Cardiopulmonary resuscitation

Dr.V.RavimohanWhat I learned in the ILS training

http://www.mrcogexam.net

Chain of survival

• Early recognition and call for help• Early cardiopulmonary resuscitation (CPR)• Early defibrillation• Post resuscitation care

Early recognition

• Most in-hospital cardiac arrests are not sudden or unpredictable events

• Hypoxia or hypotension are either not noticed by staff ,or are recognised but treated poorly.

• 2 systems early warning scores

calling criteria“cardiac arrest team” “Medical emergency team”

Medical emergency team calling criteria

Acute change in Physiology

Airway Threatened

Breathing All respiratory arrestsRespiratory rate < 5/ minRespiratory rate >36/min

Circulation All cardiac arrestsPulse rate <40/minPulse rate > 140/minSystolic pressure <90 mmHg

Neurology Sudden decrease in level of consciousnessDecrease in GCS of > 2 points Repeated or prolonged seizures

Other Any patient causing concern who doesn’t fit the above criteria

Airway obstruction

• Treatment– Remove any obstruction unless

contraindicated turn the patient to a side– Simple airway opening manoeuvres head tilt,

jaw thrust or chin lift (remember to give oxygen)– Oropharyngeal airway or nasal airway– Elective tracheal intubation– Tracheostomy– Always remember to give oxygen

Breathing problems

• Causes– Poor respiratory drive-CNS depression– Poor respiratory effort-muscle weakness/nerve

damage– Lung disorders

Breathing problems

• Recognition– Irritability, confusion, lethargy and depressed

consciousness(from hypoxia and hypercapnia)– High respiratory effort(>30/min)– Pulse oxymetry• Non invasive measure of oxygenation but not a

measure of ventilation

– Blood gas analysis

Circulation problems

• Causes– Primary heart problemsarrythmia secondary to

ischaemia– Secondary heart problems severe anaemia,

hypothermia

Acute coronary syndromes

• Unstable angina• Non ST segment elevation MI• ST segment elevation MI

– Treatment• O2 high concentration• Aspirin 300 mg• Nitro-glycerine S/L• Morphine

ABCDE approach

• A-airway• B-breathing• C-circulation• D-disability• E-exposure

Airway Obstruction

• Airway obstruction-”sea-saw” respirations– complete• no breath sounds at the mouth or nose

– Incomplete• noisy

• clear the airway• Give O2 10 l/min

Breathing

• General signs of respiratory distress– Use of accessory muscles of respiration– Sweating– Cyanosis

• Respiratory rate• Pulse oxymeter• Trachea• Percuss• Listen

Circulation• Colour & temperature of limbs• Capillary fill time

– Finger tip held at the heart level– Normal fill time is less than 2 seconds

• Pulse volumelow – poor cardiac output

high(bounding)-sepsisB.P low diastolic blood pressure arterial vasodilatation anaphylaxis or sepsis narrow pulse pressure-(normal 35-45 mmHg) arterial vasoconstrictionhypovolaemia/cardiogenic shock

Disability

• AVPU– A-Alert– V-responds to vocal stimuli– P-responds to painful stimuli– U-unresponsive to all stimuli• Measure blood glucose to exclude hypoglycaemia

This is simpler than Glasgow coma scale

Exposure

• Exposure to examine the patient properly– Minimise heat loss– Respect dignity

“collapsed patients”

• Ensure personal safety• Check for patient response– “are you alright?”• If patient respondsABCDE approach”• If patient doesn’t respondcall for help

• Airway• Breathing-”look” “feel” “hear” for not more

than 10 secs

Pulse

• Checking for pulse-can be difficult even for the trained staff

• If unsure about the pulse don’t start delaying CPR

• If there is pulse – Still call for help– Give O2 Ventilate lungs check for circulation ever 10 seconds

– Attach monitoring– IV access

If there is no pulse or signs of life

• Call for help• 30 chest compression:2 ventilation• 100 compressions/min compression depth 4-5

cm• Once the defibrillator arrives apply electrodes

to patient and analyse rhythm• Minimise interruptions to chest compressions

Advanced life support cardiac rhythm

• 2 groups of cardiac rhythm– Shock able rhythm• Ventricular fibrillation• Pulse less ventricular tachycardia

– Non shock able rhythm• Asytole• Pulse less electrical activity

Shock able Rhythm

3 possibilities

VT/VF persists

VF/VT still persists

Some tips

• Lidocaine 100mg IV is an alternative for amidarone but isn’t an option if amidarone is already given

• If there is doubt about whether a rhythm is Asystole or very fine AF

• don’t defibrillate• Very fine VF is unlikely to respond to shock

Precordial Thump

• May be useful in VF/VT cardiac arrest which was witnessed and monitored sudden collapse

• Ulnar edge of a tightly clenched fist• From height of about 20 cm• Thumb is most likely to be successful in

converting VT to sinus rhythm

PULSELESS ELECTRICAL ACTIVITY

• Definition: organised electrical activity in the absence of any palpable pulses.

Treatment for PEA

If VT/VF persists

• Follow shock able side of algorithm

Treatment for asystole and slow PEA(rate <60 min-1)

During CPR

Reversible causes4H 4T

Hypoxia Tension pneumothorax

Hypovolaemia Tamponade,cardiac

Hypo/Hyperkalaemia/metabolic Toxins

Hypothermia Thrombosis

4 HHypoxia 100% oxygen

Ensure adequate chest rise & bilateral breath sounds

Hypovolaemia Crystalloid/ColloidSurgery

Hyperkalaemia 12 ECG may help in the diagnosisCheck for hypoglycaemia

Hypothermia

4TTension pneumothorax May be a complication of inserting

central venous catheterSigns: decreased air entry decreased expansion hyperresonance percussion on affected sideDo: needle thoracocentesis

Tamponade cardiac Cardiac arrest after penetrating chest trauma 2 reasons:A.hypovolaemia B.cardiac tamponadeDo: needle pericardiocentesis or resuscitative thoracotomy

Toxins

Thrombosis Consider thrombolytic therapy

CPR in a pregnant patient

• Left lateral tilt(15-30 degrees) of patient• Periarrest caesarean section should begin

within 4 minutes• Sterile preparation is not necessary• Moving the patient to operating theatre isn’t

necessary