Cpr 2010 by Dr. Sunil Keswani, National Burns Centre, Airoli

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Cpr 2010 by Dr. Sunil Keswani, National Burns Centre, Airoli

  1. 1. Resuscitation guidelines 2010 & ACLS Updates Dr Sunil Keswani NATIONAL BURNS CENTRE Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  2. 2. Changes in 2010 Update THE QUALITY OF CHEST COMPRESSION Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  3. 3.  In basic life support, compression depth has been increased to between 5 & 6 cm.  The use of feedback technology( separate units or integrated into defibrillators) promoted, to assist in the delivery of high-quality compressions.  Previous studies on both suggested that to achieve ROSC, CPP of over 15 mmHg during chest compressions are required and that the depth previously recommended of 4–5 cm for chest compressions was inadequate. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  4. 4. Minimizing of disruption in the compression sequence Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  5. 5.  Defibrillation should take a maximum period of five seconds, with charging during chest compressions.  For tracheal intubation, ten seconds’ hands-off time for the passage of the tube is the onlypoint at which compressions are paused.  Pulse checks are only undertaken where there are signs suggestive of ROSC. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  6. 6. AIRWAY MANAGEMENT Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  7. 7.  The emphasis on tracheal intubation continues to decrease in favour of supraglottic airway devices due to:        Concerns about complications of intubation. Long pauses in compressions without basic airway management and unrecognised oesophageal intubation, especially in those who perform the skill infrequently. Intubation for cardiac arrest patients in an emergency is challenging Delaying intubation until after ROSC is suggested as a possible Approach. Many studies have shown that use of a supraglottic device in the cardiac arrest situation is quick and easy without significant change in the outcome. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  8. 8.  Professionals are advised to use both primary clinical and secondary adjunct confirmation techniques to confirm the correct placement of tracheal tubes.  However, with the low output produced by chest compressions, digital display of end-tidal CO2 alone is not very reliable, and the presence of CO2 is more positive than its absence.  The current guidelines for all age groups recommend that it should be used as enabling confirmation of tracheal tube placement, it also indicates good quality chest compressions and is an early indicator of ROSC. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  9. 9. USE & TIMING OF DRUGS Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  10. 10.  The use and timing of drugs have been simplified.  Adrenaline is given after the third shock at the same time as amiodarone, easier to remember than in separate cycles.  Atropine, long given for asystole and slow PEA, is discontinued, it remains for peri-arrest management.  The tracheal route of drug administration is not recommended except in neonates following the widespread introductionof intraosseous devices. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  11. 11. FIBRINOLYSIS? Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  12. 12.  Fibrinolysis is recommended for patients presenting with a likely diagnosis of pulmonary embolus, as well as other likely thrombotic aetiologies.  This is based on expert consensus, although the study was curtailed due to lack of a benefit trend in all-comer cardiac arrest patients. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  13. 13. POST-RESUSCITATIO CARE Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  14. 14.  Outcomes for out of-hospital cardiac arrest survivors are extremely variable between institutions, due to variable approaches and different standards of care.  Individual elements of care include:   Early Re-perfusion therapy ( use of angioplasty and primary reperfusion in comatose post-cardiac arrest patients without proven ST-elevation myocardial infarction will be controversial to some, andnot all hospitals will be able to deliver it ). Wider use of Therapeutic Hypothermia ( was incorporated into the 2005 guidelines for comatose adult survivors of out-of-hospital cardiac arrest presenting in either VF or VT ).  Titrated Oxygen therapy ( Oxygen therapy is increasingly recognised as being potentially harmful, early titration of inspired oxygen against arterial gases or oxygen saturation is recommended especially in neonatal care ).  Moderate Glucose control ( Tight glucose control was thought to be beneficial, but, may lead to masked hypoglycaemic episodes and therefore the guidance on this has been relaxed ).  Capnography is recommended as is the use of therapeutic hypothermia for babies with encephalopathy. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  15. 15. GUIDELINES FOR PAEDIATRIC PATIENTS Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  16. 16.  Diminution in the importance of a pulse check by healthcare providers in confirming cardiac arrest.  Lay bystanders are encouraged to perform compression-only CPR, whereas for trained rescuers, the Compression:Ventilation ratio of 3:1 remains.  Use of automated external defibrillator in infants is suggested.  Use of drugs is brought in line with the adult algorithm. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  17. 17. DISADVATAGES Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  18. 18. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  19. 19. Airway Control and Ventilation Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  20. 20. Ventilation and Oxygen Administration During CPR  During CPR, oxygen delivery to the heart and brain is limited by blood flow rather than by arterial oxygen content.  Rescue breaths are less important than chest compressions during the first few minutes of resuscitation and could lead to interruption in chest compressions.  Increase in intra-thoracic pressure that accompanies positive pressure ventilation decreases CPR efficacy.  Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for Nationalcardiac arrest VF Burns Dr. Sunil Keswani, Centre, www.india-burns.com, nbcairoli@gmail.com
  21. 21. Oxygen Administration During CPR  It is unknown whether 100% inspired oxygen is beneficial or whether titrated oxygen is better.  Prolonged exposure to 100% inspired oxygen has potential toxicity.  Passive oxygen delivery via mask with an opened airway during the first 6 minutes of CPR provided by (EMS) resulted in improved survival.  In theory, as ventilation requirements are lower during cardiac arrest, oxygen supplied by passive delivery is likely to be sufficient for several minutes after onset of cardiac arrest with a patent upper airway. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  22. 22.  All healthcare providers should be able to provide ventilation with a bagmask device during CPR or when the patient demonstrates cardiorespiratory compromise.  Airway control with an advanced airway, which may include an ETTor a supraglottic airway device, is a fundamental ACLS skill.  Prolonged interruptions in chest compressions should be avoided during advanced airway placement.  All providers should be able to confirm and monitor correct placement of advanced airways.  Training, frequency of use, and monitoring of success and complications are more important than the choice of a specific advanced airway device for use during CPR. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  23. 23. Management of Cardiac Arrest Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  24. 24.  Cardiac arrest can be caused by 4 rhythms: ventricular fibrillation (VF), pulseless ventricular tachycardia (VT), pulseless electric activity (PEA), and asystole.  VF represents disorganized electric activity, whereas pulseless VT represents organized electric activity of the ventricular myocardium. Neither generates significant forward blood flow.  PEA encompasses a heterogeneous group of organized electric rhythms associated with either absence of mechanical ventricular activity or mechanical ventricular activity that is insufficient to generate a clinically detectable pulse.  Asystole ( ventricular asystole ) represents absence of detectable ventricular electric activity with or without atrial electric activity. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  25. 25.  For VF/pulseless VT, attempted defibrillation within minutes of collapse. For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge.  Other ACLS therapies such as some medications and advanced airways, although associated with an increased rate of ROSC, have not been shown to increase the rate of survival to hospital discharge.  Combination of higher quality CPR and post arrest interventions such as therapeutic hypothermia and early percutaneous coronary intervention (PCI), doesn’t necessarily improves the outcome.  Periodic pauses in CPR should be as brief as possible and only as necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  26. 26.  Monitoring and optimizing quality of CPR is encouraged and includes:   Optimizing chest compression rate and depth, adequacy of relaxation, and minimization of pauses. Monitoring partial pressure of end-tidal CO2 [PETCO2], arterial pressure during the relaxation phase of chest compressions, or [ScvO2] when feasible.  In the absence of an advanced airway, a synchronized compression– ventilation ratio of 30:2 is recommended at a compression rate of at least 100 per minute.  After placement of an advanced airway, the provider performing chest compressions should deliver at least 100 compressions per minute without pauses for ventilation.  The provider delivering ventilations should give 1 breath every 6 to 8 seconds (8 to 10 breaths per minute) and should avoid delivering an excessive number of ventilations. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  27. 27. ADULT CARDIAC ARREST ALGORITHM Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  28. 28. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  29. 29. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  30. 30. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  31. 31. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  32. 32. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  33. 33. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  34. 34. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  35. 35. MANAGEMENT OF SYMPTOMATIC BRADYCARDIA & TACHYCARDIA Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  36. 36. Preface  The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable. Drugs or,  Drugs or, pacing may be used to control unstable or symptomatic bradycardia.  Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia.  ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  37. 37. BRADYARRHYTHMIA Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  38. 38. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  39. 39. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  40. 40. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  41. 41. TACHYARRHYTHMIA Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  42. 42. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  43. 43. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  44. 44. Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com
  45. 45. CARDIOVERSION ↓ DRUGS & DOSAGEDr.→ Keswani, National Burns Sunil Centre, www.india-burns.com, nbcairoli@gmail.com
  46. 46. THANK YOU Dr. Sunil Keswani, National Burns Centre, www.india-burns.com, nbcairoli@gmail.com

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