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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 t...
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...
The Cardiac Arrest Rhythms
The four cardiac arrest rhythms are
 Asystole
 PEA ( Pulseless Electrical Activity )
 Pulsel...
D. Differential Diagnosis
Review the most frequent causes
( the 6 H’s and 6 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Ta...
Cardio Pulmonary Cerebral Resuscitation
 BLS : Basic life support
 ACLS : Advance cardiac life support
 Better chance o...
How to do It- Chain of Survival
Early Recognition
(Sudden Cardiac Arrest))
Early Activation
(Emergency Medical Service)
Ea...
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...
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 minut...
• Rescuer fatigue may lead to inadequate
compression rates or depth.
• When 2 or more rescuers are available it is
reasona...
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 usuall...
 As long as the patient does not have an
advanced airway in place, the rescuers
should deliver cycles of 30 compressions ...
Ventilation With an Advanced Airway
 When an advanced airway (ie, endotracheal
tube, Combitube, or laryngeal mask airway
...
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...
International Guidelines for CPR
2010 vs 2005

Team work

No look, listen, feel

ABC -CAB sequence Beginning with 30
co...

<10 sec. for intubation

Waveform capnography (Etco2 >10 mmhg)

Intra-arterial diastolic pressure >20 mmhg

Atropine ...
THANK YOU
Biphasic vs Monophasic Defibrillation
 Advantages
- greater efficacy
- low energy produces same effect
- less myocardial ...
ADVANCED
LIFE SUPPORT
A - Airway
 Definitive airway should be secured as soon as possible
 Tracheal intubation using cricoid pressure (by trai...
B. Breathing - Confirm device placement
 Primary Confirmation
 Direct Visualisation of ETT passing through cords
 Chest...
B. Breathing –
Confirm effective oxygenation and ventilation
 No synchrony between ventilation and chest
compressions onc...
C. Circulation
 Identify the rhythm
 Defibrillation /Pacing
 Secure IV line-large easily accessible peripheral veins
 ...
Recognition of Rhythm
Cardiac Arrest (lethal rhythms)
Shockable-VF,Pulseless VT
Non Shockable – Asystole.PEA
Non Cardiac...
Defibrillation
 For shockable rhythms – VF / Pulseless VT
 Monophasic or Biphasic defibrillators (Biphasic preferred)
Mo...
Pacing
 Disappointing results for asystole, PEA
 No benefit in post shock asystole
 May be indicated for cardiac arrest...
C-Circulation
IV Access
 Wide bore peripheral upper limb vein
 Push each bolus with 20cc fluid
 Raise extremity
 Urgen...
C-Circulation
Other Drug Delivery Routes
 Tracheal
- 2-3 times IV dose
- Dilute in 10 ml saline
- Preferably inject down ...
C - Circulation
Rhythm appropriate medications
Epinephrine
 Indicated in all cardiac arrest rhythms
i.e. VF, Pulse less V...
Vasopressin
 Antidiuretic hormone and a powerful vasoconstrictor
when used in the higher doses.
 Positive effects of epi...
Atropine
 First drug of choice in symptomatic bradycardia (class I )
 Second drug after epinephrine for asystole and
bra...
Amiodarone
 Persistent or recurrent VF or VT ( class II b )
 Dose is 300 mg IV push (150 mg may be repeated after
3-5 mi...
Sodium Bicarbonate
Specific indications are as follows
 class I if known pre-existing hyperkalemia
 class II a if known ...
Calcium
Detrimental effect on ischaemic myocardium
Impairs cerebral recovery
NOT TO BE USED ROUTINELY
Indicated in PEA due...
Magnesium sulphate
 Shock refractory ventricular fibrillation in
pr of possible hypomagnesemia
 Torsades de pointes
 VT...
D. Differential Diagnosis
Review the most frequent causes
( the 5 H’s and 5 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Ta...
ACLS - Secondary ABCD
Survey
A Airway : place airway device as soon as possible
B Breathing : confirm airway device placem...
Monitoring the Victim -
To assess effectiveness of rescue efforts
 Monitor for signs of circulation and breathing
 Check...
Termination of cpr ALS
THANK YOU
Cpcr dr raj care ngp
Cpcr dr raj care ngp
Cpcr dr raj care ngp
Cpcr dr raj care ngp
Cpcr dr raj care ngp
Cpcr dr raj care ngp
Cpcr dr raj care ngp
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Cpcr dr raj care ngp

  1. 1. Cardiopulmonary Resuscitation Dr. Rajkumarr Anesthesiologist Care Hospital Nagpur
  2. 2. “No initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act” 2
  3. 3. Bad News Time Flies Good News You are the Pilot You take care of the Seconds We take care of the Minutes 3
  4. 4. 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 )
  5. 5. The Cardiac Arrest Rhythms The four cardiac arrest rhythms are  Asystole  PEA ( Pulseless Electrical Activity )  Pulseless Ventricular Tachcardia (VT)  Ventricular Fibrillation (VF)
  6. 6. 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
  7. 7. 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….?
  8. 8. 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
  9. 9. Chain Of Survival – 4 links Early Activation of EMS Early CPR Early Defibrillation Early Advanced Care BLS
  10. 10. International Guidelines for CPR 2005…..????
  11. 11. Chain of survival 2005 2010
  12. 12. International Guidelines for BLS 2010
  13. 13. 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
  14. 14. WORKSHOP Ready for hands on……?
  15. 15. 1. Check Responsiveness
  16. 16. 2. Call for help with AED defibrillator
  17. 17. 3. Check for Pulse (carotid pulse )
  18. 18. 4.Start Chest Compressions Site for chest compressions
  19. 19. Place hand 2 finger spaces above the xiphoid process
  20. 20. Place other hand over hand on sternum
  21. 21. Hand Position for Chest Compression
  22. 22. “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
  23. 23. • 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.
  24. 24. 5. Open the Airway Head Tilt –Chin Lift Maneuver
  25. 25. Open The Airway Jaw Thrust Maneuver
  26. 26. 6. Check for Breathing
  27. 27. 7. Ventilation over 1 sec. (The Chest Must Rise)  Mouth to mouth breathing  Bag and mask ventilations
  28. 28. Bag and mask ventilations
  29. 29. 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)
  30. 30.  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.
  31. 31. 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).
  32. 32. Attach defibrillator(AED) as soon as available and shock if indicated
  33. 33. 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.)
  34. 34. 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.
  35. 35.  <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.
  36. 36. THANK YOU
  37. 37. 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%)
  38. 38. ADVANCED LIFE SUPPORT
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. C. Circulation  Identify the rhythm  Defibrillation /Pacing  Secure IV line-large easily accessible peripheral veins  Give rhythm appropriate medication
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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 .
  51. 51. 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.
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Termination of cpr ALS
  59. 59. THANK YOU

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