Cardiac arrest is the cessationof normal circulation of the blood due tofailure of the heart to contracteffectively. Medical personnel can referto an unexpected cardiac arrest asa sudden cardiac arrest or SCA.
Cardiac arrest is classified based upon the ECG rhythm into: Shockable (Ventricular fibrillation and Pulseless ventricular tachycardia ) Non–shockable (Asystole and Pulseless electrical activity).
all cases accompanied with hypoxia extracardiac CAUSES OF CARDIAC ARREST cardiacPrimary lesion of cardiac muscle leading to theprogressive decline of contractility, conductivitydisorders, mechanical factors 4
a) Coronary heart disease -Approximately 60–70% of SCD is related to coronary heart disease. - Among adults, ischemic heart disease is the predominant cause of arrest. b) Non ischemic heart disease - cardiomyopathy, - cardiac rhythm disturbances (VT/VF/ Asystole/PEA) - hypertensive heart disease - congestive heart failure.
SCD is unrelated to heart problemsin 35% of cases. - Trauma - Non-trauma related bleeding (such as gastrointestinal bleeding, aortic rupture, and intracranial hemorrhage) - Medication Overdose ( Ca channel blockers, Digitalis,Beta-blockers) - Drowning - Pulmonary embolism.
Sex : The lifetime risk is three times greater in men (12.3%) than women (4.2%) Smoking Lack of physical exercise Obesity Diabetes Family history.
The most reliable sign is absence of pulse. Unconsciousness No breathing No Blood Pressure Pupils begin dialating within 45 seconds Seizures may/maynot occur Death – like appearance Lips & nail buds turn blue
Cardiac arrest is synonymous with clinical death. Lack of carotid pulse is the gold standard for diagnosing cardiac arrest. Cardiac arrest is usually diagnosed clinically by the absence of a pulse, but lack of a pulse (particularly in the peripheral pulses) may be a result of other conditions (e.g. shock), or simply an error on the part of the rescuer.
As the prime causes of cardiac arrest being ischemic heart disease - efforts to promote a healthy diet - exercise - smoking cessation For people at risk of heart disease - blood pressure control - cholesterol lowering.
This is usually carried out based upon: Basic life support (BLS) Advanced cardiac life support (ACLS) Pediatric advanced life support (PALS) Neonatal resuscitation program (NRP)
Out-of-hospital cardiac arrest (OHCA) has a worse survival rate (2-8% for discharge) than an in-hospital cardiac arrest (15% for discharge). Although mortality in case of ventricular fibrillation is high, rapid intervention with a defibrillator increases survival rate. Survival rates following an arrest induced by toxins are very much dependent on identifying the toxin and administering an appropriate antidote. The overall survival following cardiac arrest is 6.8%.
Cardiopulmonary resuscitation (CPR)is an emergency procedure which isperformed in an effort to manuallypreserve intact brain function until furthermeasures are taken to restorespontaneous blood circulation andbreathing in a person in cardiac arrest.
To restore partial flow of oxygenated blood to the brain and heart who are not breathing and do not have a pulse.
To delay tissue death and to extend the brief window of opportunity for a successful resuscitation without permanent brain damage.
5000 -3000 BC - first artificial mouth to mouth ventilation 1780 – first attempt of newborn resuscitation by blowing 1874 – first experimental direct cardiac massage 1901 – first successful direct cardiac massage in man 1946 – first experimental indirect cardiac massage 1960 – Modern CPR-indirect cardiac massage 1980 – development of cardiopulmonary resuscitation due to the works of Peter Safar 2008- AHA released additional guidelines that said Compression only CPR
a) Cardiac arrest b) Respiratory Arrest - VF - Drowning - VT - Stroke - Asystole - Foreign body airway - PEA obstruction - Smoke inhalation - Drug overdose - Electrocution (lightening injury) - Suffocation - Accident - Coma - Epiglottitis.
Cardiac arrest No blood flow & oxygenation Brain sustain damage for 4 min & after 7 min irreversible damage After1-2 hours-cells of the body die CPRBlood is manually forced to circulate to brain & heartEnough oxygen to Allows heart to remainbrain-delay brain death. responsive till defibrillation.
Standard method Standard CPR includes both mouth-to- mouth resuscitation and chest compression. Compression only involves chest compressions without artificial respiration. It is recommended as the method of choice for the untrained rescuer. In pregnancy During pregnancy when a woman is lying on her back the uterus may compress the inferior vena cava and thus decrease venous return. So that the uterus be pushed to the persons left and if this is not effective either roll the person 30°s or consider emergency cesarean section. Other Internal cardiac massage
Check for Danger Check for Response Send for help Chest compressions Open the Airway Check Breathing D stands for AED
Recognition of the arrest Compressions Managing the airway Rescue breaths
check for response , tap the victim on the shoulder and shout, “Are you all right?” no more than 10 seconds to check for a pulse Adults – Carotid artery Infants – Brachial artery
R - Responsivenes s › Tap shoulder and shout “Are you ok?”
unless the scene dictates otherwise › threat of fire or explosion › victim must be on a hard surface › Place victim level or head slightly lower than body
DIAGNOSIS OF CARDIAC ARREST Loss of time !!!Blood pressure measurement Taking the pulse on peripheral arteries Auscultation of cardiac tones 30
Maintain a head tilt with one hand over the forehead Locate the trachea, using 2 fingers of the other hand Slide these fingers into the groove between the trachea $ muscles at the side of the neck, where you can palpate carotid pulse Palpate artery for at least 5 sec $ not more than 10 seconds.
Check the pulse on carotidartery using fingers of theother hand.In infants brachial pulse ismore easily located &palpated than the carotidpulse.
Push hard & fast(100/min) Compressions to relaxation ration 50:50 To Ensure full chest recoil Minimal interruption
Position yourself at victim’s side Make sure the victim is lying on his back on a firm,flat surface.If the victim is lying face down,carefully roll him onto his back. Remove all clothings covering the victim’s chest Put the heel of one hand on the center of the victim’s bare chest between the nipples Put the heel of your other hand on the top of the first hand. Straighten your arms and position your shoulders directly over your hands. Push hard $ fast. At the end of each compression make sure that you allow the chest to recoil completely. Deliver compressions at a smooth fashion at a rate of atleast 100 compressions per minute.
C. CirculationRestore the circulation, start external cardiac massage 35
Effective CPR provides 1/4 to 1/3 normal blood flow Rescue breaths contain 16% oxygen (21%)
2 mechanisms explaining therestoration of circulation by external cardiac massage Cardiac Thoracic pump pump 38
Cardiac pump during the cardiac massage Blood pumping is assured by the compression of heart between sternum and spine Between compressions thoracic cage is expanding and heart is filled with blood 39
Thoracic pump at the cardiac massage Blood circulation is restored due to the change in intra thoracic pressure and jugular and subclavian vein valves During the chest compression blood is directed from the pulmonary circulation to the systemic circulation. Cardiac valves function as in normal cardiac cycle. 40
HEAD TILT- CHIN LIFT Place one hand on the victim’s forehead $ push with your plam to tilt the head back. Place the fingers of the other hand under the bony part of the lower jaw near the chin. Lift the jaw to bring the chin forward. JAW THRUST INDICATION: Cerviacal spine injury Place one hand on each side of the victim’s head,resting your elbows on the surface on which the victim is lying. Place your fingers under the angle’s of the victim’s lower jaw $ lift with both hands , displacing the jaw forward. If the lips close, retract the lower lip with your thumb.
A – Airway › Open the airway › Head tilt chin lift
Deliver each rescue breath over 1 second visible chest rise compression to ventilation ratio of 30 chest compressions to 2 ventilations. Advanced airway give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions 8 to 10 breaths/min
Mouth-to-Mouth Rescue Breathing Mouth-to–Barrier Device Breathing Mouth-to-Nose and Mouth-to-Stoma Ventilation Ventilation With Bag and Mask Ventilation With a Supraglottic Airway Ventilation With an Advanced Airway
Hold the victim’s airway open with a head tilt- chin-lift Pinch the nose closed with your thumb $ index finger (using the hand on the forehead) Take a regular breath (not deep) $ seal your lips around the victim’s mouth, creating an airtight seal Give 1 breath over 1 sec $ watch for chest rise. If the chest doesn’t rise, repeat the head tilt- chin-lift Give a second breath $ watch for chest rise.
› Can’t open mouth › Can’t make a good seal › Severely injured mouth › Stomach distensionMouth to stoma (tracheotomy)
Position yourself at the victim’s side Place the mask on the victim’s face, using the bridge of the nose as a guide for correct position Seal the mask against the face. # using the hand that is closer to the top of the victim’s head, place the index finger $ thumb along the border of the mask. #place the thumb of your other hand along the lower margin of the mask. Place the remaining fingers closer to the victim’s neck along the bony margin of the jaw $ lift the jaw. Deliver air over 1 second to make the victim’s chest rise.
Position yourself directly above the victim’s head Place the mask on the victim’s face. Use the E_C clamp technique to hold the mask in place # Perform head tilt # Use thumb $ index finger of 1 hand to make a “c”,pressing the edges of the mask to the face.(3 fingers form an E) # Use the remaining fingers to lift the angles of the jaw. Squeeze the bag to give breaths while watching for chest rise.
Shout and gently tap the child on the shoulder. If there is no response, position the infant on his or her back Begin chest compressions
If the baby is NOT breathing give 2 small gentle breaths. Cover the babys mouth and nose with your mouth. Each breath should be 1 second long. You should see the babys chest rise with each breath.
Component Adults Children InfantsRecognition Unresponsive (for all ages).No breathing or no Normal breathing No breathing or only (ie, only gasping) gasping No pulse palpated within 10 seconds for all agesCPR C-A-BsequenceCheck pulse Carotid pulse Brachial(<10 sec) pulseCompression Center of the breast bone between nipples just below nipple line on breastlocation bone.Compression At least 100/minrateCompression Heel of 1 hand,other hand on the top 2 fingers(2 thumb encircling hands inmethod 2 rescuer CPRCompression At least 2 At least 1⁄3 AP diameter At least 1⁄3 AP diameterdepth inches (5 cm) About 2 inches (5 cm) About 1. inches (4 cm) Chest wall Allow complete recoil between compressions.rotate compressors every 2 minutes recoilCompression Minimize interruptions in chestinterruptions compressions.Attempt to limit interrruptions to <10 secondsAirway Head tilt–chin lift (suspected trauma: jaw thrust)Compression-to- 30:2 1 or 2 30:2(Single rescuer)ventilation rescuers 15:2 (.2 rescuers)ratioVentilations:untrai Compressions onlynedVentilations with 1 breath every 6-8 seconds (8-10 breaths/min).Asynchronous with chest compressions . About 1advanced airway second per breath Visible chest rise
One should kneel down at the victim’s side and perform CPR ,while the other kneel at the opposite side near the victim’s head an deliver artificial breaths. Switch roles every 2 minutes.
The person revives and starts breathing again on their own. Medical help, such as ambulance paramedics, arrive to take over. The person performing the CPR is forced to stop from physical exhaustion Death of the victim CPR continued for 30min if the time to onset of CPR is <6min. Onset of CPR >6min CPR can be terminated after 15min
Lung expansion Pupil will react to light / will appear normal Normal heart beat will return A spontaneous gasp/breathing will occur May move legs / arms and colour may improve.
Who do not awaken immediately after CPR- most important determination is neurologic recovery. Coma > 24hrs - 10% chance of neurologic recovery. Coma > 72hrs - 5% chance of neurologic recovery. Coma > 2wks - no chance of full neurologic recovery. 72hrs point or GCS<5 – little or no chance of neurological recovery.
timing devices those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely
Delay in starting Improper procedures (ex. Forget to pinch nose) No ACLS follow-up and delay in defibrillation › Only 15% who receive CPR live to go home › Improper techniques Terminal disease or unmanageable disease (massive heart attack)
local blunt trauma Gastric inflation bruising or fracture of the sternum or ribs Compression at the xiphoid process causes laceration of liver
Vomiting › Aspiration › Place victim on left side › Wipe vomit from mouth with fingers wrapped in a cloth › Reposition and resume CPR
Air in the stomach › Creates pressure against the lungs Prevention of Stomach Distension › Don’t blow too hard › Slow rescue breathing › Re-tilt the head to make sure the airway is open › Use mouth to nose method › Cricoid pressure