Cardio pulmonary-resusictation


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Cardio pulmonary-resusictation

  2. 2. 2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care 2005 International Consensus Conference on CardioPulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommandations and ILCOR (International Liaison Committee on Resuscitation) 2005 CPR Consensus. These recommendations replace or complete the 2000 CPR guidelines. published in Circulation - December 2005
  3. 3. Grading of evidence Grade 1 Randomized clinical studies or metaanalysises with significant therapeutic effects Grade 2 Clinical studies with less significant therapeutic effects Grade 3 Prospective controlled nonrandomized studies or case series Grade 4 Retrospective nonrandomized studies Grade 5 Uncontrolled case series Grade 6 Experimental animal or mechanical studies Grade 7 Theoretical analysis Grade 8 Rationale and common practice without evidence base
  4. 4. Hierarchy of recommendations depends upon risk/benefice ratio. Class I IIa Risk/benefice ratio. benefice>>>risk benefice>> risk IIb benefice >/= risk III risk >/= benefice
  5. 5. CARDIO-PULMONARY RESUSCITATION DEFINITIONS ‡ ‡ ‡ ‡ ‡ ‡ Respiratory arrest = the absence of breathing movements. Cardiac arrest = the clinical picture of overall cessation of circulation. Clinical death = coma, apnea and pulselessness in large arteries with cerebral failure still potentially reversible. Biological death = the irreversible absence of body functions due to irreversible structural cell damage. Cerebral death = the irreversible absence of brain and brainstem functions with temporary presence of respiration and circulation. Persistent vegetative state = absence of motility and reaction to external stimuli due to persistent absence of cerebral activity with preservation of vegetative functions (respiration, circulation, swallowing).
  6. 6. CARDIO-PULMONARY ARREST Physiopathology respiratory arrest ? / cardiac arrest ? ‡ There are semnificative differences, related to age, in the incidence of primary respiratory arrest (more frequent in newborns and children) and primary cardiac arrest (more frequent in adults and old persons) ‡ There are semnificative differences of BLS in primary respiratory arrest and primary cardiac arrest. understanding physiopathology of cardio-pulmonary arrest correct CPR efficient CPR maneuvers
  7. 7. RESPIRATORY ARREST ‡ Pathophysiology ± Heart and lungs continue the tissue delivery of oxygenated blood until exhaution of alveolar O2 reserves; pulse is present, altered consciousness; ± Delay to cardio-circulatory arrest: variable (seconds-minutes); it depends on: ‡ Oxygen reserve in the moment of respiratory arrest (PAO2 şi PaO2) ‡ Miocardial capacity to sustain hypoxemia ± Uncorrected respiratory arrest results in cardiac arrest; ‡ Causes ± Drowning,, foreign body aspiration, toxic inhalation, epiglotitis, strangulation, etc. ± Coma of any origin, stroke, etc. ± Electrocution, trauma, etc. ‡ Clinical signs ± ± ± ± Absence of breathing movements Progressive cyanosis Alterations of consciousness Muscle hypotony ‡ Treatment ± Artificial ventilation in order to oxygenate the blood and to prevent secondary cardiac arrest
  8. 8. CARDIAC ARREST ‡ Pathophysiology ± ± ± ± ‡ Causes ± ± ± ± ± ‡ Loss of conscience (10 seconds; izoelectric EEg in 15-30 seconds); Agonic respirations or apneea (10-15 seconds) Pulseless Midriasis (30-60 secunde) General aspect of ³death´ ECG signs ± ± ± ± ‡ Myocardial infarction Rhythm disturbances (myocardial infarction, myocardial ischemia electrolyte disturbances,etc.) Hypovolemia (exsanguination, politrauma) Pulmonary embolism Cardiac tamponade Clinical signs ± ± ± ± ± ‡ Cardiac arrest results in circulatory arrest with the immediate cessation of tissue O2 delivery; Cessation of brain O2 delivery: ‡ Depletion of O2 reserves in 10 seconds ‡ Depletion of phosphocreatine reserves in 2 minutes ‡ Depletion of glucose and ATP reserves in 5 minutes For a short time delay (always seconds): agonal respiration (Gasping) (unefficient respiratory efforts with recruitment of accessory respiratory muscles); Always cardiac arrest result in respiratory arrest; Ventricular fibrillation Pulseless ventricular tachycardia pulseless electrical activitity Asystole Treatment ± Artificial support of ventilation and circulation
  9. 9. CARDIO-PULMONARY RESUSCITATION INDICATIONS of CPR: ‡ Respiratory arrest ‡ Cardiac arrest ‡ Cardio-respiratory arrest Primary/secondary - respiratory/cardiac arrest
  10. 10. CARDIO-PULMONARY RESUSCITATION DEFINITION = system of standard maneuvers, drugs and techniques indicated in case of cardio-respiratory arrest in order to artificially deliver the oxygenated blood to systemic circulatory beds at rates that are sufficient to preserve the vital organ function and at the same time providing the physiologic substrate for the return of spontaneous circulation.
  11. 11. CARDIO-PULMONARY RESUSCITATION FACTORS WHICH INFLUENCE THE RESULT OF RESUSCITATION: Patient related factors: ‡ The cause of cardio-respiratory arrest ‡ The functional status in the moment of cardio-respiratory arrest ‡ Co-existing diseases Resuscitator related factors: ‡ Precocity of CPR ‡ Correctness of CPR
  12. 12. CARDIO-PULMONARY RESUSCITATION CHAIN OF SURVIVAL Early access Early BLS BLS in <4 min Early defibrillation Early ALS ALS in <8 min
  13. 13. ‡ The most important determinant of survival from sudden cardiac arrest is the presence of a trained rescuer who is ready, willing, able, and equipped to act.´ (2005 AHA Guidelines for CPR and ECC, Circulation, 2005) ‡ ÄIn the 1990s some predicted that cardio-pulmonary resuscitation (CPR) could be rendered obsolete by the widespread development of community automated external defibrillator (AED) programs. Cobb noted, however, as more Seatle first responders were equipped with AEDs, survival rates from sudden cardiac arrest fell. He atributted this decline to reduces emphasis on CPR....´ (2005 AHA Guidelines for CPR and ECC, Circulation, 2005)
  14. 14. What means a successful cardio-pulmonary resuscitation? Signs of successful CPR: ± ± ± ± return of spontaneous circulation hospital admission neurologic improvement hospital discharge
  15. 15. CARDIO-PULMONARY RESUSCITATION Phases of CPR: ‡ Basic life support ± First phase of CPR; ± Goals: ‡ ‡ ‡ ‡ Artificial delivery of oxygenated blood to systemic circulatory beds; Prevention of irreversible brain damage; Preservation of chances for successful resuscitation; Return of spontaneous circulation; ± Provided without medical equipment (³with bare hands´); ‡ Advanced life support ± The second/first phase of CPR; ± Goals: ‡ ‡ ‡ ‡ Preservation of vital organ function; Return of spontaneous circulation; Postresuscitation stabilization; Cerebral protection; ± Provided using equipment, drugs and medical devices.
  16. 16. CARDIO-PULMONARY RESUSCITATION THE ARMAMENTARIUM of CPR ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ A (airway) ± airway maneuvers B (breathing) ± evaluation and support of ventilation C (circulation) ± evaluation and support of circulation D (drugs)- IV access and medication E (electrocardiography)- evaluation of electrical form of cardiac arrest F (fibrillation treatment) - defibrillation G (gauging) ± postresuscitation evaluation H (human mentation) ± cerebral protection I (intensive care) ± postresuscitation intensive care THIS IS NOT THE PROPER ORDER TO APPLY
  17. 17. Primary steps of basic life support ± ± ± ± ± ± ± ± ± ± ± Securing the inviroment Evaluation of consciousness Activation of emergency medical system (call 112) Victim positioning Airway maneuvers Assessment of spontaneous breathing (10 seconds) Artificial ventilation (2 ventilation) Assessment of circulation (10 seconds) Chest compresion (100/minute) CPR sequence: 30 chest compressions /2 artificial breath Automatic external Defibrillation
  18. 18. CARDIO-PULMONARY RESUSCITATION BLS ALGORHYTHM 1. 2. 3. 4. 5. 6. 7. 8. 9. Evaluation of consciousness Activation of emergency medical system Victim positioning Airway maneuvers Assessment of spontaneous breathing Artificial ventilation Artificial ventilation Assessment of circulation Chest compresion CPR sequence: 15 chest compressions /2 artificial breath (no matter the number of rescuers)
  19. 19. CPR recomendations 2006 ± 2 esential aspects for the success of CPR: ‡ Avoid hiperventilation ± ± ± ± ± for a pulmonary gas exchange (pulmonary blood flow decreased) encrease the intrathoracic pressure decrease the cardiac upload decrease the efficience of chest compresions stomach insuflation (encrease the risk of regurgitation/aspiration, push up the diaphragm and encrease the intrathoracic pressure) ‡ Avoid interupting the chest compresions ± CPR performed by trainned medical team ± total time of interupting chest compresions 24-49% of the cardiac arrest duration. ± Any interuption in chest compresions means the decrease of coronary perfusion pressure, which slowly rises when the chest compresions are delivered once again, and so the chances of returning to spontaneous circulation are decreased. ± In the first minutes of cardiac arrest (VF) the artificial ventilation is not so important as the chest compresions because the hipoxy is primary caused by the lack of tissulary perfussion, and there are sufficiently blood O2 rezerves in the first minutes. That is why the rescue person should concentrate in delivering efficient chest compresions. The new recommendations regarding the sequence chest compresions/ventilation 30:2 are made to minimalise the time of chest compresion interuptions.
  20. 20. The age ‡ newborn ± immediately after birth and until hospital discharge. ‡ infant ± untill the age of 1 year. ‡ child ± from 1 year until puberty (12-14 years). ‡ adult ± from puberty along
  21. 21. CARDIO-PULMONARY RESUSCITATION A AIRWAY MANEUVERS: ± ± ± ± ± Should be applyied in case of any unconscious victim; Should preceed assessment of spontaneous breathing; Should be maintained during assessment of spontaneous breathing; Should preceed artificial ventilation; Should be maintained during artificial ventilation;
  22. 22. A AIRWAY MANEUVERS: DURING BASIC LIFE SUPPORT: ± ± ± ± ± ± ± Safety position Head tilt Chin lift Head tilt and chin lift Subluxaţia anterioară a mandibulei Subluxaţia anterioară a mandibulei şi deschiderea gurii Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii (tripla manevră Safar); ± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a capului şi deget înfăşurat în pânză) DURING ADVANCED LIFE SUPPORT: ± Airway devices ± Tracheal intubation
  23. 23. A AIRWAY MANEUVERS: in pacient with posible cervical spine injury When to suspect cervical spine injury? ‡ Know the mechanism of injury ± Strangulation ± Cădere de la înălţime ± Deceleration or acceleration s.o. ‡ Traumaticsigns ± ± ± ± At the cephalic extremity In the cervical region In the region of thorax (the superior 1/3) So, superior to the intermamelonary line Mentain the had in neutral position
  24. 24. A AIRWAY MANEUVERS: in pacient with posible cervical spine injury BASIC LIFE SUPORT: ± Safety position ± Hiperextension of the had ± Chin lift ± Head tilt and chin lift ± Subluxaţia anterioară a mandibulei ± Subluxaţia anterioară a mandibulei şi deschiderea gurii ± Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii (tripla manevră Safar); ± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a capului şi deget înfăşurat în pânză) ADVANCED LIFE SUPPORT: : ± Airway devices ± Traceal intubation
  25. 25. Tracheal intubation in CPR advantages ‡ maintenance of airways patency ‡ protection of airways against the aspiration of gastric content ‡ delivery of machanical ventilation ‡ drug administration ‡ long term access to the airways ‡ endotracheal aspiration
  26. 26. AIRWAY MANEUVERS: Clinical signs of proper tracheal intubation ± visualising the endotrachel tube passing through vocal cords ± simetrical thoracic expansions ± equal respiratory sounds on bouth lungs ± water vapors on the inside surface of the endotracheal tube ± the abscence of aeric sounds in epigastric region
  27. 27. CARDIO-PULMONARY RESUSCITATION B EVALUATION AND SUPPORT OF VENTILATION: ‡ Assessment of spontaneous breathing ± maintaining MECA ± ³lisen, feel and see´ ‡ Artificiale ventilation ± În SVB ‡ ‡ ‡ ‡ ‡ ‡ Artificial ventilation ³mouth-to-mouth´ Artificial ventilation ³mouth-to-nose´ Artificial ventilation ³mouth-to-tracheostomae´ Artificial ventilation ³mouth-to-mouth and nose´ The exhalated air containe 16-18% O2 Evaluation of the efficience of artificial ventilation: chest movements ± În SVA ‡ ‡ ‡ ‡ Mask and Rueben baloon Trachel tube and Rueben baloon Trachel tube and ventilatory device Mechanical ventilation: ± ± ± ± ± IPPV (intermitent positive pressure ventilation) Current volume 8ml/kg Frequence: 14-16/min FiO2 1 (O2 100%) PEEP (positive end expiratory pressure) 0
  28. 28. Artificial ventilation CHARACTERISTICS OF ÄMOUTH-TO-MOUTH´ VENTILATION ± The rescue person take a normal inspiratory ± Insuflation - 1 second ± Current volume 500-600ml ± Chest rise ± Frecquence 10-12/minute
  29. 29. VENTILAŢIA ARTIFICIALĂ CHARACTERISTICS OF MECHANICAL VENTILATION IN SVA IN ADULT ± Current volume 6-8ml/kg ± Frecquence 8-10/minute ± Oxigen 100% ± No PEEP ± No interuptions of chest compressions for ventilation
  30. 30. CARDIO-PULMONARY RESUSCITATION C CIRCULLATORY EVALUATION AND SUPPORT: ASSESSMENT of CIRCULATION ± Always in the large arteries ± Adult: carotid or femoral artery; infant: brachial artery; CHEST COMPRESSION ± It is performed during BLS and ALS ± Best achievable results: 25-30% of spontaneous cardiac output ± Chest compression technique: ‡ ‡ ‡ ‡ Victim position Rescuer position Technique Parameters: depth, frequency/min, compression/decompression ratio ± Mechanisms of cardiac output during chest compression: ‡ Cardiac pump theory ‡ Thoracic pump theory ± Evaluation of chest compression efficency: pulse assessmente during CPR ± Options to increase the efficency of chest compression: ‡ ‡ ‡ ‡ ‡ ‡ Maximal values of recommended depth and frequency Concomitantly performed chest compression and artificial ventilation Interposed abdominal compression Kower limb elevation at 60º (not in case of ongoing bleeding or trauma) Active compression/decompression device Internal cardiac massage (only during ALS) ‡ Extracorporeal circulation
  31. 31. CHEST COMPRESSIONS Äpush hard, push fast, allow full chest recoil after each compression, and minimize interruptions in chest compression´
  32. 32. CHEST COMPRESSIONS The indication for chest compresions is the absence of pulse in large arteries. There are no contraindications for chest compressions.
  33. 33. CHEST COMPRESSIONS ADULT ‡ Depth of sternal compression 4-6 cm ‡ Frecquence of compressions 100/minute ‡ Duration of compression/Duration of decompression equal ‡ Full chest recoil after each compression ‡ Rithmic compresions ‡ Avoid interupting chest compressions
  34. 34. CHEST COMPRESSIONS complications Fractures Ribs fractures Sternal fractures Pathology of the serosas Pneumothorax Hemothorax Hemopericardium Hemoperitoneum Pulmonary rupture Hepatic rupture Splenic rupture Gastric rupture Aspiration of gastric content Visceral injuries Other complications
  35. 35. ALTERNATIVE TECHNIQUES OF CARDIAC MASSAGE ‡ ‡ ‡ ‡ High frecquence chest compressions Interpose abdominal compression Internal cardiac massage CPR through Äcoughing´
  36. 36. MECHANICAL DEVICES FOR CARDIOCIRCULATORY SUPPORT ‡ ‡ ‡ ‡ ‡ Active compression-decompresion device Resistance-level valve device Mechanical Piston device CPR vest Fazic toraco-abdominal compression-decompression manual device ‡ Extracorporeale circulation
  37. 37. CARDIO-PULMONARY RESUSCITATION C MEDICATION: ‡ Routes for drug administration ± ± ± ± ± Peripheral intravenous access ± standard route Central intravenous access Intratracheal administration Intraosseous administration Intracardiac administration ‡ Drugs: ± ± ± ± ± ± ± ± ± ± ± Oxygen Epinephrine Atropine Lidocaine Vasopresine Sodium bicarbonate Amiodarone Procainamide Magnesium sulphate Dopamine Volume solutions
  38. 38. PERIPHERAL VENOUS ACCESS Advantages ‡Simple technique ‡Short time for instalation ‡No need for the interuption of chest compressions Disavantages ‡Long time of drug circulation ‡Easy to lose venous access
  39. 39. ACCESUL INTRAOSOS ‡ Este a doua opţiune de acces venos în RCR. ‡ Oferă acces la un plex venos necolababil, deci, administrarea drogurilor este similară administrării venos centrale. ‡ Există truse dedicate cu toate materialele necesare. ‡ Doza medicamentelor în administrarea intraosoasă este aceiaşi ca în administrarea intravenoasă. ‡ La bolnavul hipovolemic cu acces venos periferic imposibil accesul intraosos oferă o bună alternativă de refacere a volemiei.
  40. 40. CENTRAL VENOUS ACCEESS Advantages ‡Short time of drug circulation ‡Safe and longlasting access ‡Hipertonic solutions/cathecolamines Disavantages ‡Temporary interuption of cardiac massage ‡Long time for instalation ‡Vital complications possible
  41. 41. ENDOTRACHEAL DRUG ADMINISTRATION IN CPR ‡ ‡ ‡ ‡ through trachel tube 2-2,5x of intravenous dose diluted in NaCl 0,9% 5-10 ml 5 vigurous ventilations
  42. 42. CARDIO-PULMONARY RESUSCITATION E ELECTROCARDIOGRAPHY: ± Electrical forms of cardiac arrest ‡ Ventricular fibrillation ‡ Pulseless ventricular tachycardia ‡ Pulseless electrical activity ± ± ± ± ± Electromechanical dissociation Pseudo Electromechanical dissociation Idio-ventricular rhythm Escape rhythm Bradiasystole ‡ Asystole Identification of the eletrical form of cardiac arrest allows the choise of the proper CPR algorhythm
  43. 43. RESUSCITAREA CARDIO-RESPIRATORIE F DEFIBRILAREA: Defibrilarea este un termen utilizat pentru a desemna livrarea nesincronizată cu complexul QRS a unui şoc electric. Şocul electric induce o depolarizare sincronă urmată de repolarizare sincronă a tuturor fibrelor miocardice. Deci, după şocul electric toate fibrele miocardice ajung la un numitor comun: ´zero´ electric. Acest fenomen permite intrarea în funcţie a centrului cardiac cu funcţie spontană de pacemaker, care va prelua controlul activităţii electrice şi mecanice a inimii.
  44. 44. CARDIO-PULMONARY RESUSCITATION F DEFIBRILLATION: ± Goal ± Defibrillation technique: ‡ ‡ ‡ ‡ ‡ ‡ Patient position Rescuer position Paddles preparation and position ³Clear´ order Energy Checking for efficiency ± Indications ± Differences cardioversion/defibrillation: ‡ ‡ ‡ ‡ Synchronic/asynchronic shock Preparations Energy Indications
  45. 45. DEFIBRILAREA TEHNICA DEFIBRILĂRII: ± ± ± ± ± ± Poziţia pacientului Poziţia resuscitatorului Pregătirea şi poziţionarea padelelor Atenţionarea Energia utilizată Verificarea eficienţei
  46. 46. CARACTERISTICILE DEBIBRILĂRII ‡ ‡ ‡ ‡ ‡ Precocitatea defibrilării ÄShock first versus CPR first´ Scurtarea intervalului între ultima compresie sternală şi şoc Ä1-Shock Protocol´ RCR după şoc
  47. 47. ENERGIA UTILIZATĂ ÎN DEFIBRILARE ‡ curent monofazic ± iniţial 360 J şi continuă cu aceiaşi energie la următoarele şocuri. ‡ curent bifazic - iniţial o energie de 200 J, apoi energii crescânde de 300 J şi 360 J. ‡ În fibrilaţia ventriculară/tahicardia ventriculară fără puls recurentă - energia utilizată pentru următorul şoc va fi energia care a convertit ritmul.
  48. 48. ŞOCUL ELECTRIC EXTERN ‡ Termenul de cardioversie este utilizat pentru livrarea sincronizată cu complexul QRS a unui şoc electric. Sincronizarea evită livrarea şocului în perioada refractară relativă a ciclului cardiac, perioadă în care şocul electric poate induce fibrilaţie ventriculară. ‡ Termenul de defibrilare este utilizat pentru livrarea nesincronizată cu complexul QRS a unui şoc electric.
  49. 49. CARDIOVERSIA PREGĂTIRI PENTRU CARDIOVERSIE ‡ Bolnavul trebuie să aibă monitorizare ECG şi monitorizarea noninvazivă a TA. ‡ Se instituie oxigenoterapia. ‡ Se instituie un acces venos. ‡ Instrumentarul, materialele şi drogurile de resuscitare trebuie să fie pregătite. ‡ Se practică analgezie şi sedare.
  50. 50. CARACTERISTICI COMPARATIVE ALE CARDIOVERSIEI ŞI DEFIBRILĂRII PARAMETRU CARDIOVERSIE DEFIBRILARE Energia iniţială 50-100 J 200 J Sincronizarea cu complexul QRS Indicaţii DA NU TPSV Flutter atrial paroxistic Fibrilaţia atrială paroxistică Tahicardia ventriculară cu puls Fibrilaţia ventriculară Tahicardia ventriculară fără puls Tahicardia ventriculară polimorfă cu puls
  52. 52. STATUSUL POSTRESUSCITARE ‡ după reluarea circulaţiei spontane ‡ perioadă de mari dezechilibre homeostatice ‡ generate de: ± leziunile hipoxice ± leziuni ischemice ± leziuni de reperfuzie.
  53. 53. FIZIOPATOLOGIA STATUSULUI POSTRESUSCITARE Hemodinamic Disfuncţie miocardică (prin ischemia miocardică globală şi defibrilare) Sindrom de debit cardic scăzut Creştere tranzitorie a enzimelor miocardice Instabilitate hemodinamică Tulburări de ritm Neurologic Comă Iniţial hiperemie cerebrală, apoi reducerea fluxului sanguin cerebrale (chiar la valori normale ale TA medii) Hipertemie de origine centrală Convulsii Respirator Disfuncţie ventilatorie Tulburări de oxigenare sanguină Metabolic Acidoză metabolică Hiperglicemie
  54. 54. STATUSUL POSTRESUSCITARE Tulburările pot fi: ‡ modeste şi cu tendinţă progresivă spre rezoluţie ‡ severe şi persistente coma persistentă hipertermia centrală convulsiile sindromul de disfuncţie multiplă de organe frecvente la 48-72 ore postresuscitare prognostic nefavorabil