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This is an attempt to clarify and stress the science behind the newer guidelines,while covering all the algorithms simultaneously

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  2. 2. CHAIN OF SURVIVAL<br />
  3. 3. Oh God!<br />For every minute without CPR, survival from witnessed VF SCA decreases 7% to 10%.CPR double or triple survival from witnessed SCA <br />
  4. 4. Saving our beloved ones…<br />CPR provides a small but critical amount of blood flow to the heart and brain.<br />
  5. 5.
  6. 6. BASIC LIFE SUPPORT<br />
  7. 7. Check for response<br />To check for response, tap the victim on the shoulder and ask, “Are you all right?”.<br />
  8. 8. Activate the EMS<br />If a lone rescuer finds an unresponsive adult (ie, no movement or response to stimulation), the rescuer should activate the EMS system, get an AED (if available), and return to the victim to provide CPR and defibrillation if needed.<br />
  9. 9. Open the Airway and Check Breathing<br />head tilt– chin lift maneuver<br />suspects a cervical spine injury  open the airway using a jaw thrust without head extension  fails  use a head tilt–chin lift maneuver if the jaw thrust does not open the airway<br />
  10. 10. Check Breathing<br />look, listen, and feel for breathing.<br />Occasional gasps are not effective breaths.<br />
  11. 11. Give rescue breaths<br />If you do not detect adequate breathing within 10 seconds Give 2 rescue breaths, each over 1 second, with enough volume to produce visible chest rise.<br />
  12. 12. Pulse check<br /><ul><li>should take no more than 10 seconds to check for a pulse</li></li></ul><li>Rescue Breathing Without Chest Compressions<br />If an adult victim with spontaneous circulation (ie, palpable pulses) requires support of ventilation, give rescue breaths at a rate of 10 to 12 breaths per minute, or about 1 breath every 5 to 6 seconds<br />
  13. 13. CPR<br />In victims of VF SCA, chest compressions increase the likelihood that a shock (ie, attempted defibrillation) will be successful. Chest compressions are especially important if the first shock is delivered 4 minutes after collapse<br />Give CPR ( about 5 cycles or about 2 minutes) A compression-ventilation ratio of 30:2 is recommended<br />In infants and children,2 rescuers should use a ratio of 15:2<br />
  14. 14. CPR<br />One cycle of CPR consists of 30 compressions and 2 breaths. When compressions are delivered at a rate of about 100 per minute, 5 cycles of CPR should take roughly 2 minutes (range: about 11⁄2 to 3 minutes)<br />
  15. 15. Later…..<br />When an advanced airway is in place [ETT/LMA/COMBITUBE]<br />the compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. <br />The rescuer delivering ventilation provides 8 to10 breaths per minute. <br />
  16. 16. PUSH HARD AND FAST<br />FAST100 compressions per minute, <br />HARD with a compression depth of 11⁄2 to 2 inches (approximately 4 to 5 cm). <br />Allow the chest to recoil completely after each compression, and <br />allow approximately equal compression and relaxation times<br />Minimize interruptions[Ideally, compression should be interrupted only for ventilation (until an advanced airway is placed), rhythm check, or shock delivery].<br />
  17. 17. Technique<br />rescuer kneeling beside the victim’s thorax.<br />The rescuer should place the heel of the hand on the in the lower half of the victim’s sternum in the center (middle) of the chest between the nipples and then place the heel of the second hand on top of the first so that the hands are overlapped and parallel<br />
  18. 18. Breath Vs Compression<br />During the first minutes of VF SCA  diminished cardiac output more significant than a lack of oxygen in the blood.<br />Both ventilations and compressions are important for victims of prolonged VF SCA<br />During CPR blood flow to the lungs is substantially reduced low Tv & RR will suffice (6-7ml/kg or 500 to 600 mL)<br />Avoid delivering breaths that are too large or too forceful (gastric distension)<br />
  19. 19. Breath Vs Compression<br />Rate &gt;12 breaths per minute during CPR<br />leads to increased intrathoracic pressure, impeding venous return to the heart during chest compressions  diminished cardiac output decreased coronary and cerebral perfusion.<br />
  20. 20. oxygen<br />O2 &gt;40%, a minimum flow rate of 10 to 12 L/min when available. Ideally the bag should be attached to an oxygen reservoir to enable delivery of 100%oxygen.<br />LMA and the esophageal-tracheal combitube are currently within the scope of BLS practice<br />
  21. 21. Keep your reserves…..<br />The 2 rescuers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions<br />
  22. 22. Also note…<br />Lay rescuers should continue CPR until an AED arrives/the victim begins to move/EMS personnel take over CPR<br />patients not be moved while CPR is in progress unless the patient is in a dangerous environment or is a trauma patient in need of surgical intervention.<br />
  23. 23. Defibrillation <br />Early defibrillation is critical to survival from sudden cardiac arrest (SCA) for several reasons: <br />(1) the most frequent initial rhythm in witnessed SCA is ventricular fibrillation <br />(2)the treatment for VF is electrical defibrillation, <br />(3) the probability of successful defibrillation diminishes rapidly over time<br />(4) VF tends to deteriorate to asystolewithin a few minutes<br />
  24. 24. What it does to heart…?<br />defibrillation “stuns” the heart, briefly stopping VF and other cardiac electrical activity <br />
  25. 25. 1 shock followed by immediate CPR<br />Biphasic  high first dose efficacy<br />1st fails=VF of low amplitude incremental benefit less for repeated shocks<br />Termination of VF non perfusing rhythms Rx is CPR ; not another shock!<br />Next step is not a rhythm check; but CPR x 5<br />The goal is to minimize the time between chest compressions and shock delivery and between shock delivery and resumption of chest compressions(&lt;15 sec)<br />
  26. 26. Energy selection<br />Biphasic truncated exponential waveform150-200J<br />Biphasic rectilinear120J<br />Monophasic  360J<br />Child (initial)2J/Kg<br />Child (subsequent)4J/Kg<br />
  27. 27. Also note..<br />If a provider is operating a manual biphasic defibrillator and is unaware of the effective dose range for that device to terminate VF, the rescuer may use a selected dose of 200 J for the first shock and an equal or higher dose for the second and subsequent shocks<br />If VF is initially terminated by a shock but then recurs later in the arrest, deliver subsequent shocks at the previously successful energy level.<br />
  28. 28. Defibrillation<br />There is no evidence that attempting to “defibrillate” asystoleis beneficial.<br />It is difficult to justify any interruption in chest compressions to attempt shock delivery for asystole.<br />
  29. 29. Don’t give up!<br />In the first few minutes after successful defibrillation, asystoleor bradycardia may be present and the heart may pump ineffectively.<br />Therefore, CPR may be needed for several minutes following defibrillation until adequate perfusion is present.<br />
  30. 30. WHICH FIRST?<br />There is insufficient evidence to support or refute CPR before defibrillation for in-hospital cardiac arrest<br />Out of hospital witnessed SCA AED first<br />Out-of-hospital cardiac arrest is not witnessed  give about 5 cycles of CPR before checking the ECG rhythm and attempting defibrillation<br />
  31. 31. Whats AED?<br />Lay rescuers can be trained to use a computerized device called an AED to analyze the victim’s rhythm and deliver a shock if the victim has VF or rapid VT.<br />The AED uses audio and visual prompts to guide the rescuer.<br />extremely accurate<br />cprYouTube - High-quality CPR and AED.flv<br />
  32. 32. Заголовок слайда<br />
  33. 33. CARDIAC ARREST-BLS-ACLS<br />Four rhythms produce pulseless cardiac arrest:<br /> ventricular fibrillation (VF), <br />rapid ventricular tachycardia (VT),<br />pulselesselectrical activity (PEA), and <br />asystole. <br />Survival from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS).<br />
  34. 34. ACLS<br />intravenous(IV) access <br />drug therapy, and <br />inserting an<br />advanced airway<br />recall the H’s and T’s to identify the cause<br />.<br />
  35. 35. ACCESS to circulation<br />peripheral venous routebolusinjection andfollowwith a 20-mL bolus of IV fluid. <br />Intraosseous (IO) cannulation provides access to a noncollapsiblevenous plexus<br />spontaneous circulation does not returncentral line<br />Endotracheal route2 - 2 ½ times iv dose dilute the recommended dose in 5 to 10 mL of water or normal saline<br />
  36. 36. .<br />
  37. 37. VF/VTDRUGS<br />If VF/VT persists after delivery of 1 or 2 shocks plus CPR, give a vasopressor (epinephrine every 3 to 5 minutes during cardiac arrest; one dose of vasopressinmay replace either the first or second dose of epinephrine<br />When VF/pulseless VT persists after 2 to 3 shocks plus CPR and administration of a vasopressor, consider administering an antiarrhythmic such as amiodarone[ if unavailablelignocaine]<br />magnesium for torsades de pointes associated with a long QT interval<br />
  38. 38. Drugs when?<br />Drug doses should be prepared before the rhythm check so they can be administered as soon as possible after the rhythm check,<br />Do not interrupt CPR to give medications<br />The drug should be administered during CPR and as soon as possible after the rhythm is checked<br /> If a drug is administered immediately after the rhythm check (before or after the shock) it will be circulated by the CPR given before and after the shock.<br />
  39. 39. Tips…<br />perfusing rhythm is transiently restored but not<br /> successfully maintained early treatment with antiarrhythmics<br />shorter the time between chest compression and shock delivery, the more likely the shock will be successful<br />
  40. 40. PEA and ASYSTOLE<br />PEA:pseudo-electromechanical dissociation(pseudo-EMD), idioventricular rhythms, ventricular escape rhythms, postdefibrillationidioventricular rhythms, and bradyasystolic rhythms.<br />Too weak contractions to produce a BP detectable with NIBP<br />often caused by reversible conditions<br />The survival rate from cardiac arrest with asystoleis dismal.<br />similarity in causes and management<br />
  41. 41. BRADYCARDIA<br />
  42. 42. .<br />
  43. 43. BRADYCARDIA<br />ATROPINE :dose for bradycardia is 0.5 mg IV every 3 to 5 minutes to a maximum total dose of 3 mg.<br />Doses of atropine of 0.5 mg may paradoxically result in further slowing of the heart rate.<br />EPINEPHRINE :Begin the infusion at 2 to 10 g/min and titrate to patient response<br />DOPAMINE :2 to 10 g/kg per minute)<br />
  44. 44. TACHYCARDIAS<br />.<br />
  45. 45. NARROW QRS TACHYCARDIA<br />(QRS &lt;0.12)<br />— Sinus tachycardia<br />— Atrialfibrillation&lt;irregular&gt;<br />— Atrialflutter&lt;irregular&gt;<br />— AV nodal reentry<br />— Accessory pathway–mediated tachycardia<br />— Atrial tachycardia (ectopic and reentrant)<br />— Multifocal atrial tachycardia (MAT)<br />— Junctional tachycardia<br />
  46. 46. WIDE QRS TACHYCARDIA<br />(QRS &gt;0.12 second)<br />— Ventricular tachycardia (VT)<br />— SVT with aberrancy<br />— Pre-excited tachycardias<br />
  47. 47. .<br />
  48. 48. Approach….<br />Rate-related cardiovascular compromise[altered mental status, ongoing chest pain, hypotension], provide immediate synchronized cardioversion<br />stable 12-lead ECG and evaluate the rhythm determine treatment options/may await expert consultation [because treatment has the potential for harm].<br />
  49. 49. Synchronized Cardioversion<br />synchronized with the QRS complex  avoids shock delivery during the relative refractory period of the cardiac cycle<br />Low-energyshocks should always be delivered as synchronized shocks because delivery of low energy unsynchronized shocks is likely to induce VF.<br />If cardioversionneeded,but cant synchronize give high energy unsynchronized shock<br />
  50. 50. CARDIOVERSION- indications<br />(1)unstable SVT due to reentry, <br />(2) unstable atrial fibrillation,<br />(3) unstable atrial flutter.<br />(4) unstable monomorphic VT<br />administer sedation if the patient is conscious<br />Don’t delay it…..<br />
  51. 51. Cardioversion- <br />100 J to 200 J with a monophasicwaveform<br />100 J to 120 J is with a biphasic waveform.<br />Atrial flutter50-100J with monophasic<br />Monomorphic VT100 ---&gt;360J<br />NB:- Cardioversion to junctional /multifocal atrialtachycardiaincrease rate<br />
  52. 52. PALS<br />
  53. 53. PALS<br />
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  59. 59. THANK YOU<br /> HAPPY ONAM<br />