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
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