OBJECTIVES• How to perform BLS procedures• How to use AED.• Know when to stop and when not to initiate CPR.• Principles of ALS.• Performing some procedures that may improve the out come as (ET tube, cricothyroidtomy ,etc..)• Arrested pregnant,drowing,chocking• Diagnosing death.
BACK GROUND• Two factors were found to be crucial determinants of survival from cardiac arrest. The first was the presence of bystanders able to perform basic life support. The second was the speed with which defibrillation was performed.• Early Resuscitation and defibrilation increase survival to 60%.• Approximately 700,000 cardiac arrest cases seen in eurpe /y.
Agonal Breathing• Heavy , noisy and gasping breath.• It is recognized as a sign of cardiac arrest. CAROTID PULSE CHECK IF PRESENT THEN DO RESCUE BREATH 10/MIN RECHECK BREATH AND PULSE AFTER 1 MIN.
• Don’t over ventilate.• Pericordial thump: if the onset is witnessed and defibrilator not available immediately and cardiac arrest confirmed.• It has a good out come in the first 10 seconds of the time of the arrest .• No evidence confirm that HIV may be transferred by mouth to moth breathing
IN HOSPITAL CARE• 1- DON’T INTERRUPT CPR.• 2- SECURE AIR WAY• 3- IV ACCESS.• 4- ATTACH VITAL SIGNS MONITOR TO ANALYS ECG TRACE.• 5- START ALS .• 6-FINDOUT AND TREAT THE REVersibles
Methods of securing the air way• tracheal intubation is the optimal method of providing and maintaining a clear and secure airway.(should not take more than 30 sec. and if 2 trials failed turn to other methode of airway securing.• Gudele air way• LMA, Combi tube• Cricothyroidotomy : delivery of oxygen through a cannula or surgical cricothyroidotomy may be life saving.
Give O2 80-100% 10-12 ml/min and do Spo2(normal 93%) We should not forget removing denture and do suction as needed
IV ACCESS• PERIPHERAL VEIN• CENTRAL VEIN(JUGULAR,SUBCLAVIAN,FEMORAL)• INTEROSSEOUS• INTRA TRACHEAL
SHOCKABLE STATE• VF/VT1-Attempt defibrillation (one shock - 150-200 J biphasic or 360 Jmonophasic).2-Immediately resume chest compressions (30:2) without reassessing the rhythm or feeling for a pulse.3-Continue CPR for 2 min, then pause briefly to check the monitor:
• IF STILL VT/VF.1-Give a further (2nd) shock (150-360 J biphasic or 360 J monophasic).2- PROCEED CPR for 2 min (5 cycle)CHECK THE MONITOR:If still VT/VF1-give adrenalin 1 mg iv2-give 3rd shock (150-360 J biphasic or 360 J monphasic)3- proceed CPR for 2 min
• CHECK THE MONITOR• If still VF?VT1- give amiodaron 300mg iv2- give 4th shock (150-360 J biphasic or 360 J monphasic)3- proceed CPRTHEN AFTER CHECK EVERY 2 MIN AND GIVE SHOCK IF STILL VT/VF.Give adrenalin with alternate shockes (i.e.every 3-5 minutes)
• IF BRIEF ELECTRICAL ACTIVITY SEEN IN PAUSING PERIOD THEN: check the pulse if pulseless shift to unshockable algorithm.• If pulse felt thet post resucitation care.• If asystole develop then non shockable algorythm.• Fine VF that is difficult to distinguish from asystole is very unlikely to be shocked successfully into a perfusing rhythm
NON SHOCKABLE STATE• Asystole/PEA Pulseless electrical activity (PEA) is defined as cardiac electrical activity in the absence of any palpable pulse. These patients often have some mechanical myocardial contractions but they are too weak to produce a detectable pulse or blood pressure. PEA may be caused by reversible conditions that can be treated• 1-start CPR• 2-give adrenalin 1mg IV.• 3- check pulse every 2 min• 4-give adrenalin then every 5 min• 5- in asystole or PEA 60 bpm give atropin 1 mg IV.IF VT/VF appear then shift to shockable algorythmIF pulse palpated and regular rhythm them post res. care
Pregnant Resuscitation• The causes of pregnant arrest: Embolus post C.Section “amniotic embolism” , sepsis ,• The problems of CPR in pregnancy; hypertrophied breast ,enlarged uterus,uterus obstruct IVC.• We have to put pt. inLateral position and dis-Place uterus laterally. AndRaise pt. legs.
• Don’t put paddles into the breast tissues.• If BLS and ALS not succed in 5 min EMPTY UTERUS to safe fetus life and decompress IVC.
DROWING AND PEDIATRIC CPR• GIVE 5 RESCUE BREATH IN THE BEGINNING.• AED CAN USED IF PT. BECAME DRY.• IN PEDIATRIC DO 5 RESCUE BREATH FIRST THEN PROCEED CPR 15:2 FOR 1 MIN THEN REASSES SIGNS OF LIFE.
Managing Reversible conditions• HYPORVOLEMIA:Usually caused by hemorrhage(trauma as rupture spleen or rupture aortic anurysm) excessive diarrhoea and vomiting.Treated by stop bleeding and fluid replacments:2000ml NS (PEDIATRICS 100ml/kg) thenstart colloids(volume expanders):except in cardiogenic shock Hemagel , Hypertonic saline7.5% , Dextran.Blood (if urgent = O -ve)If still no response start inotrpes.(BP required for brain perfusion systolic 80 mmHg)
• Excessive IV fluid cause : Hypothermia that precipitate coma and arrythmia, dilutional coagulopathy and pulmonary edema.• Aim for systolic = 90• Raising the foot improve venous return.
HYPOXIA• ENSURE adequate ventilation 100% O2.• Check chest raise and breath sound.• Ensure no tracheal disposition as being inserted into the esophagus.• Check Spo2 and ABG.
HYPOTHERMIA• Core rectal Temp less than 35 degree Cent.• Suspect in DRAWING.or excess expose to cold.• Also in impaired level of conseciousness(eg. Following alcohole or drug overdose as diuretics and anti depressants)• Do axilary thermometry if less than 36.5 Use low grade thermometer for rectal.• Ecg may shoe j wave.Treated by external heating. Or internal heat. Slowly aiming 1/2 degree C/hour
HYPERKALEMIA• Plasma K more than 6.5mmol/L need urgent tt• History will make you predict it.as RF,drugs.• ECG tall tented t wave,wide QRS,VF• Treated by:1-10%Ca gluconate 10ml IV over 2 min. repeated as necesay according to ecg change.2-insulin + glucose (20units+50ml of 50% glucos)3-salbutamol inhaler can be used 2.5mg(1/2 ml)4-calsium resonium.
HYPOKALEMIA• K below 2.5mmol/L need urgent ttt.• ECG inverted t, st depresion, prolonged PR int.• IF K more than 2.5 then oral replacment
TENSION PNEUMOTHORAX• May follow attemp for central venous line.• Diagnosis done clinically• Thoracocentesis then chest tube. Temponad Deficult to diagnose clinically in arrest victim Suspected in chest trauma Do urgent pericardiocentesis
THROMBOEMBOLICThe commonest cause is Masive pulmonary emboplism.Treated by thrombolytic drugs immediately.Give heparin 10000 unit iv bolous if sys BP more than 90 then start warafrin 10mg/24hIf BP less than 90 consider hypovolemia ttt regimen TOXINESRvealed by Lab study.Treat it by antidots if available or either gastric aspiration with charcoal.
POST RESUSCITATION CARE• The pt. should be transferred to ICU or CCU.• If not then put the pt. on Recovery Position.1-airway and breathing: intubate if not done.Adjust ventilation by monitoring co2 by ABG.2- NGT to decompress stomach.3-CXR: to ensure ET tube position and ensure no pneumothorax happen by rib fracture at CPR.4-monitor BPlPR and give IV fluids.5-inotropes to achive optimal BP and UOP6-diuretics if HF
7-if coronary thrombus consider thrombolysis or angioplasty.8- treat electrolyte disturbance mainly K.9-control seizure which common in post CPR.10- sedation if required.11-treat hyperthermia that commonly occur post resuscitation by cooling and antipyretics.12-blood glucose control: by Insulin There is a strong association between high blood glucose levels after resuscitation from cardiac arrest and poor neurological outcome.
WHEN NOT START CPR• Valid DNAR order or advanced directive• Signs of irreversible death (eg, rigor mortis, decapitation, decomposition)• Futility--No expected physiologic benefit(eg, deterioration of vital functions despite maximal therapy, pre-hospital blunt trauma arrest)• EMS: Danger to the rescuer
WHEN STOP CPR1-Interval B/W BLS and ALS more than 30 min.(except hypothermia and drug toxicity)2- asystole who not resond to CPR after 20 min.3- advance directive by physecian.4-fatigue.- If interval B/W arrest and ALS more than 5 min poor prognosis- If the pt. received sedatives or hypnotics CPR time will increased.
DIAGNOSING DEATH• 1-brain stem absence of reflexes• 2-coma (unresponsiveness) i.e.absence of motor reflexes• 3-Determin Etiology and irreversibility of condition .• 4-. apnoea with Pco2 more than 60mmHg• 5- lab tests ; as ECG confirmation.(source ; American Academy of Neurology 1994)
WHO CAN CONFIRM DEATHThese tests should be carried out on two occasions,the time interval between the tests being a matter ofclinical judgement. The tests should be carried out bytwo medical practitioners registered for more than fi veyears, at least one of whom should be a consultant.They should be competent in the field and not membersof the transplant team.• SOURCE (APPLIED BASIC SCIENCE FOR BASIC SURGICAL TRAINING BY Andrew T. Raftery 2ND Edition)
References REFERENCES * Resuscitation council UK 2005 guidelines * American Heart Assosciation 2005 guidelines *ABC of resuscitation by 2004 5thedition1- By M C Colquhoun, A J Handley and T R2- *American Academy of Neurology *Oxford hand book of clinical medicine3- edition 6. *APPLIED BASIC SCIENCE FOR BASIC4- SURGICAL TRAINING BY Andrew T. Raftery 2008 2ND Edition)