This document discusses cardiopulmonary resuscitation (CPR) and the classification and treatment of terminal patients. It covers the reversible stages of dying, defines clinical death as the cessation of circulation and breathing, and notes the timeframes for tissue survival without circulation. It describes the types of cardiac arrest and the basic ABC therapy approach. The document outlines techniques for CPR including chest compressions, ventilation, medications like epinephrine, and airway management methods. It discusses challenges with CPR delivery and notes recommendations to minimize interruptions in compressions.

1. Odessa national medical university
Department of Anesthesiology, Intensive Care
and Emergency medicine
Classification of terminal status of
patients. Cardiopulmonary
resuscitation (CPR). Types of
cardiac arrest. Basic therapy
(A,B,C) and advanced medical
resuscitation.

2. Reversible stages of dying -
these stages include successively
critical condition, preagony, agony,
and clinical death.
-

3. Clinical death
 Clinical death is the popular term for
cessation of blood circulation and
breathing. It occurs when the heart stops
beating in a regular rhythm, a condition
called cardiac arrest. The term is also
sometimes used in resuscitation research
At the onset of clinical death,
consciousness is lost within several
seconds. Measurable brain activity stops
within 20 to 40 seconds. During clinical
death, all tissues and organs in the body
steadily accumulate a type of injury called
ischemic injury.

4. Blood circulation can be stopped in the entire body below
the heart for at least 30 minutes (Detached limbs may be
successfully reattached after 6 hours of no blood circulation at warm
temperatures. Bone, tendon, and skin can survive as long as 8 to 12
hours).
 The brain appears to accumulate ischemic
injury faster than any other organ. Without
special treatment after circulation is restarted,
full recovery of the brain after more than 3
minutes of clinical death at normal body
temperature is rare. Usually brain damage or
later brain death results after longer intervals of
clinical death even if the heart is restarted and
blood circulation is successfully restored. Brain
injury is therefore the limiting factor for recovery
from clinical death.

5.  In 1990, the laboratory of resuscitation
pioneer Peter Safar discovered that
reducing body temperature by three
degrees Celsius after restarting blood
circulation could double the time window
of recovery from clinical death without
brain damage from 5 minutes to 10
minutes. This induced hypothermia
technique is beginning to be used in
emergency medicine.

6. Cardiac arrest -
sudden stoppage of the pumping function
of the heart and collapse of arterial blood
pressure to immeasurable level; it usually
leads to death unless corrected, but may
be temporary or paroxysmal.

7. Cardiac arrest can be subclassified roughly into
one of three types:
1)ventricular fibrillation;
2) asystole;
3)electromechanical dissociation.
Though not used for the sole diagnosis of cardiac
arrest, the monitor–ECG provides valuable
information of therapeutic and prognostic importance.

8. Cardiac arrest - a clinical diagnosis,
based on the key symptoms of unconsciousness
and pulselessness.
Other symptoms associated with cardiac arrest are apnoe
and pupillary dilation.
Apnoe may be cause of cardiac arrest but more frequently
occurs simultaneously with it. It is not exceptional to find
respiration maintained for a minute or so, hence apnoea
should not be included in the definition.
Cyanosis often occurs rapidly, but may be completely
absent (anaemia, CO-and CN-intoxication).
Pupillary dilation also usually occurs with a delay; its
value as a prognostic sign is discussed later .

9. Pulselessness - absence of palpable pulse in the
carotid arteries

10. The aims of emergency medical
care are:
to diagnose the condition of emergency
patient,
to provide the basic vital support and
emergency special therapy
to choice of suitable clinic or unit for
admission for the continuing of
emergency care.

11. Cardiopulmonary resuscitation
(CPR)

12. Basic therapy – A B C
•A – airway
•B – breath
•C – circulation
(P – position)

13. PRECORDIAL THUMP
 The precordial thump is recommended
when ventricular fibrillation or ventricular
tachycardia are observed while the patient
is being monitored. Although spontaneous
conversion with this technique is low, the
minimal risk and insignificant time
expenditure make it an acceptable initial
maneuver.

14. Closed-chest cardac massage -
CCM
(Kouwenhouven, 1960)
Compression technique should aim at
1) Creating an increase in intrathoracic pressure
2) Without causing complications
3) Economizing one‘s own power
The site of compression is lower sternum, with center
between middle and lower third.
To economize your strenght, use the weight of your own
body by holding your arms straight and vertical over
the patient
The classically recommended compression rate is 100 p.m.
with a compression-ventilation ratio 30 : 2

15. Right Atrial
Pressure
(RAP)
Aortic
Pressure
(AP)
Coronal perfusion pressure (СPP)
CPP = AP minus RAP

16. Coronal perfusion and renewal of
spontaneous circulation of blood(ROSC)
Myocardium with sufficient perfusion provides the
mortgage of renewal of spontaneous circulation of
blood

17. Recommendations of American
Association of Cardiologists, 2005:
… press on strongly, press on quickly,
watch after complete decompression
of thorax, minimize interruptions in
compressions…

18. The compressions of thorax must be executed
high-quality, constantly with minimum
interruptions for providing of rescue inhalations
or at a stretch at artificial ventilation
Press on with sufficient effort and necessary
frequency
Correlation of compressions with a vent support
- 30:2
Frequency: 100 manual compressions p.m.
Depth: 4 - 5 cm
2 rescuers by turns: 50% - 50%
Ventilation: 8 -10 breathings p.m.

19. Typical difficulties of the CPR
 Bad quality of indirect massage
 Inconstant frequency, depth, insufficient
amount of rescuers
 Interruptions are in compressions
 Caused fatigability of rescuers, transporting
of patient
 Cerebral and coronal hypoperfusion
 Uneffective defibrillation

20. Typical difficulties of the CPR
Parameter (first 5 min) Criterion
% to time of wrong
leadthrough of СРR
Insufficient frequency < 90/min 28.1%
Insufficient depth < 4 сm 37.4%
Frequency of rescue
inhalations is higher than
normal
> 20/min 60.9%

21. The hand massage of heart is
provided by minimum of blood
circulation of heart and brain
30% - 40% from a
normal cerebral blood
stream
10% - 20% from a
normal myocardial
blood stream

22. 4 min after began fibrillation of ventricles, myocardium
is almost exhausted, an ATP-index goes down which
is a key factor for the lead through of successful
defibrillation .
Effective compressions help to recover a level
ATP, step-up probability of leadthrough of successful
defibrillation
*Adenosine triphosphate (ATP), which breaks down into adenosine diphosphate (ADP).

23. AutoPulse

24. Ventilation

25.  Mouth-to-mouth or mouth-to-mask ventilation
is the initial resuscitation measure of choice
for ventilation of the arrested patient.
 In the hospital, bag-valve-mask ventilation is
initially used, and airway potency and
ventilation are usually evaluated
simultaneously. If the patient is not breathing,
the airway is opened and two breaths are
delivered to the patient.

26. PRIMARY TECHNIQUES
 Airway management is
the first priority of
resuscitation. After the
patient's state of
consciousness is known,
the airway is evaluated
for potency. The ability
of the patient to talk
confirms a patent airway
and ventilation
 Absence of air flow
about the face implies
upper airway
obstruction, absence of
ventilation, or both.

27. The initial maneuver in the patient with upper
airway obstruction is to manually open the airway

28. The tongue often causes upper airway obstruction
in the arrested patient

29. Insertion of an oropharyngeal airway, which
prevents the tongue from falling into the posterior
pharynx, may help maintain airway potency during
resuscitation

30. Cricothyroidotomy –
a small incision horizontally in the skin and
vertically in the cricoid membrane permit insertion
of a tube

31. Objective analysis of adequate ventilation:
 Skin color should improve with ventilation and
oxygenation.
 The chest should rise with each breath and
should be symmetric in patients without
asymmetric lung disease.
 Auscultation for good breath sounds in multiple
areas of each lung (in particular, the midaxillary
area high in the chest) is mandatory. There
should not be an obvious gaseous sound over the
stomach with each breath.
 Unfortunately chest examination is never an
absolute assurance of proper placement

32. RESUSCITATION PHARMACOLOGY
EPINEPHRINE.
Epinephrine is the pressor drug of choice for primary
cardiac arrest. It is recommended in patients with ventricular
fibrillation and pulseless ventricular tachycardia who are
unresponsive to initial defibrillation attempts. In these
patients it facilitates maintenance of desirable
postdefirillation rhythms. Epinephrine is also recommended
in patients with electromechanical dissociation (EMD) and
asystole. Its mechanism of action is not related to its central
beta-adrenergic effects, but to its alpha-vasopressor effects
In the patient who is converted to a rhythm with potential for
generating a pulse, epinephrine may facilitate coronary
artery perfusion and cardiac output by raising aortic diastolic
pressure. Epinephrine also increases cardiac work load
and, if used inappropriately, may increase cardiac injury in
the patient with ischemic myocardium.

33. RESUSCITATION PHARMACOLOGY
 ATROPINE. Atropine is currently recommended
for patients with bradycardiac dysrhythmias and
hypotension; asystole; and electromechanical
dissociation. It is the initial drug of choice in
patients with severe sinus bradycardia and atrio-
ventricular blocks (except those related to beta-
blocker and calcium channel-blocker overdose,
for which glucagon and calcium, respectively,
are recommended).

34. RESUSCITATION PHARMACOLOGY
BICARBONATE. Considerable controversy has been
generated in the last several years concerning
bicarbonate therapy. Original American Heart
Association guidelines for the arrested patient included
bicarbonate given empirically in a dosage of 1 meq/kg
and repeated at 0.5 meq/kg every 15 minutes during
resuscitation attempts, until arterial blood gas results
were obtained for more definitive decisions on pH
adjustment. It was subsequently noted that when
patients who had only recently arrested received rec-
ommended bicarbonate therapy in combination with
early CPR and were successfully resuscitated, an
impressive iatrogenic metabolic alkalosis often resulted.

35. RESUSCITATION PHARMACOLOGY
ISOPROTERENOL. Current recommendations for
isoproterenol in cardiac arrest are as a
secondary drug in patients with sinus
bradycardia and atrioventricular blocks with hy-
potension who do not respond to atropine.
Isoproterenol significantly increases myocardial
oxygen demand and may be associated with
life-threatening ventricular dysrhythmia. If a
noninvasive pacer is immediately available, we
feel it is a preferred alternative.

36. RESUSCITATION PHARMACOLOGY
CALCIUM. Calcium is no longer
recommended in arrest, with these
exceptions: arrest due to calcium channel
blockers, documented hypocalcemia,
cycloplegic arrest, arrest subsequent to
massive stored blood transfusion, or
documented hyperkalemia.

37. RESUSCITATION PHARMACOLOGY
DOPAMINE. Dopamine is the drug of choice for
hypotension in the successfully resuscitated arrest due to
myocardial ischemia. It has strong beta-one inotropic and
alpha-adrenergic vasoconstrictor effects. Dopamine
dosages usually range from 2 mkg/kg/min to 25
mkg/kg/min. The 2 to 5 mkg/kg/min range is a transition
from a primarily renal dopaminergic effect (increased
renal blood flow) to a primarily inotropic effect. The 5
mkg/kg/min to 12 mkg/kg/min range is a transition from
an inotropic to a peripheral vasoconstrictor effect.
Dosages higher than 25 mkg/kg/min offer no significant
advantage over norepinephrine. At such dosages, the
primary effect is alpha-adrenergic stimulation with
significant beta-one inotropic effects. If dopamine is used
in the arrest patient with EMD it is usually begun at a
higher dose than in the hypotensive patient, that is, 15
mkg/kg/min.

38. DEFIBRILLATION
Pulseless ventricular tachycardia and ventricular
fibrillation are treated identically in the arrest
patient. These patients should receive immediate
defibrillation with a voltage of 200 joules (J)
repeated once and followed by countershock
with maximum voltage (360 J). If a defibrillator is
not immediately available, then ventilation and
chest compressions should begin. Some would
advocate that if a defibrillator is immediately
available, chest compressions should not be
started until after failure of initial countershocks,
but there may be some advantage to early CPR
even in this circumstance. This distention may
occur within 15 seconds after arrest. With
increasing distension successful defibrillation
becomes more difficult.

42. Thank you for your
attention!!!