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CARDIOPULMONARY RESUSCITATION Dr A. Anvaripour Cardiac Anesthesiologist

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History of resuscitation back to 1966 Standards for the performance of CPR Most recent recommendations Guidelines 2005 New guidelines has undergone comprehensive evidence- based evaluation

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BASIC LIFE SUPPORT Early recognition of medical emergencies Emergency response system (e.g., dialing 911 in the United States) BLS assessments : Airway, breathing, and circulation performed without equipment BLS interventions: breathing/Heimlich maneuver/application- use of an automated external defibrillator (AED)/CPR

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GOAL supporting the circulation until restoration of spontaneous circulation occurs after SCA

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FOR THOSE PERFORMING BLS INTERVENTIONS Importance of prompt initiation and expert performance of these skills cannot be overemphasized

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Antegrade systemic arterial blood flow continues after cardiac arrest until the pressure gradient between the aorta and right heart structures reach equilibrium Similar process occurs during cardiac arrest with antegrade pulmonary blood flow between the pulmonary artery and the left atrium

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Arterial-venous pressure gradients dissipate left heart becomes less filled/the right heart becomes more filled/venous capacitance vessels become increasingly distended

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CORONARY PERFUSION AND CEREBRAL BLOOD FLOW STOP When arterial and venous pressure equilibrates (approximately 5 minutes after cardiac arrest)

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CPR is performed until return of spontaneous circulation occurs CPR is far less efficient than the native circulation, it can provide coronary circulation and cerebral blood flow sufficient to afford full recovery in many case Push hard and push fast chest compressions performed at a rate of 100/min until generate a palpable carotid or femoral pulse are considered ideal.

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CHEST COMPRESSIONS Must not frequently interrupted

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CURRENT RECOMMENDATIONS Placing increased emphasis on limiting interruptions in chest compressions single- and two-person CPR compression-ventilation ratios of 30 : 2

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CARDIAC PUMP MECHANISM Blood is ejected Actual compression heart between the sternum and the vertebral column Reduction in left and right ventricular volume Closure of the tricuspid and mitral valves Ejection of blood into the arterial system

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COUGH CPR Forceful coughing sustain consciousness during ventricular fibrillation (VF) 100 seconds Coughing arterial pressure pulse opens the aortic valve

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THORACIC PUMP MECHANISM Increases in intrathoracic pressure generate forward blood flow

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cardiac pump and thoracic pump mechanisms exist during resuscitation

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Systemic, coronary, and cerebral blood flow during CPR is dependent on effective chest compressions Modest increases in intrathoracic pressure will impair return of venous blood reducing the chance of spontaneous circulation Cardiac output during effective CPR: 25% 30% oxygen content in the lungs at the time of cardiac arrest usually sufficient for maintaining an acceptable arterial oxygen content during the first several minutes of CPR

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RESULT Breaths are less important than initiating chest compressions immediately after the onset of SCA

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MONITORING DURING CPR palpation of the carotid or femoral observation of pupillary size Initial pupillary size and changes during CPR are of some prognostic value 1978, Kalenda described the use of capnography as a guide to the effectiveness of external chest compressions

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Rapid decrease in P ETCO 2 with the onset of arrest Immediate increase with resuscitation Noninvasive guide to advanced life support interventions during CPR

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Severe reductions in pulmonary blood flow acute failure of delivery of O 2 to the lungs very low P ETCO 2 External chest compression & ventilaiton P ETCO 2 increased to 1.9% 0.3%, After successful defibrillation and 12 minutes of CPR P ETCO 2 immediate increase to 4.9% 0.3%

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RESULT Close correlation was found between changes in cardiac output and P ETCO 2

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MAJOR DETERMINANTS OF P ETCO 2 CO 2 production Alveolar ventilation Pulmonary blood flow.

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BREATHING Breathing is indicated for a nontracheally intubated cardiac arrest two 1-second breaths are delivered after the 30th compression Provide only enough force and volume to cause chest rise Excessive ventilation gastric inflation With tracheal tube 8 to 10 breaths per minute independent of chest compressions

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SCISSORS MANEUVER

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SNIFF POSITION

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MACINTOSH LARYNGOSCOPE IN POSITION

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SCHEMATIC VIEW OF THE GLOTTIC OPENING DURING DIRECT LARYNGOSCOPY

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SUPRAVENTRICULAR TACHYARRHYTHMIA Atrial flutter Atrial fibrillation AV junctional tachycardia Multifocal atrial tachycardia Paroxysmal reentrant tachycardia

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HEMODYNAMIC COMPROMISE Paroxysmal supraventricular tachycardia (PSVT) Atrial fibrillation (or flutter) with rapid ventricular rates Multifocal atrial tachycardia

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PSVT

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With hemodynamic deterioration cardioversion 100 to 200 J if a monophasic defibrillator 100 to 120 J with a biphasic defibrilator

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PSVT Energy can be increased as needed if the arrhythmia is resistant to therapy

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HEMODYNAMICALLY STABLE PSVT vagal maneuvers (Valsalva ) before initiating pharmacologic interventions terminate about 20% to 25% Adenosine (very effective in terminating PSVT)

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ADENOSIN slows sinoatrial and AV nodal conduction prolongs refractoriness diagnostic usefulness with uncertain origin

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AFTER INJECTION OF 6 MG ADENOSIN

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short half-life (