Cpcr

2,003 views

Published on

Published in: Health & Medicine, Business
  • Be the first to comment

Cpcr

  1. 1. Cardiopulmonary Resuscitation
  2. 2. 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 )
  3. 3. The Cardiac Arrest Rhythms The four cardiac arrest rhythms are     Asystole PEA ( Pulseless Electrical Activity ) Pulseless Ventricular Tachcardia (VT) Ventricular Fibrillation (VF)
  4. 4. 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
  5. 5. 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
  6. 6. Chain Of Survival – 4 links BLS Call for help Early Defibrillation Early CPR Early Advanced Care
  7. 7. 1. Check Responsiveness
  8. 8. 2. Call for help with AED defibrillator
  9. 9. 3. Open the Airway Head Tilt –Chin Lift Maneuver
  10. 10. 3. Open The Airway Jaw Thrust Maneuver
  11. 11. 4. Check for Breathing “ Look, Listen and Feel ”
  12. 12. 5. Give 2 slow rescue breaths (over 1 second ) “The Chest Must Rise”
  13. 13. 6. Check for Pulse (carotid pulse )
  14. 14. 7.Start Chest Compressions (if pulse absent) Site for chest compressions
  15. 15. Locate the margin of the ribs and follow upto xiphoid process
  16. 16. Place hand 2 finger spaces above the xiphoid process
  17. 17. Place other hand over hand on sternum
  18. 18. A C Chest Compressions B D
  19. 19. “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
  20. 20. Attach defibrillator(AED) as soon as available and shock if indicated
  21. 21. 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.)
  22. 22. 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%)
  23. 23. 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
  24. 24. ADVANCED LIFE SUPPORT
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. C. Circulation  Identify the rhythm  Defibrillation /Pacing  Secure IV line-large easily accessible peripheral veins  Give rhythm appropriate medication
  29. 29. 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
  30. 30. 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
  31. 31. 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 
  32. 32. 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 
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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 .
  37. 37. 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.
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. THANK YOU

×