Cpcr dr raj care ngp
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Transcript of Cpcr dr raj care ngp
Cardiopulmonary Resuscitation
Dr. Rajkumarr Anesthesiologist
Care HospitalNagpur
“No initial intervention can be delivered to the victim of cardiac arrest unless bystanders are ready, willing, and able to act”
2
Bad News Time Flies
Good News You are the Pilot
You take care of the Seconds
We take care of the Minutes
3
Cardiac Arrest
Cardiac arrest is the cessation of all cardiac mechanical activity. It’s clinical diagnosis is confirmed by
UnresponsivenessAbsence of detectable pulseApnea (or agonal respirations )
The Cardiac Arrest Rhythms
The four cardiac arrest rhythms are
Asystole PEA ( Pulseless Electrical Activity ) Pulseless Ventricular Tachcardia (VT) Ventricular Fibrillation (VF)
D. Differential Diagnosis Review the most frequent causes ( the 6 H’s and 6 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Tamponade - cardiac
Hydrogen ions – acidosis Tension pneumothorax
Hyper / hypokalemia Thrombosis - coronary
Hypothermia Trauma
Hypoglycemia Thrombosis - pulmonary
Cardio Pulmonary Cerebral Resuscitation
BLS : Basic life support
ACLS : Advance cardiac life support
Better chance of survival Brain damage starts in 4-6 minutes Brain damage is certain after 10 minutes
without CPR
What is treatment of cardiac arrest….?
How to do It- Chain of Survival
Early Recognition
(Sudden Cardiac Arrest))
Early Activation
(Emergency Medical Service)
Early Chest Compression
(Push Hard &Push Fast)
Early Shock
(Automated External Defibrillator
Early Advanced care
Chain Of Survival – 4 links
Early Activation of EMS
Early CPR
Early Defibrillation
Early Advanced Care
BLS
International Guidelines for CPR 2005…..????
Chain of survival
2005
2010
International Guidelines for BLS 2010
BLS Algorithm Step 1. Assess Responsiveness
Step 2. Activate the EMS and call for the defibrillator(AED)
Step 3. check for pulse in 10 sec.
Step 4. Start chest Compressions (30:2), minimize interruption Beginning with 30 compressions rather than 2 ventilations l/t shorter delays.Step 5. Open airway
Step 6. Check breathing
Step 7. Give rescue breaths, avoid excessive ventilations
As soon as a AED is available attach and fallow instructions
WORKSHOP
Ready for hands on……?
1. Check Responsiveness
2. Call for help with AED defibrillator
3. Check for Pulse (carotid pulse )
4.Start Chest Compressions
Site for chest compressions
Place hand 2 finger spaces above the xiphoid process
Place other hand over hand on sternum
Hand Position for Chest Compression
“Push hard and Push fast” Minimise interruption of chest compression
• >100 /min.
• 30:2 ratio ( C:V )
• 5 cycles (2 minutes)
• 50% : 50 % ( C/R )
• minimum 5 cm sternal depression
• Arms Straight, elbows locked,
shoulder over hands
• Complete recoil of chest
• Rescuer fatigue may lead to inadequate compression rates or depth.
• When 2 or more rescuers are available it is reasonable to switch chest compressors approximately every 2 minutes (or after about 5 cycles of compressions and ventilations at a ratio of 30:2) to prevent decreases in the quality of compressions .
• Every effort should be made to accomplish this switch in 5 seconds.
5. Open the Airway
Head Tilt –Chin Lift Maneuver
Open The Airway
Jaw Thrust Maneuver
6. Check for Breathing
7. Ventilation over 1 sec.(The Chest Must Rise)
Mouth to mouth breathing
Bag and mask ventilations
Bag and mask ventilations
Ventilation With Bag and Mask
• Rescuers can provide bag-mask ventilation with room air or oxygen.
• This amount is usually sufficient to produce visible chest rise and maintain oxygenation and normocarbia in apneic patients (Class IIa).
• If the airway is open and a good, tight seal is established between face and mask.
• Avoid excessive ventilation (30:2 for bag & mask and 8-10 breaths/min after intubation)
As long as the patient does not have an advanced airway in place, the rescuers should deliver cycles of 30 compressions and 2 breaths during CPR.
The rescuer delivers ventilations during pauses in compressions and delivers each breath over 1 second (Class IIa).
The healthcare provider should use supplementary oxygen (O2 concentration 40%, at a minimum flow rate of 10 to 12 L/min) when available.
Ventilation With an Advanced Airway When an advanced airway (ie, endotracheal
tube, Combitube, or laryngeal mask airway [LMA]) is in place during 2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths/minute).
There should be no pause in chest compressions for delivery of ventilations (Class IIb).
Attach defibrillator(AED) as soon as available and shock if indicated
D – Early Defibrillation Automated External Defibrillator
(AED)
Single greatest advance in CPR
The survival rate is 90% if the patient is defibrillated within 1 min. and only 10% if it is delayed till 10mins (Circulation 1984;69:943-8.)
Survival rate after cardiac arrest has been reported to go up from 30% to 49% (Ann Emerg Med 1996;28:480-5.)
International Guidelines for CPR 2010 vs 2005
Team work No look, listen, feel ABC -CAB sequence Beginning with 30
compressions rather than 2 ventilations . Chest compressions – >5 cm Rescuer specific cpr strategy Untrained: Hands only cpr Pulse checks are only undertaken where
there are signs suggestive of ROSC.
<10 sec. for intubation Waveform capnography (Etco2 >10 mmhg) Intra-arterial diastolic pressure >20 mmhg Atropine no longer recommended in PEA /Asystole
and it remains for peri-arrest management. Chronotrophic drug infusions used as alternative to
pacing. Advanced airway: includes supraglottic airway
devices, capnography. Interruption is allowed for only 5 sec.e.g.
Defibrillation, change over The tracheal route of drug administration is not
recommended except in neonates following the widespread introductionof intraosseous devices.
THANK YOU
Biphasic vs Monophasic Defibrillation
Advantages - greater efficacy - low energy produces same effect - less myocardial damage - less incidence of S-T changes ( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )
Energy - Monophasic 360 J - Biphasic 150/200 J
All AEDs are Biphasic
High first shock success of Biphasic defibrillation (84%-95%)
ADVANCED LIFE SUPPORT
A - Airway
Definitive airway should be secured as soon as possible
Tracheal intubation using cricoid pressure (by trained
personnel only)
Laryngeal Mask Airway (LMA) and Esophageal–tracheal
Combitube are accepted alternatives for others
Cricothyrotomy to be performed in an emergency
B. Breathing - Confirm device placement
Primary Confirmation
Direct Visualisation of ETT passing through cords
Chest expansion
5 point auscultation - L and R anterior,
- L and R mid-axillary
- Over stomach
Still in doubt –repeat laryngoscopy
Further confirmation - Exhaled CO2 detector (ETCO2) - Oesophageal detector device
Inflate cuff and secure the tube
B. Breathing – Confirm effective oxygenation and
ventilation
No synchrony between ventilation and chest
compressions once definitive airway is secured
No longer 30 : 2 compression ventilation cycles
COMPRESSION @100/min
VENTILATION @ 6 – 8 breaths/min
C. Circulation
Identify the rhythm
Defibrillation /Pacing
Secure IV line-large easily accessible peripheral veins
Give rhythm appropriate medication
Recognition of Rhythm
Cardiac Arrest (lethal rhythms)
Shockable-VF,Pulseless VT
Non Shockable – Asystole.PEA
Non Cardiac Arrest (non lethal rhythm)
Rate too fast - >120/min
Rate too slow- <60/min
Defibrillation For shockable rhythms – VF / Pulseless VT
Monophasic or Biphasic defibrillators (Biphasic preferred) Monophasic 360 J ~ Biphasic 200 J
Steps of Defibrillation - Mains plugged in or on battery, On Defib mode - ECG size/gain maximum - Set on leads: Only set on paddles if no leads - Select joules (200,300 & all others 360) - Charge, (“all clear”chant to count of 3 before discharge) - Discharge
Pacing
Disappointing results for asystole, PEA No benefit in post shock asystole
May be indicated for cardiac arrest with narrow QRS complexes
Not useful during terminal wide complex agonal rhythms
Extensive use in pre-arrest bradyarrhythmias Transcutaneous or transvenous
C-CirculationIV Access
Wide bore peripheral upper limb vein Push each bolus with 20cc fluid Raise extremity Urgent central/femoral line only if peripheral
access impossible or difficult & taking a long time to cannulate
C-Circulation Other Drug Delivery Routes
Tracheal - 2-3 times IV dose - Dilute in 10 ml saline - Preferably inject down a suction catheter which
is wedged deep into the bronchus - Rapid bagging
Intracardiac route - Not recommended - Dangerous can result in refractory VF or convert to
nonshockable rhythm
C - Circulation Rhythm appropriate medications
Epinephrine
Indicated in all cardiac arrest rhythms
i.e. VF, Pulse less VT, Asystole and PEA
IV dose is 1mg administered every 3-5 minutes
followed by 20 ml IV saline flush
Adrenaline causes intense cardio-cerebral sparing vasoconstriction CPR generates CO 25% of normal
Beneficial effects outweigh negative effects on the myocardium
Vasopressin Antidiuretic hormone and a powerful vasoconstrictor
when used in the higher doses.
Positive effects of epinephrine with lesser adverse
effects . Effect lasts for 20 minutes
Dose - 40 IU
Drug of choice for all 4 rhythms Pulseless VT , VF, Asystole and PEA
One dose of vasopressin may replace either the first or the second dose of epinephrine
Atropine
First drug of choice in symptomatic bradycardia (class I )
Second drug after epinephrine for asystole and
bradycardic PEA ( class II b ).
Dose is 1mg IV push, repeat every 3-5 minutes up to a
maximum dose of 0.04 mg /kg .
Amiodarone
Persistent or recurrent VF or VT ( class II b )
Dose is 300 mg IV push (150 mg may be repeated after
3-5 minutes ) may be followed by a 24 hour infusion of
1mg / minute for 6 hours and then 0.5 mg/minute for the
remaining 18 hours.
Amiodarone preferred over Lignocaine (class
indeterminate ) in the treatment of persistent or
recurrent VF /VT.
Sodium BicarbonateSpecific indications are as follows
class I if known pre-existing hyperkalemia class II a if known bicarbonate responsive acidosis -
TCA overdose class II b after prolonged resuscitation with
effective ventilation class III hypercarbic acidosis
The dose is 1 meq/kg bolus, repeat half this dose every
10 minutes thereafter
Calcium
Detrimental effect on ischaemic myocardiumImpairs cerebral recovery
NOT TO BE USED ROUTINELY
Indicated in PEA due to Hyperkalaemia Hypocalcaemia Ca channel blocker overdose
Magnesium sulphate
Shock refractory ventricular fibrillation in pr of possible hypomagnesemia
Torsades de pointes VT in pr of possible hypomagnesemia
Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2 min,can be repeated after 10 –15 min
D. Differential Diagnosis Review the most frequent causes ( the 5 H’s and 5 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Tamponade - cardiac
Hydrogen ions – acidosis Tension pneumothorax
Hyper / hypokalemia Thrombosis - coronary
Hypothermia trauma
hypoglycemia Thrombosis - pulmonary
ACLS - Secondary ABCD Survey
A Airway : place airway device as soon as possible
B Breathing : confirm airway device placement by examination plus confirmation device
B Breathing : secure airway deviceB Breathing : confirm effective oxygenation & ventilation
C Circulation : identify rhythm – monitorC Circulation : Defibrillation/PacingC Circulation : establish IV accessC Circulation : give medications appropriate for rhythm and condition
D Differential Diagnosis : search for and treat identified reversible causes
Monitoring the Victim - To assess effectiveness of rescue
efforts Monitor for signs of circulation and breathing
Check pulse during compression to assess
effectiveness of compression
To determine ROSC after 2 minutes of chest
compression check for pulse
ETCO2
Termination of cpr ALS
THANK YOU