICSAMIODARONE For VF/Pulseless VT unresponsive to CPR, defibrillation ,vasopressor Initial 300mg IV/IO can be followed by 150mg38Lidocaine

if amiodarone not available initial dose 1 to 1.5 mg/kg IV addl. Dose 0.5 to 0.75 mg/kg if not responding39Magnesium sulphate

Used in torsades de pointes Dose 1-2gm diluted in 5% D40Post - cardiac arrest careObjectiveOptimise cardio pulmonary function Try to identify precipitating causes Control body temperature to optimise Neurological recovery Identify and treat ACS

41Induced hypothermiaIn comatose (lack of meaningful response to verbal commands) adult patientsWith ROSC after out of hospital VF arrest (class 1)In hospital arrest with any rhythm (class2 b)Cooled to 32-340C for 12 -24 hrs42Inhibitory effect on adverse enzymatic and chemical reactions initiated by ischemiaInhibits the release of glutamic and dopamine Induces brain derived neurotropic factors

43Cooling blanketIce packsDirect immersion in ice waterIV ice-cold fluids (500 ml to 30 ml/kg NS or Ringers lactate)Monitor with esophageal thermometer or bladder catheters in nonanuric patients44

45THANK U

THANK U461.current recommendation for compression ventilation ratio15:230:215:11:5472.initial dose of amiodarone in ACLSa)300 mg bolusb)150 mg bolusc)450 mgd)200 mg483) Therapeutic hypothermiaa)32-34b)30-32c)27-30d)35

494)1st shock for VF with monophasic defibrillator isa)300 jb)360 jc)250 jd)200 j505)Breath/min with advanced airway in CPR isa)8-10b)5c)7d)2516)Max .rate of defibrillation success is in which phase of VTa)Circulatory phaseb)Electrical phasec)Metabolic phased)Equal in all phase527) rate of chest compression /min at leastA)60b)80c)100d)120538)drug not used routinely in adult ACLS a)Epinephrineb)Amiodaronec)Vasopressind)atropine549)depth of chest compression A)3 cmb)5 cmc)4 cmd)6 cm5510)not a part of BLSA)Chest compressionb)Bag and mask ventillationc)Manual defibrillationd)AED56

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