Cardiopulmonary resuscitation Dr.V.Ravimohan What I learned in the ILS training http://www.mrcogexam.net

Chain of survival Early recognition and call for help Early cardiopulmonary resuscitation (CPR) Early defibrillation Post resuscitation care

Early recognition and call for help

Early cardiopulmonary resuscitation (CPR)

Early defibrillation

Post resuscitation care

Early recognition Most in-hospital cardiac arrests are not sudden or unpredictable events Hypoxia or hypotension are either not noticed by staff ,or are recognised but treated poorly. 2 systems early warning scores calling criteria “ cardiac arrest team” “Medical emergency team”

Most in-hospital cardiac arrests are not sudden or unpredictable events

Hypoxia or hypotension are either not noticed by staff ,or are recognised but treated poorly.

2 systems

early warning scores

calling criteria

“ cardiac arrest team” “Medical emergency team”

Medical emergency team calling criteria Acute change in Physiology Airway Threatened Breathing All respiratory arrests Respiratory rate < 5/ min Respiratory rate >36/min Circulation All cardiac arrests Pulse rate <40/min Pulse rate > 140/min Systolic pressure <90 mmHg Neurology Sudden decrease in level of consciousness Decrease in GCS of > 2 points Repeated or prolonged seizures Other Any patient causing concern who doesn’t fit the above criteria

Airway obstruction Treatment Remove any obstruction unless contraindicated turn the patient to a side Simple airway opening manoeuvres head tilt, jaw thrust or chin lift (remember to give oxygen) Oropharyngeal airway or nasal airway Elective tracheal intubation Tracheostomy Always remember to give oxygen

Treatment

Remove any obstruction unless contraindicated turn the patient to a side

Simple airway opening manoeuvres head tilt, jaw thrust or chin lift (remember to give oxygen)

Oropharyngeal airway or nasal airway

Elective tracheal intubation

Tracheostomy

Always remember to give oxygen

Breathing problems Causes Poor respiratory drive-CNS depression Poor respiratory effort-muscle weakness/nerve damage Lung disorders

Causes

Poor respiratory drive-CNS depression

Poor respiratory effort-muscle weakness/nerve damage

Lung disorders

Breathing problems Recognition Irritability, confusion, lethargy and depressed consciousness(from hypoxia and hypercapnia) High respiratory effort(>30/min) Pulse oxymetry Non invasive measure of oxygenation but not a measure of ventilation Blood gas analysis

Recognition

Irritability, confusion, lethargy and depressed consciousness(from hypoxia and hypercapnia)

High respiratory effort(>30/min)

Pulse oxymetry

Non invasive measure of oxygenation but not a measure of ventilation

Blood gas analysis

Circulation problems Causes Primary heart problems  arrythmia secondary to ischaemia Secondary heart problems  severe anaemia, hypothermia

Causes

Primary heart problems  arrythmia secondary to ischaemia

Secondary heart problems  severe anaemia, hypothermia

Acute coronary syndromes Unstable angina Non ST segment elevation MI ST segment elevation MI Treatment O 2 high concentration Aspirin 300 mg Nitro-glycerine S/L Morphine

Unstable angina

Non ST segment elevation MI

ST segment elevation MI

Treatment

O 2 high concentration

Aspirin 300 mg

Nitro-glycerine S/L

Morphine

ABCDE approach A-airway B-breathing C-circulation D-disability E-exposure

A-airway

B-breathing

C-circulation

D-disability

E-exposure

Airway Obstruction Airway obstruction-”sea-saw” respirations complete no breath sounds at the mouth or nose Incomplete noisy clear the airway Give O 2 10 l/min

Airway obstruction-”sea-saw” respirations

complete

no breath sounds at the mouth or nose

Incomplete

noisy

clear the airway

Give O 2 10 l/min

Breathing General signs of respiratory distress Use of accessory muscles of respiration Sweating Cyanosis Respiratory rate Pulse oxymeter Trachea Percuss Listen

General signs of respiratory distress

Use of accessory muscles of respiration

Sweating

Cyanosis

Respiratory rate

Pulse oxymeter

Trachea

Percuss

Listen

Circulation Colour & temperature of limbs Capillary fill time Finger tip held at the heart level Normal fill time is less than 2 seconds Pulse volume low – poor cardiac output high(bounding)-sepsis B.P low diastolic blood pressure arterial vasodilatation  anaphylaxis or sepsis narrow pulse pressure-(normal 35-45 mmHg) arterial vasoconstriction  hypovolaemia/cardiogenic shock

Colour & temperature of limbs

Capillary fill time

Finger tip held at the heart level

Normal fill time is less than 2 seconds

Pulse volume

low – poor cardiac output

high(bounding)-sepsis

B.P

low diastolic blood pressure

arterial vasodilatation  anaphylaxis or sepsis

narrow pulse pressure-(normal 35-45 mmHg)

arterial vasoconstriction  hypovolaemia/cardiogenic shock

Disability AVPU A-Alert V-responds to vocal stimuli P-responds to painful stimuli U-unresponsive to all stimuli Measure blood glucose to exclude hypoglycaemia This is simpler than Glasgow coma scale

AVPU

A-Alert

V-responds to vocal stimuli

P-responds to painful stimuli

U-unresponsive to all stimuli

Measure blood glucose to exclude hypoglycaemia

This is simpler than Glasgow coma scale

Exposure Exposure to examine the patient properly Minimise heat loss Respect dignity

Exposure to examine the patient properly

Minimise heat loss

Respect dignity

“ collapsed patients” Ensure personal safety Check for patient response “ are you alright?” If patient responds  ABCDE approach” If patient doesn’t respond  call for help Airway Breathing-”look” “feel” “hear” for not more than 10 secs

Ensure personal safety

Check for patient response

“ are you alright?”

If patient responds  ABCDE approach”

If patient doesn’t respond  call for help

Airway

Breathing-”look” “feel” “hear” for not more than 10 secs

Pulse Checking for pulse-can be difficult even for the trained staff If unsure about the pulse don’t start delaying CPR If there is pulse Still call for help Give O 2 Ventilate lungs check for circulation ever 10 seconds Attach monitoring IV access

Checking for pulse-can be difficult even for the trained staff

If unsure about the pulse don’t start delaying CPR

If there is pulse

Still call for help

Give O 2 Ventilate lungs check for circulation ever 10 seconds

Attach monitoring

IV access

If there is no pulse or signs of life Call for help 30 chest compression:2 ventilation 100 compressions/min compression depth 4-5 cm Once the defibrillator arrives apply electrodes to patient and analyse rhythm Minimise interruptions to chest compressions

Call for help

30 chest compression:2 ventilation

100 compressions/min compression depth 4-5 cm

Once the defibrillator arrives apply electrodes to patient and analyse rhythm

Minimise interruptions to chest compressions

Advanced life support cardiac rhythm 2 groups of cardiac rhythm Shock able rhythm Ventricular fibrillation Pulse less ventricular tachycardia Non shock able rhythm Asytole Pulse less electrical activity

2 groups of cardiac rhythm

Shock able rhythm

Ventricular fibrillation

Pulse less ventricular tachycardia

Non shock able rhythm

Asytole

Pulse less electrical activity

Shock able Rhythm

3 possibilities

VT/VF persists

VF/VT still persists

Some tips Lidocaine 100mg IV is an alternative for amidarone but isn’t an option if amidarone is already given If there is doubt about whether a rhythm is Asystole or very fine AF don’t defibrillate Very fine VF is unlikely to respond to shock

Lidocaine 100mg IV is an alternative for amidarone but isn’t an option if amidarone is already given

If there is doubt about whether a rhythm is Asystole or very fine AF

don’t defibrillate

Very fine VF is unlikely to respond to shock

Precordial Thump May be useful in VF/VT cardiac arrest which was witnessed and monitored sudden collapse Ulnar edge of a tightly clenched fist From height of about 20 cm Thumb is most likely to be successful in converting VT to sinus rhythm

May be useful in VF/VT cardiac arrest which was witnessed and monitored sudden collapse

Ulnar edge of a tightly clenched fist

From height of about 20 cm

Thumb is most likely to be successful in converting VT to sinus rhythm

PULSELESS ELECTRICAL ACTIVITY Definition: organised electrical activity in the absence of any palpable pulses.

Definition: organised electrical activity in the absence of any palpable pulses.

Treatment for PEA

If VT/VF persists Follow shock able side of algorithm

Follow shock able side of algorithm

Treatment for asystole and slow PEA(rate <60 min -1 )

During CPR

Reversible causes 4H 4T Hypoxia Tension pneumothorax Hypovolaemia Tamponade,cardiac Hypo/Hyperkalaemia/metabolic Toxins Hypothermia Thrombosis

4 H Hypoxia 100% oxygen Ensure adequate chest rise & bilateral breath sounds Hypovolaemia Crystalloid/Colloid Surgery Hyperkalaemia 12 ECG may help in the diagnosis Check for hypoglycaemia Hypothermia

4T Tension pneumothorax May be a complication of inserting central venous catheter Signs: decreased air entry decreased expansion hyperresonance percussion on affected side Do: needle thoracocentesis Tamponade cardiac Cardiac arrest after penetrating chest trauma 2 reasons:A.hypovolaemia B.cardiac tamponade Do: needle pericardiocentesis or resuscitative thoracotomy Toxins Thrombosis Consider thrombolytic therapy

CPR in a pregnant patient Left lateral tilt(15-30 degrees) of patient Periarrest caesarean section should begin within 4 minutes Sterile preparation is not necessary Moving the patient to operating theatre isn’t necessary

Left lateral tilt(15-30 degrees) of patient

Periarrest caesarean section should begin within 4 minutes

Sterile preparation is not necessary

Moving the patient to operating theatre isn’t necessary