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Cpcr dr raj care ngp

Cpcr dr raj care ngp



basic life support

basic life support



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Cpcr dr raj care ngp Cpcr dr raj care ngp Presentation Transcript

  • Cardiopulmonary Resuscitation Dr. Rajkumarr Anesthesiologist Care Hospital Nagpur
  • “No initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act” 2
  • Bad News Time Flies Good News You are the Pilot You take care of the Seconds We take care of the Minutes 3
  • 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)
  • D. Differential Diagnosis Review the most frequent causes ( the 6 H’s and 6 T’s ) Hypovolemia Tablets ( Toxins) Hypoxia Tamponade - cardiac Hydrogen ions – acidosis Tension pneumothorax Hyper / hypokalemia Thrombosis - coronary Hypothermia Trauma Hypoglycemia Thrombosis - pulmonary
  • Cardio Pulmonary Cerebral Resuscitation  BLS : Basic life support  ACLS : Advance cardiac life support  Better chance of survival  Brain damage starts in 4-6 minutes  Brain damage is certain after 10 minutes without CPR What is treatment of cardiac arrest….?
  • How to do It- Chain of Survival Early Recognition (Sudden Cardiac Arrest)) Early Activation (Emergency Medical Service) Early Chest Compression (Push Hard &Push Fast) Early Shock (Automated External Defibrillator Early Advanced care
  • Chain Of Survival – 4 links Early Activation of EMS Early CPR Early Defibrillation Early Advanced Care BLS
  • International Guidelines for CPR 2005…..????
  • Chain of survival 2005 2010
  • International Guidelines for BLS 2010
  • BLS Algorithm Step 1. Assess Responsiveness Step 2. Activate the EMS and call for the defibrillator(AED) Step 3. check for pulse in 10 sec. Step 4. Start chest Compressions (30:2), minimize interruption Beginning with 30 compressions rather than 2 ventilations l/t shorter delays. Step 5. Open airway Step 6. Check breathing Step 7. Give rescue breaths, avoid excessive ventilations As soon as a AED is available attach and fallow instructions
  • WORKSHOP Ready for hands on……?
  • 1. Check Responsiveness
  • 2. Call for help with AED defibrillator
  • 3. Check for Pulse (carotid pulse )
  • 4.Start Chest Compressions Site for chest compressions
  • Place hand 2 finger spaces above the xiphoid process
  • Place other hand over hand on sternum
  • Hand Position for Chest Compression
  • “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 ) • minimum 5 cm sternal depression • Arms Straight, elbows locked, shoulder over hands • Complete recoil of chest
  • • Rescuer fatigue may lead to inadequate compression rates or depth. • When 2 or more rescuers are available it is reasonable to switch chest compressors approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions . • Every effort should be made to accomplish this switch in 5 seconds.
  • 5. Open the Airway Head Tilt –Chin Lift Maneuver
  • Open The Airway Jaw Thrust Maneuver
  • 6. Check for Breathing
  • 7. Ventilation over 1 sec. (The Chest Must Rise)  Mouth to mouth breathing  Bag and mask ventilations
  • Bag and mask ventilations
  • Ventilation With Bag and Mask • Rescuers can provide bag-mask ventilation with room air or oxygen. • This amount is usually sufficient to produce visible chest rise and maintain oxygenation and normocarbia in apneic patients (Class IIa). • If the airway is open and a good, tight seal is established between face and mask. • Avoid excessive ventilation (30:2 for bag & mask and 8-10 breaths/min after intubation)
  •  As long as the patient does not have an advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR.  The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class IIa).  The healthcare provider should use supplementary oxygen (O2 concentration 40%, at a minimum flow rate of 10 to 12 L/min) when available.
  • Ventilation With an Advanced Airway  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 (Class IIb).
  • 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.)
  • International Guidelines for CPR 2010 vs 2005  Team work  No look, listen, feel  ABC -CAB sequence Beginning with 30 compressions rather than 2 ventilations .  Chest compressions – >5 cm  Rescuer specific cpr strategy  Untrained: Hands only cpr  Pulse checks are only undertaken where there are signs suggestive of ROSC.
  •  <10 sec. for intubation  Waveform capnography (Etco2 >10 mmhg)  Intra-arterial diastolic pressure >20 mmhg  Atropine no longer recommended in PEA /Asystole and it remains for peri-arrest management.  Chronotrophic drug infusions used as alternative to pacing.  Advanced airway: includes supraglottic airway devices, capnography.  Interruption is allowed for only 5 sec.e.g. Defibrillation, change over  The tracheal route of drug administration is not recommended except in neonates following the widespread introductionof intraosseous devices.
  • 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%)
  • 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 trauma hypoglycemia 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 B Breathing : secure airway device B Breathing : confirm effective oxygenation & ventilation C Circulation : identify rhythm – monitor C Circulation : Defibrillation/Pacing C Circulation : establish IV access C Circulation : 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
  • Termination of cpr ALS