CPR & ELECTRICAL THERAPIES

BAGIAN ANESTESIFK UNISSULA SEMARANG

CARDIAC ARREST

• The cessation of cardiac mechanical activity, as confirmed by the absence of signs of circulation.

SUDDEN CARDIAC ARREST

• Circumstances– Witnessed– Unwitnessed

• Settings– Out of hospital– In hospital

A single approach to resuscitation is not practical, but a core set of actions provides a universal strategy for achieving successful resuscitation.

Chain of Survival

CONCEPTUAL FRAMEWORK FOR CPR

• Rescuer : everyone can be a lifesaving rescuer for a cardiac arrest victim. CPR skills and their application depend on the rescuer’s training, experience, and confidence.

• The 30 : 2 ratio in adults is based on a consensus among experts and on published case series.

CONCEPTUAL FRAMEWORK FOR CPR

• When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates.

• A brief period of chest compression can deliver oxygen and energy substrates and “unload” the volume-overloaded right ventricle, increasing the likelihood that a perfusing rhythm will return after shock delivery.

5 CHAIN OF SURVIVALAHA 2010

SURVIVAL RATES

• Survival rates from witnessed VF SCA decrease 7% to 10% if no CPR is provided.

• When these links are implemented in an effective way, survival rates can aprroach 50% following witnessed out of hospital VF arrest.

BASIC LIFE SUPPORT

• BLS care in the out of hospital setting is often provided by laypersons.

• The first 3 BLS links in the adult Chain of Survival : recognition and activation, early CPR, and rapid defibrillation (when appropriate).

ADVANCED LIFE SUPPORT

• ACLS in the chain of survival that include interventions to prevent cardiac arrest, treat cardiac arrest, and improve outcomes of patients who achieve ROSC.

• For the treatment of cardiac arrest, ACLS interventions build on the BLS + increase ROSC with drug therapy, advanced airway management, and physiologic monitoring.

1. Immediate Recognition of SCA (ERS)

• Check for response based on assesing unresponsiveness while looking at the patient to determine the absence of normal breathing (the victim is not breathing or only gasping). Suspect cardiac arrest if victim is not breathing or only gasping.

2. Look, Listen, and Feel has been removed

• Performance of these steps is inconsistent and time consuming. For this reason the 2010 AHA Guidelines for CPR and ECC stress immediate activation of the emergency response system and starting chest compressions for any unresponsive adult victim.

3. Hands only CPR

• Only about 20 – 30% of adults with out-of-hospital cardiac arrest recieve any bystander CPR.

• Hands-Only CPR (compression-only) for the untrained lay rescuer. Hands-Only CPR is easier to perform by those with no training and can be more readily guided by dispatcher over the telephone.

3. Hands only CPR

• If a bystander is not trained in CPR, then the bystander should provide Hands-Only (chest compression only) CPR, with an emphasis on “push hard and fast”.

• How can bystander CPR be effective without rescue breathing? Initially during SCA with VF, rescue breaths are not as important as chest compressions because the oxygen level in the blood remains adequate for the first several minutes after cardiac arrest.

4. C – A – B rather than A – B – C

• A change in the 2010 AHA Guidelines for CPR and ECC is to recommend the initiation of chest compression before ventilation (rescue breath).

5.   Minimal Interruption in Chest Compressions

• Limiting the frequency and duration of interruptions in chest compressions may improve clinically meaningful outcomes in cardiac arrest patients.”

• Health care providers continue effective chest compression / CPR until ROSC or termination of resuscitative efforts.

5.   Minimal Interruption in Chest Compressions

• Vascular access, drug delivery and advanced airway placement should not cause significant interruptions in chest compression or delay defibrillation.

• During CPR, a goal to limit interruptions to no more than 10 seconds.

6. Increased high-quality CPR• Compressions of adequate rate and depth,

allowing full chest recoil between compressions, minimizing interruptions in chest compressions.

• The adult sternum should be depressed at least 2 inches (5 cm)”.

• “It is reasonable for lay rescuers and healthcare providers to perform chest compressions at a rate of at least 100x/min.”

7. Cricoid Pressure isn’t Recommended

• CP is a technique of applying pressure to the victim’s cricoid cartilage to push the trachea posteriorly and compress the esophagus againts the cervical vertebrae.

• 2005 : CP can prevent gastric inflation & reduce the risk of regurgitation & aspiration during BVM ventilation.

7. Cricoid Pressure isn’t Recommended

• New RCT : CP can delay prevent the placement of advanced airway & the aspiration can occur despite application of CP.

8. Precordial Thump

• Precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrythmias when a defibrillator is not immediately ready for use, but should not delay CPR and shock delivery.

• In 3 case series : VF / pulseless VT was converted to a perfusing rhthm by a PT.

• There is insufficient evidence to recommend for againts the witnessed onset of asystole.

CHEST COMPRESSION

1. Care should be taken to minimize interruptions in chest compressions when placing, or ventilating with an advanced airway.

2. Because delay in chest compressions should be minimized, the HP should take no more than 10 seconds to check for a pulse, and if the rescuer does not definitely feel a pulse within that time period the rescuer should start chest compressions.

CHEST COMPRESSION

3. Incomplete recoil during BLS CPR is associated with ↑ intrathoracic pressure significantly ↓ hemodynamics (↓ coronary perfusion, ↓ cardiax index, ↓ myocardial blood flow & ↓ cerebral perfussion).

4. It is reasonable to switch chest compressors approximately every 2 minutes to prevent decreases in the quality of compressions.

COMPRESSION : VENTILATION

• When an advanced airway (ET, combitube or LMA) is in palce during 2 person CPR, continuous chest compressions (there should be no pause in chest compressions for delivery of ventilations). Performed at a rate of at least 100/min without pauses and give 1 breath every 6 – 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths/minute).

VENTILATION

• Studies in anesthetized adults (normal perfusion) suggest that a tidal volume of 8 – 10 ml/kg maintains normal oxygenation and elimination of CO2.

• During CPR, cardiac output is ≈ 25 – 33% of N oxygen uptake from the lungs and CO2 delivery to the lungs are also reduced. As a result, a low minute ventilation (lower than normal TV and respiratory rate) can maintain effective oxygenation and ventilation.

VENTILATION

• For that reason during adult CPR tidal volumes of approximately 500 – 600 mL (6 – 7 ml/kg) should suffice. This is consistent with a tidal volume that produces visible chest rise.

VENTILATION

• Excessive ventilation is unnecessary & can cause gastric inflation and its resultant complications, such as regurgitation and aspiration.

• Excessive ventilation can be harmful increase intrathoracic pressure decrease venous return to the heart diminishes cardiac output and survival.

VENTILATION

• Bag mask ventilation : the rescue should use an adult (1 to 2 L) bag to deliver approximately 600 mL TV for adult victims.

• Deliver by squeezing a 1 L adult bag about two thirds of its volume.

• The HP should use supplementary oxygen (O2 concentration >40%, at minimum flow rate of 10 – 12 L/min) when available.

DROWNING

• The duration and severity of hypoxia sustained as a result of drowning.

• There is no evidence that water acts as an obstructive foreign body. Manuevers to relieve FBAO are not recommended for drowning victims because such manuevers aren’t necessary and they can cause injury, vomiting, aspiration & delay CPR.

DROWNING

• When rescuing a drowning victim of any age, it is reasonable for the lone HP to give 5 cycles of CPR before leaving the victim to activate the EMS system.

DROWNING

• As soon as the unresponsive victim is removed from the water open the airway check for breathing if there’s no breathing give 2 rescue breaths that make the chest rise check the pulse if there’s no pulse begin chest compressions.

• Dry the chest area before applying the defibrillation pads and using the AED.

HYPOTHERMIA

• Body temperature : mild (> 34oC), moderate (30-34oC), severe hypothermia (< 30oC).

• If the victim is unresponsive with no normal breathing, lay rescuer should begin chest compressions (CPR) immediately.

• Do not wait to check the victim’s temperature and do not wait until the victim is rewarmed to start CPR.

HYPOTHERMIA

• To prevent further heat loss, remove wet clothes from the victim; insulate from wind, heat or cold; and if possible, ventilate the victim with warm, humidified oxygen.

• If VF is detected, emergency personnel should deliver shocks using the same protocols of CPR.

FBAO

• If the adult victim with FBAO becomes unresponsive, the recuer should carefully support the patient to the ground, immediately activate (or send someone to activate) EMS, and then begin CPR (without a pulse check).

• Each time the airway is opened during CPR, the rescuer should look for an object in the victim’s mouth and if found, remove it.

FBAO

• Simply looking into the mouth should not significantly increase the time needed to attempt the ventilations and proceed to the 30 chest compressions.

• No studies have evaluated the routine use of the finger sweep to clear an airway in the absence of visible airway osbtruction case report documented harm to the victim or rescuer.

PREGNANCY

• Patient positioning has emerged as an important strategy to improve the quality of CPR and resultant compression force and output.

• Left lateral tilt is used to improve maternal hemodynamics during cardiac arrest.

PREGNANCY

• Chest compressions should be performed slightly higher on the sternum than normally recommended.

• Defibrillation : use of an AED on a pregnant victim has not been studied but is reasonable.

VASOPRESSOR

• A vasopressor can be given as soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC.

• Epinephrine iv/io dose : 1 mg every 3 – 5 minutes.

• Vasopressin iv / io dose : 40 units can replace epinephrine.

VASOPRESSOR

• Three RCTs and a meta-analysis of the trials demonstrated no differences in outcomes (ROSC, survival to discharge or neurologic outcome) with vasopression 40U iv VS epinephrine 1mg as a first-line vasopressor in cardiac arrest.

• Because the effects of vasopressin haven’t been shown to differ from those of epinephrine in cardiac arrest, 1 dose of V 40 units may replace either the first/second dose of E in cardiac arrest.

ANTIARRHYTMIC AGENT• Amiodarone is the first-line AAA given

during cardiac arrest because it has been clinically demonstrated to improve the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT.

• Amiodarone iv/io : first dose : 300 mg bolus, second dose : 150 mg bolus.

• If it is unavailable, lidocaine may be considered, dose : 1 – 1,5 mg/kg iv bolus.

SULFAS ATROPINE

• Atropine sulfate reverses cholinergic-mediated decrease heart rate and atrioventricular nodal conduction.

• No prospective controlled clinical trials have examined the use of atropine in cardiac arrest.

• For this reason atropine is no longer recommended for routine use in the management of PEA / asystole & has been removed from the cardiac arrest algorithm..

OVERVIEW• Early defibrillation is critical to survival from

sudden cardiac arrest (SCA).

• The most frequent initial rhythm in out of hospital witnessed SCA is ventricular fibrillation (VF) all BLS providers should be trained to provide.

• If bystanders provide immediate CPR, many adults in VF can survive with intact neurologic function, especially if defibrillation is performed within 5 – 10 minutes after SCA.

OVERVIEW

• Rapid defibrillation is the treatment of choice for VF (witnessed out of hospital cardiac arrest or for hospitalized patients whose heart rhythm is monitored).

• Performing chest compressions while another rescuer retrieves and charges a defibrillator improves the probability of survival.

OVERVIEW

• Electrical therapies (AHA 2010) are manual defibrillator, AED, synchronized cardioversion and pacing.

• AED may be used by lay rescuers and HP as part of basic life support.

• Manual defibrillation, cardioversion and pacing are advanced life support therapies.

When Defibrillator is Performed• First provider should start CPR and second

provider should get or turn on the defibrillator, place the adhesive pads or paddles, and check the rhythm.

• Rhytm checks should be brief, and if “an organized rhythm” is observed (included VT) by manual defibrillator or cardiac monitor, a pulse check should be performed.

• If there is any doubt about the presence of a pulse, chest compression should be resumed immediately.

AUTOMATED EXTERNAL DEFIBRILLATOR

• AED are sophisticated, reliable computerized devices that use voice and visual prompts to guide lay rescuers & HP.

• Some devices are programmed to detect spontaneous movement by the patient.

AUTOMATED EXTERNAL DEFIBRILLATOR

• In studies in which EMS call-to-arrival intervals were 4 – 5 minutes or longer, 11/2 – 3 minutes of CPR before defibrillation increased the rate of initial resuscitation (ROSC), survival to hospital discharge, and 1 year survival when compared with immediate defibrillation for VF SCA.

MANUAL DEFIBRILLATOR

• The recommended energy dose of biphasic defibrillator is 200 J for terminating VF.

• The recommended energy dose of monophasic defibrillator is 360 J for terminating VF.

• In pediatrics : initial monophasic doses of 2 J/kg are effective in terminating 18% - 50% of VF.

MONOPHASIC VS BIPHASIC

• Biphasic waveform shock has been reported to be safer and more effective than a monophasic waveform shock.

• A biphasic defibrillator has lower energy requirements and is smaller and lighter in weight than a monophasic defibrillator.

• Almost all defibrillators currently available commercially are biphasic defibrillator.

MONOPHASIC VS BIPHASIC

• A study in Japan 2005 – 2007 hypotesis : the survival of patients at 1 month with minimal neurological impairment who recieved defibrillation shock with the BD is better than the survival of patients who received defibrillation shock with the MD.

• Minimal neurological impairment was defined as Glasgow-Pittsburgh cerebral performance category 1 (good) or 2 (moderate disability).

MONOPHASIC VS BIPHASIC

• Results : no significant difference was observed between the patients who were shocked with a biphasic defibrillator or with a monophasic defibrillator.

• Discussion : BD have several advantages compared with MD, including a lower burden for EMS personnel because of their lower weight and greater portability.

ROSC• When a rhythm check using a manual

defibrillator or cardiac monitor reveals an organized rhythm, a pulse check is performed.

• If a pulse is detected ROSC it is important to begin post-cardiac arrest care immediately to avoid re-arrest and optimize the patient’s chance of long term-survival with good neurologic function.

ROSC• The treatable causes of cardiac arrest : The

H’5 and T’5– Hypoxia - Toxins– Hypovolemia - Tamponade– Hydrogen ion (acidosis) (cardiac)– Hypo/hyperkalemia - Tension– Hypotermia pneumothorax

- Thrombosis

(pulmonary)

- Thrombosis

(coronary)

TREAT H’5 & T’5

1. Hypoxemia placement of an advanced airway to achieve adequate oxygenation or ventilation.

2. Hypovolemia administer iv/io crystalloid or blood transfusion.

3. Pulmonary embolism fibrinolitic therapy.

4. Tension pneumothorax needle decompression.

5. Etc

RECOVERY POSITION

• Applied for out of hospital cardiac arrest.

• Used for unresponsive adult victims who clearly have normal breathing and effective circulation.

• RP is designed to maintain a patent airway and reduce the risk of airway obstruction and aspiration.

• The victim is placed on his or her side with the lower arm in front of the body.

RECOVERY POSITION

• No single position is perfect of for all victims.

• The position should be stable, near a true lateral position, with the head dependent and with no pressure on the chest to impair breathing.

TERMINATION OF RESUSCITATIVE EFFORTS

BY TIME

• Basic Life Support Asystole ≥ 10 minutes.

• Advanced Life Support 20 minutes.