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Cpcr
 

Cpcr

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    Cpcr Cpcr Presentation Transcript

    • Cardiopulmonary Resuscitation
    • Cardiac Arrest Cardiac arrest is the cessation of all cardiac mechanical activity. It’s clinical diagnosis is confirmed by Unresponsiveness Absence of detectable pulse Apnea (or agonal respirations )
    • The Cardiac Arrest Rhythms The four cardiac arrest rhythms are     Asystole PEA ( Pulseless Electrical Activity ) Pulseless Ventricular Tachcardia (VT) Ventricular Fibrillation (VF)
    • International Guidelines for CPR 2005  International consensus on the art & science of CPR  Based on the most extensive evidence review of CPR  Recommendations designed to improve survival from sudden cardiac arrest (SCA)  Circulation Volume 112, Issue 24 Supplement; December 13, 2005
    • AHA Class of Recommendation  Class I Definitely recommended  Class II a Acceptable and useful  Class II b Acceptable and useful  Indeterminate Promising, evidence lacking, immature  Class III May be harmful: no benefit documented excellent evidence good to very good evidence fair to good evidence no harm and no benefit not acceptable, not useful, may be harmful
    • Chain Of Survival – 4 links BLS Call for help Early Defibrillation Early CPR Early Advanced Care
    • 1. Check Responsiveness
    • 2. Call for help with AED defibrillator
    • 3. Open the Airway Head Tilt –Chin Lift Maneuver
    • 3. Open The Airway Jaw Thrust Maneuver
    • 4. Check for Breathing “ Look, Listen and Feel ”
    • 5. Give 2 slow rescue breaths (over 1 second ) “The Chest Must Rise”
    • 6. Check for Pulse (carotid pulse )
    • 7.Start Chest Compressions (if pulse absent) Site for chest compressions
    • Locate the margin of the ribs and follow upto xiphoid process
    • Place hand 2 finger spaces above the xiphoid process
    • Place other hand over hand on sternum
    • A C Chest Compressions B D
    • “Push hard and Push fast” Minimise interruption of chest compression • 100 /min. • 30:2 ratio ( C:V ) • 5 cycles (2 minutes) • 50% : 50 % ( C/R ) • 1 ½ -2 inches sternal depression • Arms Straight, elbows locked, shoulder over hands • Complete recoil of chest
    • Attach defibrillator(AED) as soon as available and shock if indicated
    • D – Early Defibrillation Automated External Defibrillator (AED)  Single greatest advance in CPR  The survival rate is 90% if the patient is defibrillated within 1 min. and only 10% if it is delayed till 10mins (Circulation 1984;69:943-8.)  Survival rate after cardiac arrest has been reported to go up from 30% to 49% (Ann Emerg Med 1996;28:480-5.)
    • Biphasic vs Monophasic Defibrillation  Advantages - greater efficacy - low energy produces same effect - less myocardial damage - less incidence of S-T changes ( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )  Energy - Monophasic 360 J - Biphasic 150/200 J  All AEDs are Biphasic  High first shock success of Biphasic defibrillation (84%-95%)
    • BLS Algorithm ( Primary ABCD ) Step 1. Assess Responsiveness Step 2. Activate the EMS and call for the defibrillator Step 3. Open the airway Step 4. Assess Breathing (“ look, listen and feel ” ) Step 5. If Breathing is absent, give two slow rescue breaths Step 6. Check for pulse (carotid pulsations) Step 7. If pulse is absent initiate “ Chest Compressions ” As soon as a defibrillator is available attach and defibrillate if indicated
    • ADVANCED LIFE SUPPORT
    • A - Airway  Definitive airway should be secured as soon as possible  Tracheal intubation using cricoid pressure (by trained personnel only)  Laryngeal Mask Airway (LMA) and Esophageal–tracheal Combitube are accepted alternatives for others  Cricothyrotomy to be performed in an emergency
    • B. Breathing - Confirm device placement  Primary Confirmation  Direct Visualisation of ETT passing through cords  Chest expansion  5 point auscultation - L and R anterior, - L and R mid-axillary - Over stomach  Still in doubt –repeat laryngoscopy  Further confirmation - Exhaled CO2 detector (ETCO2) - Oesophageal detector device  Inflate cuff and secure the tube
    • B. Breathing – Confirm effective oxygenation and ventilation  No synchrony between ventilation and chest compressions once definitive airway is secured  No longer 30 : 2 compression ventilation cycles COMPRESSION @100/min VENTILATION @ 6 – 8 breaths/min
    • C. Circulation  Identify the rhythm  Defibrillation /Pacing  Secure IV line-large easily accessible peripheral veins  Give rhythm appropriate medication
    • Recognition of Rhythm Cardiac Arrest (lethal rhythms) Shockable-VF,Pulseless VT Non Shockable – Asystole.PEA Non Cardiac Arrest (non lethal rhythm) Rate too fast - >120/min Rate too slow- <60/min
    • Defibrillation  For shockable rhythms – VF / Pulseless VT  Monophasic or Biphasic defibrillators (Biphasic preferred) Monophasic 360 J ~ Biphasic 200 J  Steps of Defibrillation - Mains plugged in or on battery, On Defib mode - ECG size/gain maximum - Set on leads: Only set on paddles if no leads - Select joules (200,300 & all others 360) - Charge, (“all clear”chant to count of 3 before discharge) - Discharge
    • Pacing Disappointing results for asystole, PEA  No benefit in post shock asystole  May be indicated for cardiac arrest with narrow QRS complexes  Not useful during terminal wide complex agonal rhythms  Extensive use in pre-arrest bradyarrhythmias  Transcutaneous or transvenous 
    • C-Circulation IV Access Wide bore peripheral upper limb vein  Push each bolus with 20cc fluid  Raise extremity  Urgent central/femoral line only if peripheral access impossible or difficult & taking a long time to cannulate 
    • C-Circulation Other Drug Delivery Routes  Tracheal - 2-3 times IV dose - Dilute in 10 ml saline - Preferably inject down a suction catheter which is wedged deep into the bronchus - Rapid bagging  Intracardiac route - Not recommended - Dangerous can result in refractory VF or convert to nonshockable rhythm
    • C - Circulation Rhythm appropriate medications Epinephrine  Indicated in all cardiac arrest rhythms i.e. VF, Pulse less VT, Asystole and PEA  IV dose is 1mg administered every 3-5 minutes followed by 20 ml IV saline flush  Adrenaline causes intense cardio-cerebral sparing vasoconstriction CPR generates CO 25% of normal  Beneficial effects outweigh negative effects on the myocardium
    • Vasopressin  Antidiuretic hormone and a powerful vasoconstrictor when used in the higher doses.  Positive effects of epinephrine with lesser adverse effects . Effect lasts for 20 minutes  Dose - 40 IU  Drug of choice for all 4 rhythms Pulseless VT , VF, Asystole and PEA  One dose of vasopressin may replace either the first or the second dose of epinephrine
    • Atropine  First drug of choice in symptomatic bradycardia (class I )  Second drug after epinephrine for asystole and bradycardic PEA ( class II b ).  Dose is 1mg IV push, repeat every 3-5 minutes up to a maximum dose of 0.04 mg /kg .
    • Amiodarone  Persistent or recurrent VF or VT ( class II b )  Dose is 300 mg IV push (150 mg may be repeated after 3-5 minutes ) may be followed by a 24 hour infusion of 1mg / minute for 6 hours and then 0.5 mg/minute for the remaining 18 hours.  Amiodarone preferred over Lignocaine (class indeterminate ) in the treatment of persistent or recurrent VF /VT.
    • Sodium Bicarbonate Specific indications are as follows  class I if known pre-existing hyperkalemia  class II a if known bicarbonate responsive acidosis TCA overdose  class II b after prolonged resuscitation with effective ventilation  class III hypercarbic acidosis The dose is 1 meq/kg bolus, repeat half this dose every 10 minutes thereafter
    • Calcium Detrimental effect on ischaemic myocardium Impairs cerebral recovery NOT TO BE USED ROUTINELY Indicated in PEA due to  Hyperkalaemia  Hypocalcaemia  Ca channel blocker overdose
    • Magnesium sulphate  Shock refractory ventricular fibrillation in pr of possible hypomagnesemia  Torsades de pointes  VT in pr of possible hypomagnesemia Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2 min,can be repeated after 10 –15 min
    • D. Differential Diagnosis Review the most frequent causes ( the 5 H’s and 5 T’s ) Hypovolemia Tablets ( Toxins) Hypoxia Tamponade - cardiac Hydrogen ions – acidosis Tension pneumothorax Hyper / hypokalemia Thrombosis - coronary Hypothermia Thrombosis - pulmonary
    • ACLS - Secondary ABCD Survey A Airway : place airway device as soon as possible B Breathing : confirm airway device placement by examination plus confirmation device secure airway device confirm effective oxygenation & ventilation B Breathing : B Breathing : C C C C Circulation : Circulation : Circulation : Circulation : identify rhythm – monitor Defibrillation/Pacing establish IV access give medications appropriate for rhythm and condition D Differential Diagnosis : search for and treat identified reversible causes
    • Monitoring the Victim - To assess effectiveness of rescue efforts  Monitor for signs of circulation and breathing  Check pulse during compression to assess effectiveness of compression  To determine ROSC after 2 minutes of chest compression check for pulse  ETCO2
    • THANK YOU