17 Cpr


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17 Cpr

  1. 1. Cardiopulmonary Resuscitation Chai-yanfen Department of Emergency Medicine, Tianjin Medical University General Hospital
  2. 2. OBJECTIVE <ul><li>At the end of the course the student will be able to </li></ul><ul><li>1.Define the sudden cardiac arrest, the clinical death and biologic death. CPR defination </li></ul><ul><li>2.Master the cardiopulmonary cerebral resuscitation skill, procedure and the method of BLS. </li></ul><ul><li>3.Know the complication of CPR. </li></ul><ul><li>4.Know the chain of survival . </li></ul>
  3. 3. The contents <ul><li>一、 General consideration </li></ul><ul><li>二、 CPR Steps </li></ul><ul><li>三、 Complication of CPR </li></ul><ul><li>四、 Monitoring during CPR </li></ul><ul><li>五、 Terminating Resuscitation </li></ul>
  4. 4. Part Ⅰ <ul><li>General consideration </li></ul>
  5. 5. Part Ⅰ <ul><li>CPR definition ★ </li></ul><ul><li>The History of CPR </li></ul><ul><li>The Goals of CPR ★ </li></ul><ul><li>4. Anatomy and function of the circulatory system </li></ul><ul><li>5. Death concepts ★ </li></ul><ul><li>6. Epidemiology of Sudden cardiac death </li></ul><ul><li>7. The chain of survival ★ </li></ul><ul><li>8. Do Not Attempt Resuscitation ,DNAR </li></ul>Gerneral consideration
  6. 6. 1.CPR Defination <ul><li>The term cardiopulmonary resuscitation means: the revival or return to function of the heart and lungs. </li></ul>Part Ⅰ
  7. 7. <ul><li>CPR is a technique through mechanical, physiologic and pharmacologic methods to resuscitate the patients in sudden unexpected death resulting from reversible disease. </li></ul>
  8. 8. 2.The goals of resuscitation <ul><li>There are three goals of resuscitaition: </li></ul>③ Correction of the underlying disease state, while supporting and protecting all organs and assisting them in recovery to as near prearrest state as possible. ② Restoration of spontaneous cardiac and respiratory activity and establishment of circulatory self-sufficiency ① Basic life support, providing temporary perfusion of vital tissues.
  9. 9. 3.History of CPR <ul><li>The history of CPR and cerebrial arrest prophylaxis begins in ancient times. </li></ul><ul><li>5000 -first artificial mouth to mouth ventilation in 3000 BC </li></ul><ul><li>1780 – first attempt of newborn resuscitation by blowing </li></ul><ul><li>1874 – first experimental direct cardiac massage </li></ul><ul><li>1901 – first successful direct cardiac massage in man </li></ul><ul><li>1946 – first experimental indirect cardiac massage and defibrillation </li></ul><ul><li>1960 – indirect cardiac massage </li></ul><ul><li>1980 – development of cardiopulmonary resuscitation due to the works of Peter Safar </li></ul>
  10. 10. History of CPR
  11. 11. History of CPR
  12. 12. History of CPR <ul><li>There were no immediately applicable effective emergency resuscitation techniques available before 1950s. </li></ul><ul><li>Modern respiratory resuscitation was pioneered in 1950s </li></ul><ul><li>safar: opening airway 1958, </li></ul><ul><li>Elam: mouth to mouth breath,), </li></ul><ul><li>Modern circulatory resuscitation in the 1960s Kouwenhoven :external cardiac compression,1960 , </li></ul><ul><li>Therapeuticall promising reseach on brain resuscitation began in 1970. </li></ul>
  13. 13. 4. Anatomy and function of the circulatory system <ul><li>The circulatory system is similar to a city water system: </li></ul><ul><li>The heart functions as a pump </li></ul><ul><li>The blood vessels as a network pipes </li></ul><ul><li>The blood as fluid </li></ul>Part Ⅰ
  14. 14. 4. Anatomy and function of the circulatory system <ul><li>After blood picks up oxygen in the lungs ,it goes to the heart ,which pumps the oxygenated blood to rest of the body. </li></ul><ul><li>The cells of the body absorb oxygen and nutrients from the blood and produce waste products(including carbon dioxide),that blood carries back to the lungs.In lungs ,the blood exchanges the carbon dioxide for more oxygen .Then the oxygenated blood returns to the heart to be pumped out again. </li></ul>Part Ⅰ
  15. 15. <ul><li>If the heart stop contracting,and no blood is pumped through the blood vessels.Without a supply of blood, the cells of the body will die because they cannot get any oxygen and nutrients and they cannot eliminate waste products. </li></ul>Part Ⅰ
  16. 16. 5. Death concepts <ul><li>Death is a physiologic and biologic process ,it just occurs after cardiac arrest. </li></ul><ul><li>Clinical Death </li></ul><ul><li>Biologic death </li></ul><ul><li>Sudden cardiac death </li></ul>Part Ⅰ
  17. 17. * Clinical Death <ul><li>Clinical Death has been defined by Negovsky as “the period of respiratory,circulatory,and brain arrest during which initiation of resuscitation can lead to recovery with prearrest central nervous system function.” Clinical Death is a reversible state </li></ul><ul><li>The duration of clinical death depends on the length of time of the cerebral cortex survives in the absence of circulation and respiration. </li></ul><ul><li>Under normal temperature ,from clinical death to biologic death ,the period does not exceed 3-6min. </li></ul>Death concepts Part Ⅰ
  18. 18. * Biologic death <ul><li>Biologic death which sets in after clinical death,is an irreversible state of cellular destruction. </li></ul>Death concepts Part Ⅰ
  19. 19. * Sudden cardiac death <ul><li>Sudden cardiac death (also called sudden arrest) is death resulting from an abrupt loss of heart function (cardiac arrest). The victim may or may not have diagnosed heart disease. The time and mode of death are unexpected . It occurs within minutes to 1 hour after symptoms appear. The most common cause of cardiac arrest is coronary heart disease. </li></ul>Death concepts Part Ⅰ
  20. 20. <ul><li>Sudden cardiac death is the clinical death,This is a reversible condition.In most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation. </li></ul>Death concepts
  21. 21. Causes of cardiac arrest cardiac extracardiac Primary lesion of cardiac muscle leading to the progressive decline of contractility, conductivity disorders, mechanical factors all cases accompanied with hypoxia Death concepts
  22. 22. Causes of circulation arrest <ul><li>Cardiac </li></ul><ul><li>Ischemic heart disease (myocardial infarction, stenocardia) </li></ul><ul><li>Arrhythmias of different origin and character </li></ul><ul><li>Electrolytic disorders </li></ul><ul><li>Valvular disease </li></ul><ul><li>Cardiac tamponade </li></ul><ul><li>Pulmonary artery thromboembolism </li></ul><ul><li>Ruptured aneurysm of aorta </li></ul><ul><li>Extracardiac </li></ul><ul><li>airway obstruction </li></ul><ul><li>acute respiratory failure </li></ul><ul><li>shock </li></ul><ul><li>Reflective cardiac arrest </li></ul><ul><li>embolisms of different origin </li></ul><ul><li>drug overdose </li></ul><ul><li>Electrocution( 处电) </li></ul><ul><li>poisoning </li></ul>Death concepts
  23. 23. * Sudden cardiac death -ECG <ul><li>● Ventricular fibrillation </li></ul><ul><li>● pulseless Ventricular </li></ul><ul><li>tachycardia </li></ul><ul><li>● Asystole </li></ul><ul><li>● Electric –mechanical activity dissociation </li></ul>Part Ⅰ Death concepts
  24. 24. 6. Epidemiology of Sudden cardiac death <ul><li>Cardiac arrest accounts for between 250 000-350 000 death each year in USA. </li></ul><ul><li>Expert estimate that the overall survival rate may be beween 3% -5%,in many large urban areas maybe less than 2%. </li></ul><ul><li>In China, cardiac arrest approximately is 1 000 000 。 Mortality of cardiac arrest is 95%-98% in USA , and 98%-99% in China . </li></ul><ul><li>Delay Initiation of CPR are the most common cause of low rates of survival from out-of-hospital cardiac arrest. </li></ul>Part Ⅰ
  25. 25. <ul><li>Sudden cardiac arrest is reversible ,in most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation. </li></ul>Part Ⅰ
  26. 26. Part Ⅰ
  27. 27. 7.chain of survival <ul><li>Early Access to Medical Care (calling 911 in USA ,and calling 120 in China immediately) </li></ul><ul><li>Early CPR (within 4 min after cardiac arrest) </li></ul><ul><li>Early Defibrillation (for an out –of hospital sudden cardiac death within 5min,for a in hospital victims within 3min In guidelins 2000 ) </li></ul><ul><li>Early Advanced Care (including intubation and IV medication)should be initiated within 8min of arrest. </li></ul>Part Ⅰ In 1991 , American Heart Association has introduced
  28. 28. Early Access Early CPR Early Defibrillation Early Advanced Care Part Ⅰ
  29. 29. <ul><li>No CPR 0%-2% survive Delayed defibrillation </li></ul><ul><li>Early CPR 2%-8% survive Delayed defibrillation </li></ul><ul><li>Early CPR 20% survive Early defibrillation </li></ul><ul><li>Early CPR 30% survive Very early defibrillation Early ACLS </li></ul>Survival Rates Source: American Heart Association, 1994
  30. 30. Early Defibrillation <ul><li>Resuscitation success is dependent on each link in the chain. Early defibrillation has emerged as a single element of ALS that appears to have the greatest impact on ultimate survival.When defibrillation alone is added to the BLS regimen,survival increases from 6% to 25% for prehospital VF. </li></ul>
  31. 31. A victim's chances of survival are reduced by 7 to 10 percent with every minute that passes without defibrillation.
  32. 32. Rususcitation success and time <ul><li>Sudden death is unique.Time constraints are extreme. If resuscitative interventions are not begun within 5-7min,there is little likelihood of sucessful resuscitation and functional survival.Few attempts at resuscitation succeed after 10 minutes. </li></ul>
  33. 33. Most survivors of cardiac arrest are from the group of patients . . . <ul><li>Whose collapse is witnessed by a bystander, </li></ul><ul><li>Who receive cardiopulmonary resuscitation (CPR) within 4 to 5 minutes, and </li></ul><ul><li>Who receive advanced cardiac life support (ACLS), e.g., defibrillation, intubation, drug therapy, within the first 10 minutes. </li></ul>
  34. 34. 8. Do Not Attempt Resuscitation <ul><li>Decapition the head is separated from the rest of body.When this occurs,there no chance of saving the patient. </li></ul><ul><li>Rigor morits This is the temporary stiffening of muscles that occurs several hours after death. The presence of this stiffening indicate the patient dead and cannot be resuscitated . </li></ul><ul><li>Evidence of tissue decompositon Tissure decomposition or actual flesh decay occurs after a person has been dead for more than a day. </li></ul><ul><li>Dependent livdity It is the red or purple color that appears on the parts of the patien’s body that are closest to the ground.It is caused by blood seeping into the tissure on the dependent,or lower, part of the persion’s body. It occurs after a persion has been dead for several hours </li></ul>Part Ⅰ
  35. 35. The contents <ul><li>一、 Gerneral consideration </li></ul><ul><li>二、 CPR Steps </li></ul><ul><li>三、 Complication of CPR </li></ul><ul><li>四、 Monitoring during CPR </li></ul><ul><li>五、 Terminating Resuscitation </li></ul><ul><li>  </li></ul>
  36. 36. <ul><li>CPR steps </li></ul>Part Ⅱ
  37. 37. CPR steps <ul><li>Basic Life Support, BLS </li></ul><ul><li>Advanced Life Support, ALS </li></ul>Part Ⅱ
  38. 38. Basic Life Support <ul><li>BLS is the application of artificial ventilation and circulation without special equipment or drugs to prevent brain damage. </li></ul>Part Ⅱ BLS
  39. 39. <ul><li>Revives heart (cardio) and lung (pulmonary) functioning </li></ul><ul><ul><li>Use when there is no breathing and no pulse </li></ul></ul><ul><li>Provides O2 to the brain until ALS arrives </li></ul>BLS Combines rescue breathing and chest compressions
  40. 40. <ul><li>Effective CPR provides 1/4 to 1/3 normal blood flow </li></ul><ul><li>Rescue breaths contain 16% oxygen (21%in air) </li></ul>BLS
  41. 41. Basic Life Support, BLS <ul><li>◆ recognition of cardiac arrest </li></ul><ul><li>◆ A- airway control </li></ul><ul><li>◆ B-breathing support </li></ul><ul><li>◆ C-circulation support </li></ul>
  42. 42. Adult Basic Life Support Check responsiveness Call for help Correctly place and open airway Check breathing breathe Assess 10 second only Pulse present Continue rescue breathing No pulse Compress chest Shake and shout Head tilt/chin lift Look,listen and feel 2 effective breatha Signs of a circulation 100per minute 30:2 BLS
  43. 43. <ul><li>CALL Check the victim for </li></ul><ul><li>unresponsiveness </li></ul><ul><li>2. BLOW Tilt the head back and listen for breathing . . </li></ul><ul><li>3. PUMP If the victim is still not breathing normally, coughing or moving, begin chest compressions.   </li></ul><ul><li>Push </li></ul><ul><li>. </li></ul>BLS Part Ⅱ
  44. 44. 1.recognition of cardiac arrest <ul><li>Sudden cardiac death can be confirmed by the absence of detectable pulse, unresponsiveness, and apnea or gasping (喘息) ” . </li></ul>BLS Part Ⅱ Note: The presence of spontaneous respiration dose not exclude cardiac arrest. respiratory motion may persist for approximately 1 minute after cardiac arrest <ul><li>Responsiveness </li></ul><ul><ul><li>Tap shoulder and shout “Are you ok?” </li></ul></ul>
  45. 45. Diagnosis of cardiac arrest Symptoms of cardiac arrest <ul><li>Loss of conscious ★ </li></ul><ul><li>Absence of pulse on carotid arteries ★ </li></ul><ul><li>Respiration arrest cardiac arrest </li></ul><ul><li>E nlargement of pupils </li></ul>Blood pressure measurement  Taking the pulse on peripheral arteries  Auscultation of cardiac tones Loss of time !!!
  46. 46. <ul><li>follwing cardiac arrest : </li></ul><ul><li>loss on consciousness at about 10-15 seconds </li></ul><ul><li>Electro-encephalogram becomes falt after 30 sec </li></ul><ul><li>respiration arrest – may be in 30 seconds after cardiac arrest </li></ul><ul><li>pupils dilate fully after 60 seconds </li></ul><ul><li>Brain damage takes place wthin 4 to 6 minutes after cardiac arrest. </li></ul><ul><li>irreversible cerebral cortical damage occurring within 8-10 min after cardiac arrest. </li></ul>Part Ⅰ
  47. 48. Positioning the patient supine on a flat, firm surface with arms along the sides of the body, Always be aware of head and spinal cord injuries stabilize the cervical spine by maintaining the head ,neck, and trunk in a straight line
  48. 49. 2.A – airway control BLS Part Ⅱ Ensure open airway by preventing the falling back of tongue, tracheal intubation if possible
  49. 50. 2.A - Airway control BLS Part Ⅱ <ul><li>In an unconscious patient,airway obstruction is most commonly due to relaxation of the muscles of the tongue allowing it to rest against the posterior pharyngeal wall. </li></ul>
  50. 51. <ul><li>The several simple airway maneuver to ensure open airway by preventing the falling back of tongue. </li></ul>Part Ⅱ BLS
  51. 52. Head-tilt/chin-lift <ul><li>Head-tilt/chin-lift is usually the first maneuver , if no concern cervical spine injury . This is done by placing one hand on the forehead ,and placing the tips of fingers of other hand under the bony part of the chin.life the chin foreward,bring the entire lower jaw with it ,helping to tilt the head back. </li></ul>Part Ⅱ BLS
  52. 53. Jaw-thrust <ul><li>Jaw-thrust </li></ul><ul><li>This is the safest method for opening the airway if there is the possibility of cervical spine injury.this is done by playing placing the fingers behind the angle of the jaw and bring the head foreward. </li></ul>BLS Part Ⅱ
  53. 54. Cleaning airway tract <ul><li>Cleaning the secration of airway tract or foreign body(such as gastric contents regurgitation 、 blood clotting or denture in the mouth inspired into the airway) 。 </li></ul>BLS Part Ⅱ
  54. 55. 3.B -Breathing support <ul><li>After opening the airway , you should quickly ( take 3~5s ) Check For Breathing </li></ul>BLS Part Ⅱ look the patient’s chest and abdomen movement
  55. 56. <ul><li>listening for sounds of breathing, placing your ear over the patient’s nose and mouth </li></ul>feel and hear the movement of air If no spontaneous breathing ,you must begin artifical ventilation immediately.
  56. 57. mouth to mouth or mouth to nose respiration ventilation by a face mask and a self-inflating bag with oxygen 2 initial subsequent breaths wait for the end of expiration 10-12 breaths per minute with a volume of app. 800 ml, each breath should take 1,5-2 seconds Algorithm for artificial ventilation Control over the ventilation check chest movements during ventilation check the air return
  57. 58. Breathing method <ul><li>* Pinch the nose- prevent air escape </li></ul><ul><li>* take a deep breath </li></ul><ul><li>* Seal the mouth with yours </li></ul><ul><li>* give two breaths (1 second or longer) </li></ul><ul><li>Vent rate of 12 to 20 minute </li></ul><ul><li>If the first two don’t go in, re-tilt and give two more breaths (if breaths still do not go in, suspect choking) </li></ul>BLS Part Ⅱ ① Mouth-to-mouth
  58. 59. Breathing methods <ul><li>* Can’t open mouth </li></ul><ul><li>* Can’t make a good seal </li></ul><ul><li>* Severely injured mouth </li></ul><ul><li>* Stomach distension </li></ul><ul><ul><li>mouth-to-nose ventilation may be more effective . </li></ul></ul>BLS Part Ⅱ ② mouth-to nose
  59. 60. Breathing methods <ul><li>After tracheotomy , </li></ul><ul><li>the stoma becomes the patient ’ s airway.. </li></ul>BLS Part Ⅱ ③ mouth-to-stoma
  60. 61. Caution <ul><li>To prevent transmission of disease from the victim to rescuer,a bag –valve mask or other suitable device should be used in place of mouth-to-mouth technique. </li></ul>
  61. 62. BLS Part Ⅱ ④ Mouth-to-Mask
  62. 63. <ul><li>Both mouth to mouth and mouth to nose ventilation can provide large volumes , the concentration of oxygen delivered to the patient is 16%~17% , may produce an alveolar partial pressure of oxygen of 80mmHg,more than enough to patient’s life. </li></ul><ul><li>● With mouth to mask ventilation connected to high flow oxygen , the concentration of oxygen is 55% 。 </li></ul>
  63. 64. 4.C -Circulation BLS Part Ⅱ Restore the circulation, that is start external cardiac compression-ECC
  64. 65. <ul><li>Once the airway has been established and the lungs ventilated , If there is not carotid pulse , ECC should be started. </li></ul>
  65. 66. ECC method <ul><li>* The rescuer position- bedside the victim’s chest. </li></ul><ul><li>* Locate proper hand position for chest compressions </li></ul><ul><li>* Place heel of one hand on the lower half of the sternum . </li></ul><ul><li>* The fingers interlocked </li></ul><ul><li>* Keeping the arms straght (will reduce fatigue) </li></ul><ul><li>* Compression rate 100/min </li></ul><ul><li>* Depth of compressions: 1 .5 to 2 inches(4-5cm) </li></ul>BLS Part Ⅱ
  66. 67. <ul><li>● After 30 chest compressions give:2 slow breaths ( Ratio of compression-to-ventilations 30:2) </li></ul><ul><li>Continue until help arrives or victim recovers </li></ul><ul><li>If the victim starts moving: check breathing </li></ul>Part Ⅱ BLS
  67. 68. mechanisms explaining the restoration of circulation by external cardiac massage Cardiac pump Thoracic pump
  68. 69. 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
  69. 70. Thoracic pump at the cardiac massage <ul><li>Blood circulation is restored due to the change in intra thoracic pressure and jugular and subclavian vein valves </li></ul><ul><li>During the chest compression blood is directed from the pulmonary circulation to the systemic circulation. Cardiac valves function as in normal cardiac cycle . </li></ul>
  70. 71. Assessment of the effects of ECC <ul><li>The effects of ECC can be check in several ways : </li></ul><ul><li>★ With each compression,an arterial pulse should appear.The carotid artery pulse is more meaningful than either the radial artery or femoral artery pulse. </li></ul><ul><li>★ The ECG also responds to the ECC,Various types of electrocardiographic artifacts may appear with each compression. Occasionally,each ECC cause a recognizable QSR complex and T wave to appear. </li></ul><ul><li>★ The reaction of the pupils ,if present,is a good indicator of cerebral circulation </li></ul>
  71. 72. WRONG 1
  72. 73. WRONG 2
  73. 74. Advanced Life Support <ul><li>ALS refers to used special equipment to manage airway,breathing and circulation and provide definitive care,including defibrillation and pharmacotherapy of dysrhythimas and acid- base disturbance. </li></ul><ul><li>ALS may be applied by trained individuals operating within an emergency medical services system in the community,in transport, and in the hospital setting. </li></ul>Part Ⅱ
  74. 75. Advanced Life Support <ul><li>◆ Artificial airway </li></ul><ul><li>◆ D- defibrillation </li></ul><ul><li>◆ E-electrocardiaogram </li></ul><ul><li>◆ F -fluid and drugs </li></ul>
  75. 77. 1. Artificial airway <ul><li>1 . Oropharyngeal airway has two major purpose.The first is to keep the tongue from blocking the upper airway.The second is to make suctioning the airway.This should be inserted in unconscious patients, and is often used inconunction with BVM ventilation </li></ul><ul><li>2 . Nasopharyngeal airway </li></ul><ul><li>often used for a conscious patient who is not able to maintain an airway.This airway is usually well tolerated and is not a likely a the oropharygeal airway to cause vomiting. </li></ul>ALS Part Ⅱ
  76. 78. 1. Artificial airway <ul><li>3. Endotracheal intubation </li></ul><ul><li>Is the definitive technique for airway management in ALS. It should be performed as soon as possible in all patients for whom CPR .especially in the patient who cannot be rapidly resuscitated .It is a mandatory skill for any physician who cares for critically ill patients. </li></ul><ul><li>Note :The resuscitative efforts should not be interrupted by more than 30s with each attempt. </li></ul>Part Ⅱ ALS
  77. 79. 1. Artificial airway <ul><li>The Advantages Endotracheal intubation </li></ul><ul><li>● It can completely controls and protects the airway, </li></ul><ul><li>● It delivers better minute volume. </li></ul><ul><li>● It maybe left in place for a long time ,if necessary. </li></ul><ul><li>● It prevents gastric distention,and less regurgitation ,so it prevents aspiration of stomach contents. </li></ul><ul><li>● It allows for direct access to suctioning of trachea. </li></ul><ul><li>● It allows for administration of certain medication </li></ul>ALS Part Ⅱ
  78. 80. 2. Artificial ventilation <ul><li>⑴ Bag-valve-mask manual ventilation </li></ul><ul><li>This technique may be used after cardiac arrest immediately. </li></ul><ul><li>If the bag connected to a gas reservoir ,It can deliver 21 % ~ 100 % oxygen . This device should be used with oropharyngeal or nosopharyngeal airway or endotracheal intubation . </li></ul>ALS Part Ⅱ
  79. 81. 2. Artificial ventilation <ul><li>⑵ Mechanical ventilation </li></ul><ul><li>Early mechanical ventilators were not adequate for the management of cardiac arrest . High –pressure ventilation via endotracheal tube results in severe arterial respiratory alkalemia during CPR. </li></ul><ul><li>At present ,the safest approach is manual ventilation guided by arterial blood gases analysis . </li></ul>ALS Part Ⅱ
  80. 82. 3. Support of circulation <ul><li>Chest compression during ALS are performed in the same manner as in BLS. </li></ul><ul><li>Newer techniques include the use of compression-decompression devices and abdominal counterpulsation compression-decompression device. These mechanical devices were used,have result in improved rates of return of spontaneous circulation but not in improved ultimate survial. </li></ul>Part Ⅱ ALS
  81. 83. 3. Support of circulation <ul><li>Automated extral chest compression-decompresion devices </li></ul>Part Ⅱ ALS
  82. 84. 4.D - Defibrillation <ul><li>Defibrillation is the defnitive treatment for the vast majority of cardiac arrests.It should be delivered as early as posible. </li></ul><ul><li>At least 50% of patient in cardiac arrest are in VF when the first ECG. </li></ul><ul><li>In early 1970s “blind”defibrillation was recommended as soon as a defibrillator was available. </li></ul><ul><li>However, current defibrillators with quick-look paddles enable visualization of the rhythm disturbance upon arrival the defibrillator.As soon as ventricular fibrillation is documented,defibrillation as described below should be perform. </li></ul>
  83. 85. The method of defibrilation <ul><li>Precordial thump If an electrical defibrillator is not immediately available,a precordial thump should be employed.A sharp blow with the outside of a fist is delivered to the sternum from height of 8-12in (25 ~ 30cm). </li></ul><ul><li>If this successfully results in sinus rhythm, a bolus of lidocaine should be given.If VF persists, proceed to BLS and to defibrillation as soon as the defibrillator is available. </li></ul>ALS Part Ⅱ
  84. 86. The method of defibrilation <ul><li>● Electrical defibrillation: passing an electrical current through a fibrillating heart, and causing synchronous depolarization the disorganized contracting myofibrils at once ,and allowing for uniform repolarization and subsequent organized cardiac electromechanical activity. </li></ul>ALS Part Ⅱ
  85. 87. ALS Part Ⅱ defibrillator
  86. 88. defibrillator <ul><li>Automated external defibrillators (AED) </li></ul><ul><li>AED with a large pads.This machine can recognize VF and deliver direct current(DC) countershock with better than 85% sensivity and with 100%specificity.Defibrillation success rate appears equal traditional handheld defibrillator. The potential impact of using this technology widely in public setting such as office building,stadiums( 体育场) ,factorices airport railway stations,and rural areas served by volunteer rescue personnel. </li></ul>
  87. 89. <ul><li>While awaiting arrival of a defibrillator, effective BLS must be maitained. </li></ul><ul><li>If you do not know the duration of arrest ,first you should perform BLS for 2 min,then perform electrical defibrillation. </li></ul>
  88. 90. Procedure of Electrical defibrillation <ul><li>⑴ perform BLS untill the equipment and personnel arrive. </li></ul><ul><li>⑵ Assess the patient’s pulse and ECG. </li></ul><ul><li>⑶ choice asynchronous mode </li></ul><ul><li>⑷ Seletion of proper enery level </li></ul>ALS Part Ⅱ 2000 AHA guidelines forCPR and ECC recommed enery level Initial 200J next 300J Third and sequent 360J 2005 AHA guidelines forCPR and ECC recommed enery level Only one shock 360J
  89. 91. Procedure of Electrical defibrillation <ul><li>⑸ Adequate contact (Apply electrode gel or saline-soaked4×4 gauze pads) between paddles and skin </li></ul><ul><li>⑹ Proper position of the paddles </li></ul>ALS
  90. 92. Antero-apical position: one paddle is placed to the right of the sternum just below the clavicle.another paddle is placed to the normal cardiac apex . Antero-posterior position : the anterior paddle placed over the apex,and the posterior paddle on the back in the left or right infrascapular ( 肩胛下的 ) region. Proper position of the paddles There two widely accepted positions for the paddles that optimize current delivery to the heart:
  91. 93. ALS Part Ⅱ ⑺ Clear the area ,no contact with anyone other than the victim. ⑻ Recheck the ECG ⑼ Activate the firing button. ⑽ If no skeletal muscle twitch or spasm has occurred , you should check the equipment , contacts , and synchronizer switch Procedure of Electrical defibrillation ⑾ The rhythm should be assessed after each countershock and the patient should be checked for a pulse at appropriate time. ⑿ If unsuccessful,,repeat steps 4~11.
  92. 94. Possible arrhythmias after cardiac defibrillation <ul><li>ventricular tachycardia </li></ul><ul><li>bradyarrythmia including electromechanical dissociation and asystole </li></ul><ul><li>supraventricular arrhythmia accompanied with tachycardia </li></ul><ul><li>supraventricular arrhythmia with normal blood pressure and pulse rate </li></ul>
  93. 95. <ul><li>If several shocks fail to stop VF , optimal chest compression,oxygen and intermittent positive-pressure ventilation, epineprine, lidocaine, and sodium bicarbonate should be given in this sequence. If this measure is unsuccessful, bretylium is indicated.Patients have occasionllay recovered after more than 1 hour of external CPR with multiple defibrillation attempts </li></ul>ALS Part Ⅱ
  94. 96. 5. Venous access ALS Part Ⅱ To establish a reliable intravenous route is an essential part of ALS , this allow administration of necessary drugs and fluids during the CPR .
  95. 97. <ul><li>● Peripherial veins :usually recommed median cubital vein( 肘静脉) , particularly during the arrest situation when access to the neck and chest is restricted by BLS procedure. when these route are being used,IV medication should be administered rapidly by bolus injection and following by a 20ml fluid bolus injection and elevate the extremity. </li></ul>
  96. 98. Peripherial veins
  97. 99. <ul><li>● Central venous offers more secure route for drug administration , internal jugular or subclavian are preferable because of proximity to the heart , but their placement should not be allowed delay defibrillation attempts or interfere with BLS. femoral vein cannulation is difficult to achieve during CPR. </li></ul>
  98. 101. Other access <ul><li>If intravenous lines cannot be established quickly , some drugs ( such as epinephrine , lidocaine , atropine ) can be administered by endotracheal , and intracardiac routes. </li></ul>ALS Part Ⅱ
  99. 102. <ul><li>★ Endotracheal route requires a higher dose to achieving an equivalent blood level .It is suggested that 2.5 times the IV dose be administered.Delivery of the drug to the circulation is facilitated by diluting the drug to a 10ml volume ,delivering it though a catheter positioned to the tip of the endotracheal tube. </li></ul>
  100. 103. <ul><li>★ Intracardiac injection should be avoided and is indicated only if intravenous and endotracheal routes are not available. </li></ul>
  101. 104. 6. fluid therapy and Drug administration <ul><li>The roles of fluid and drug therapy are : </li></ul><ul><li>● Increase central volume , rising the perfusion presure of myocardium and brain. </li></ul><ul><li>● Treat arrhythmias and prevent recurrent cardiac arrest. </li></ul><ul><li>● Correct acidosis and hypoxia </li></ul><ul><li>● Correct the causes of cardiac arrest. </li></ul>ALS Part Ⅱ
  102. 105. IV fluid <ul><li>To maintain the IV access and increased central volume are often required during CPR.The standard fluid infusion for ALS should be normal saline or lactated Ringer’s solution , rather than dextrose in water ,because glucose may exacerbate anoxic injury to the brain. </li></ul>Part Ⅱ ALS
  103. 106. Drug therapy <ul><li>During CPR ,only a few drugs have proved useful.I introduce epinephrine, Vasopresine, Amiodarone lidocaine , atropine , magneium ,and sodium bicarbonate. </li></ul>Part Ⅱ ALS
  104. 107. ① Epinephrine ALS Part Ⅱ . Actions: Epinephrine can stimulate peripheral α-adrenergic receptor and cardial β adrenergic receptor , increases resistance in non-cerebral and non-coronary arteries,result in decreased blood flow to non-cerebral and non coronary vessels.in creased aortic blood pressure and increased perfusion of heart and brain vessel .
  105. 108. ① Epinephrine <ul><li>It can help convert fine VF into coarse VF , which is more susceptible to stop by electrical shock . </li></ul><ul><li>Indication : include all forms cardiac arrest. It is recommeded in VF/VT cardiac arrest if there is no ROSC(return of spontaneous circulation) after first three defibrillation.It is recommended in EMD and asystole after initiation of CPR </li></ul>Part Ⅱ ALS
  106. 109. ① Epinephrine <ul><li>The standard adult dose is 1mg IV bolus and repeated every 3~5min until return of spontaneous circulation </li></ul>
  107. 110. ② Vasopresine <ul><li>Actions: is a endogenous peptide hormone .It produces vasoconstriction in non vital tissues whle perserving blood flow to the coronary and cerebral circulations </li></ul><ul><li>In some cases 40 U can replace adrenaline ( Epinephrine) </li></ul>ALS
  108. 111. ③ Lidocaine <ul><li>Actions: Lidocaine is a class IB agent that depresses myocardial excitability by blocking sodium channels without extending action potential duration. </li></ul><ul><li>Indication : The drug is indicated in Ventricular ectopy, ventricular tachycardia and ventricular fibrillation that has recurred after a successful defibrillation or that has been refractory to defibrillation. Prophylactic lidocaine therapeutic dose is deemphasized. </li></ul><ul><li>Dose : The recommened dose is 1.5mg/kg bolus repeated in 5~10 min for total dose of 3mg/kg . </li></ul>Part Ⅱ ALS
  109. 112. ④ Amiodarone <ul><li>Actions: Amiodarone is classIII agent that has some classI activity weak non-competitive β-blocking effects.It lowers the defibrillation threshold and has potent antifibrillatory effect.its broad spectrum of antidysrhythmic effects make it a potentially useful agent. </li></ul><ul><li>Indication and dose: can be considered if multiple electrial shocks and epinephrine have failed to revert VF/VT.The initial dose is 5mg/kg given as a slow intravenous infusion over 5-15min.This may be repeated if indicated </li></ul>
  110. 113. ⑤ Atropine <ul><li>Actions: Atropine antagonizes parasympathetic nervous effects on the heart by blocking cholinergic receptors,leading to increased sinoatrial and atrioventricular automaticity and rate on conduction. </li></ul><ul><li>Indication and dose: It is retained as pharmacotherapy for symptomatic bradycardia. It is given in dosages of 0.5~1.0mg every 3~5min, The total dose of atropine is 0.04mg/kg(3mg) </li></ul>Part Ⅱ ALS
  111. 114. <ul><li>Class I recommendation (definitely helpful) : symptomatic sinus bradycardia </li></ul><ul><li>Class II recommendation (acceptable, or possibly helpful) : atrioventricular block ( AVB ) at the nodal level, or in asystole. </li></ul><ul><li>Class III recommendation (not indicated, maybe harmful) : In Mobitz AVB or CHB. </li></ul>⑤ Atropine
  112. 115. Actions: Magnesiun is an essential electrolyte that may be depleted by duretics,severe diarrhoae and alcohol abuse.Hypomagnesaemia may cause cardiac dysrhythmias . Indication : Magnesium may be considered in refractory VF/VT,particularly hypokalaemia is present,and is an agent of choice in torsaded de pointes. Dose: The initial dose is 5mmol given over1 minute, which may be repeated if indicated and followed by an infusion of 20 mmol over 4 hours . ⑤ Magnesium Sulfate
  113. 116. ⑥ Sodium bicarbonate <ul><li>Acidosis is often present in victims of cardiaorespiratory arrest,particulary if the arrest condition has persisted for more a few minurtes. </li></ul>Part Ⅱ ALS
  114. 117. <ul><li>There two components contributing to the acid load. </li></ul><ul><li>Respiratory acidosis :result from failure carbon dioxide eliminition, carbon dioxide(CO 2 ) production continues , but it can not be remove because pulmonary and heart failure during CPR, the PaCO 2 rise. </li></ul><ul><li>Metabolic acidosis: develops prolonged tissue hypoperfusion and conversion to anaerobic forms of metabolism. </li></ul>⑥ Sodium bicarbonate
  115. 118. ⑥ Sodium bicarbonate <ul><li>Actions: Sodium bicarbonate (NaHCO 3 )is an alkalinizing agent,that theoretically reverse the metabolic acidosis associated with profound ischemia.However,provided CPR is effective, acidosis does not develop rapidly or severely in otherwise healthy individuals during during cardiac arrest. </li></ul><ul><li>Indication and dose:It is unneccessary in brief resuscitation when the patient have been previously well.It can be considered if cardiac arrest exceeds 10-15mintures duration.It should be considered when cardiac arrest occurs in a patient with a prexisting profound acidosis or in special conditions,such as hyperkalaemia and tricyclie antidepressant overdose . </li></ul>Part Ⅱ ALS
  116. 119. <ul><li>Note: If alveolar ventilation is not adquate,the CO 2 released from the NaHCO 3, ,and correction of the acidosis will not be attained, and may result inincreased central venous and tissue PaCO 2 level .Tissue acidosis may worsen following NaHCO 3, administration. </li></ul>
  117. 120. Sodium bicarbonate <ul><li>* Sodium bicarbonate administration is not indicated for hypoxic lactic acidosis. </li></ul><ul><li>The initial dose should be 1mmol/kg </li></ul>Part Ⅱ ALS ④
  118. 121. The contents <ul><li>一、 Gerneral consideration </li></ul><ul><li>二、 CPR Steps </li></ul><ul><li>三、 Complication of CPR </li></ul><ul><li>四、 Monitoring during CPR </li></ul><ul><li>五、 Terminating Resuscitation </li></ul>
  119. 122. Part III <ul><li>The complication of CPR </li></ul>
  120. 123. <ul><li>The complication of CPR </li></ul><ul><li>The complication of CPR are legion,but unavoidable complications are acceptable compared with an otherwise certain death . </li></ul>Part Ⅲ
  121. 124. <ul><li>fractures of ribs, sternum or spine; </li></ul><ul><li>laceration of lungs or liver or other abdominal organs; </li></ul><ul><li>pulmonary or cerebral fat embolism; </li></ul><ul><li>laceration or rupture of heart; </li></ul><ul><li>herniation of the heart through the pericardium; </li></ul><ul><li>cardiac tamponade; </li></ul><ul><li>hemothorax or pneumothorax . </li></ul>The complication of CPR Part Ⅲ ● Complication of ECC : These complications can be minimized by careful attention to the details of ECC .
  122. 125. The complication of CPR <ul><li>● Complication of artificial ventilation: </li></ul>Part Ⅲ Gastric distention and regurgitation and aspiration are common without endotracheal.
  123. 126. <ul><li>These complications are more likely to occur when ventilation pressure exceeded the opening pressure of the lower esophageal sphincter .In mouth-to-mouthe ventilation,1.5~2.0seconds shouled be allowed for air delivery to the lungss to prevent airway pressure from exceeding 20~25cmH 2 O.Breathing rapidly without allowing full exhalation should be avoided for same reason. </li></ul>
  124. 127. ● Complication of defibrillaton Skin burns (common) Skeletal muscle injury or thoracic vertebral fractures (uncommon) Myocadial injury and post-defibrillation dysrhythmias (high-energy shocks) The rescuer can receve electrical injures(due to electrical contact with the patients during defbrillation The complication of CPR
  125. 128. The complication of CPR <ul><li>pulmonary edema </li></ul><ul><li>gastrointestinal hemorrhage </li></ul><ul><li>pneumonia </li></ul><ul><li>recurrent cardiopulmonary arrest. </li></ul><ul><li>Anoxic brain injury can occur in a resuscitated victim who suffered prolonged hypoxia .It is the most common cause of death in resuscitated patients </li></ul>● Late complication:
  126. 129. The contents <ul><li>一、 Gerneral consideration </li></ul><ul><li>二、 CPR Steps </li></ul><ul><li>三、 Complication of CPR </li></ul><ul><li>四、 Monitoring during CPR </li></ul><ul><li>五、 Terminating Resuscitation </li></ul>
  127. 130. Part Ⅳ Monitoring during CPR
  128. 131. Monitoring during CPR <ul><li>ECG monitoring is essential during resuscitation, both as a diagnostic tool and as a guide to the most effective therapy.Initially,the “quick look” paddles should be used.if available,the standard ECG machine or monitoring unit with a display screen should be attached as soon as possible. </li></ul><ul><li>Blood pressue Intra- arterial pressure monitoring provides an accurate and continuous measure of SBP 、 DBP and MAP.Continous intra-arterial monitoring during CPR allows for rational titration of vasoconstrictor therapy and accurate assessment of the hemodynamic effectiveness of spontaneous rhythms 。 </li></ul>Part Ⅳ
  129. 132. Monitoring during ALS <ul><li>Endotracheal CO 2 monitoring provide a noninvasive measure of pulmonary perfusion (CO).Which also has been shown to correlate with coronary perfusion pressure.Patients who have undergoing 10~15 min of ECC with accompanying ALS ,and have an endotracheal CO2 above 10-15mmHg are unlikely to survive. </li></ul><ul><li>Laboratory investigation will guide ongoing therapy.The most useful initial measurements include arterial blood gas,the hematocrit,serum glucose, sodium, potassium, calcium.if abnormalities are noted,they may be treated, and the succes of such treatment maybe monitored by repeated measurement. </li></ul>Part Ⅳ
  130. 133. <ul><li>一、 Gerneral consideration </li></ul><ul><li>二、 CPR Steps </li></ul><ul><li>三、 Complication of CPR </li></ul><ul><li>四、 Monitoring during CPR </li></ul><ul><li>五、 Terminating Resuscitation </li></ul>The contents
  131. 134. <ul><li>Part Ⅴ </li></ul><ul><li>Terminating Resuscitation </li></ul>
  132. 135. <ul><li>When Can I Stop CPR? </li></ul><ul><li>Victim revives </li></ul><ul><li>Trained help arrives </li></ul><ul><li>The rescuer Too exhausted to continue </li></ul><ul><li>Unsafe scene </li></ul><ul><li>Physician directed (do not resuscitate orders) </li></ul><ul><li>Cardiac arrest of longer than 30 minutes </li></ul><ul><ul><li>(controversial) </li></ul></ul>Part Ⅴ
  133. 136. <ul><li>Recovery from cardiac arrest depends on time to CPR and rhythm-specific intervention. Resuscitation and long-term outcome in normothermic patients with arrest times of 20 min or more are very poor. </li></ul><ul><li>The decision to terminate unsusccesful resuscitative efforts is always a difficute one,particulary if the patient is a child or a young adult. </li></ul>