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CARDIOPULMONARY RESUSCITATION

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Title: CARDIOPULMONARY RESUSCITATION


1
CARDIOPULMONARY RESUSCITATION
Department of Anaesthesia Visakha Steel General
Hospital
2
Cardio Pulmonary Resuscitation
  • Consists of mouth-to-mouth respiration and chest
    compression.
  • Allows oxygenated blood to circulate to vital
    organs such as the brain and heart.
  • Keep the person alive until more advanced
    procedures (such as defibrillation - an electric
    shock to the chest) can treat the cardiac arrest.

3
Cardio Pulmonary Resuscitation
  • Effective CPR is based on the artificial
    delivery of oxygenated blood to systemic
    circulatory beds at a rate that are sufficient to
    preserve vital organ function at same time
    providing the physiologic substrate for rapid
    return of spontaneous circulation.

4
HISTORICAL REVIEW
  • 5000 - first artificial mouth to mouth
    3000 BC ventilation
  • 1780 first attempt of newborn
    resuscitation by blowing
  • 1874 first experimental direct cardiac
    massage
  • 1901 first successful direct cardiac massage
    in man
  • 1946 first experimental indirect cardiac
    massage and defibrillation
  • 1960 indirect cardiac massage
  • 1980 development of cardiopulmonary
    resuscitation due to the works of Peter
    Safar

5
all cases accompanied with hypoxia
extracardiac
Causes of cardiac arrest
cardiac
Primary lesion of cardiac muscle leading to the
progressive decline of contractility,
conductivity disorders, mechanical factors
6
Diagnosis of cardiac arrest
Blood pressure measurement ? Taking the pulse on
peripheral arteries ? Auscultation of cardiac
tones
Loss of time !!!
Symptoms of cardiac arrest
  • absence of pulse on carotid arteries a
    pathognomonic symptom
  • respiratory arrest may be in 30 seconds after
    cardiac arrest
  • enlargement of pupils may be in 90 seconds
    after cardiac arrest

7
Sequence of operations
  • Check responsiveness
  • Call for help
  • Correctly place the victim and ensure the open
    airway
  • Check the presence of spontaneous respiration
  • Check pulse
  • Start external cardiac massage and artificial
    ventilation

8
Cardio Pulmonary Resuscitation
  • BLS basic life support.
  • ACLS advanced cardiac life support.

9
Main stages of resuscitation
  • A irway ensure open airway by preventing the
    falling back of tongue, tracheal intubation
  • Breathing start artificial respiration of lungs
  • Circulation restore the circulation by external
    cardiac massage
  • Differentiation, Drugs, Defibrillation quickly
    perform differential diagnosis of cardiac arrest,
    use different medication and electric
    defibrillation in case of ventricular
    fibrillation

10
A (Airway) ensure open airway
11
A (Airway)  ensure open airway
12
B (Breathing)   Tilt the head back and listen
for. If not breathing normally, pinch nose and
cover the mouth with yours and blow until you see
the chest rise.
13
B (Breathing)
  • EFFCTIVE RESCUE BREATHS

14
Airway management
  • Mouth-mouth respiration (pocket face masks).
  • Mouth-mouthnose respiration.
  • Bag mask ventilation.
  • Airways (nasal oral).
  • Endotracheal tubes.
  • Laryngeal mask airways.
  • Combitubes.

15
Airways (nasal oral)
16
Laryngeal mask airways
17
Endotracheal tubes.
18
  • Closed chest compressions only effective if
    the patient successfully ventilated.

19
Algorithm for artificial ventilation
mouth to mouth or mouth to nose respiration
ventilation by a face mask and a self-inflating
bag with oxygen
2 initial resecuebreaths
wait for the end of expiration
10-12 breaths per minute with a volume of app.
800 ml, each breath should take 1,5-2 seconds
20
Air way obstruction
  • Choking Conscious Infant (lt1 years old)
  • Determine if the infant can cry or cough. If not,
    proceed to next step
  • Give 5 back blows.
  • Give 5 chest thrusts.
  • Repeat steps 2 3 above until effective or the
    infant becomes unconscious. If the infant becomes
    unresponsive, perform CPR- if you see an object
    in the throat or mouth, remove it.

21
Choking Conscious Child - adult
  • Perform an abdominal thrust (Heimlich Maneuver)
    repeatedly until the foreign body is expelled.
  • If the adult or child becomes unresponsive
    perform CPR.if you see an object in the throat
    or mouth, remove it.

22
Circulation-Check the pulse
Check the pulse on carotid artery using fingers
of the other hand. In infants brachial pulse is
more easily located palpated than the carotid
pulse.
23
C. Circulation Restore the circulation, start
external cardiac massage
24
C. Circulationexternal cardiac massage
  • EFFECTIVE CHEST COMPRESSIONS

25
  • Delivery of oxygenated blood during cardiac
    arrest CPR is dependent on the effectiveness of
    chest compressions
  • Interruption of chest compression lt10 sec except
    during ET insertion or defibrillation.

26
2 mechanisms explaining the restoration of
circulation by external cardiac massage
Cardiac pump
Thoracic pump
27
Cardiac pump during the cardiac massage
Blood pumping is assured by the compression of
heart between sternum and spine
Between compressions thoracic cage is expanding
and heart is filled with blood
28
Thoracic pump at the cardiac massage
  • Blood circulation is restored due to the change
    in intra thoracic pressure and jugular and
    subclavian vein valves
  • During the chest compression blood is directed
    from the pulmonary circulation to the systemic
    circulation. Cardiac valves function as in normal
    cardiac cycle.

29
ALGORITHM of Cardiopulmonary resuscitation
a
2 breaths (duration 1.5 2 sec.)
palpation of pulse on carotid arteries (5 10
sec.)
in case of absence of pulse initiate external
cardiac massage
2 persons
1 person
a
compression rate 80 100/min. compression/breath
15 2
compression rate 80 100/min compression/breath
5 1
a
2 breaths in 4 7 sec.
breath during 1 1.5 sec. after each 5th
compression
4 cycles 15 compression and 2 breaths
10 cycles 5 compression and 1 breath
check the pulse on carotid arteries (5 sec)
in case of absence of pulse continue resuscitation
30
During CPR
  • Push hard fast(100/min)
  • Compressions to relaxation ration 5050
  • Ensure full chest recoil

31
During CPR
  • Avoid hyperventilation
  • Secure airway confirm placement
  • Rotate compressors every 2min with rhythm checks
  • After an advanced airway is placed, rescuers no
    longer deliver cycles of CPR. Give continuous
    chest compressions without pause for breaths.
    Give 8-10 breaths/min. check every 2min.

32
Infant CPR
  • Shout and gently tap the child on the shoulder.
    If there is no response, position the infant on
    his or her back

33
Infant CPR
  • If the baby is NOT breathing give 2 small gentle
    breaths.
  • Cover the baby's mouth and nose with your mouth.
  • Each breath should be 1 second long.
  • You should see the baby's chest rise with each
    breath.

34
Child CPR 1-8 years
  • CPR for children is similar to CPR for adults.
    The compression to ventilation ratio is 152.
    There are, however, 3 differences.
  • 1) If you are alone with the child give two
    minutes of CPR before calling help
  • 2) Use the heel of one hand as for adults for
    chest compressions
  • 3) Press the sternum approximately one-third the
    depth of the chest

35
CPR
  • Pushing on the Chest
  • Sometimes you may hear a cracking sound.
  • The sound is caused by cartilage or ribs
    cracking.
  • Even if this occurs the damage is not serious.
  • The risk of delaying CPR or not doing CPR is far
    greater than the risk of a broken rib.

36
Types of CPR
  • Closed Compression CPR.
  • ACD-CPR active compression decompression CPR.
  • IAP-CPR (Interposed Abdominal Counterpulsation
    CPR).
  • Vest-CPR.
  • Invasive CPR.

37
Search for treat possible contributing factors
  • Toxins
  • Tamponade,
  • Tension pneumothorax
  • Thrombosis(coronary or pulmonary)
  • Trauma
  • Hypovolemia
  • Hypoxemia
  • Hydrogen ion
  • Hypo/hyperkalemia
  • Hypoglycemia
  • Hypothermia

38
Summary of recommended BLS techniques
39
Possible arrhythmias
  • ventricular tachycardia fibrillation
  • bradyarrythmia including electromechanical
    dissociation and asystole
  • supraventricular arrhythmia accompanied with
    tachycardia
  • supraventricular arrhythmia with normal blood
    pressure and pulse rate

40
VENTRICULAR FIBRILLATION OR PULSELESS TACHYCARDIA
Witnessed
Unwitnessed
Precordial thump
Check pulse, if none
  • Begin CPR
  • Defibrillate with 200 joules
  • Establish IV access, intubate
  • Defibrillate with 200 joules
  • Adrenaline 1 mg push
  • Defibrillate with 200 joules
  • Amiodarone 300mg IV,followed by 150mg or
    lidocaine 1-1.5mg IV, followed by 0.5 -0.75mg/kg

41
How to use defibrillator
  • Turn on defibrillator
  • Select energy level
  • Apply gel to pads
  • Position the paddles
  • Press charge button
  • When defibrillator fully charged state firmly in
    a forceful voice
  • I am going to shock on three.
  • Two youre clear
  • Three ever body clear
  • Apply 25lb of pressure on both paddles
  • Press the 2 paddle discharge button
    simultaneously

42
  • Defibrillation
  • Complete depolarisation
  • Asystole
  • Resumption normal cardiac automaticity

43
  • A single shock strategy preferable to the
    traditional triple shock strategy

44
DEFIBRILLATION
  • Treatment of choice for VT VF
  • Single most effective resuscitative measure for
    improving survival in cardiac arrest
  • Time elapsed from the cardiac arrest to the first
    electric shock is the most important factor in
    determining the survival
  • Biphasic defibrillators needs lower energy than
    monophasic

45
DEFIBRILLATION
  • Shock should be delivered with in 3min
  • CA occurs outside the hospital response time is
    gt5min ,a brief period of CPR followed by shock
  • Chance of survival declines 7-10 for every min
    without defibrillation

46
AED(automated external defibrillation)
  • Technologically advanced, microprocessor-based
    devices that are capable of electrocardiographic
    analysis, with excellent recognition of cardiac
    rhythm VF
  • Deliver impendence compensating biphasic shocks.
  • One electrode is placed on the upper rt sternal
    border, just below the clavicle other lateral
    to the lt nipple below the axilla.

47
AED(automated external defibrillation)
48
AED (automated external defibrillation
49
AED
50
Energy Requirements Monophasic Shocks
51
Operations in case of asystole
Asystole/PEA
  • Start CPR
  • IV line
  • AdrenalineIV 1 mg, each 3-5 min.
  • or
  • intratracheal 2 - 2.5 mg
  • in the absence of effect increase the dose
  • Atropine 1 mg push (repeated once in 5 min)
  • Na Bicarbonate 1 Eq/kg IV
  • Consider pacing

52
Drug Administration During CPR
  • Cannulation of peripheral veins- does not require
    interruption of CPR.
  • Injected as bolus followed by 10-20ml of IV
    fluid.
  • If initial drug injection is unsuccessful,
    perform CVP.
  • Alternate sites - Intraosseous(I O),ET tube
  • Drugs administered through ET tube
    atropine,adrenaline,vasopressin,xylocaine

53
Cardiac arrest drugs vasopressors
54
Cardiac arrest drugsantiarrhythmic agents
55
Monitoring during CPR
  • Arterial pulse pressure are not reliable
    markers of blood flow during CPR.
  • Size of the pressure pulse 50mmHg systole
    indicates chest compressions were successful in
    promoting systemic blood flow.
  • CPP gt 15mmof Hg successful outcome.
  • End Tidal CO2 indirect indicator of the CO
    generated during CPR.
  • Increase in ETCO2 during CPR is predictive of
    successful outcome.

56
Monitoring during CPR
  • Pupillary size
  • Pupil that are persistently contracted or
    initially dilated but subsequently contracted
    are associated with a greater likelihood of
    successful resuscitation neurological recovery
    than persistently dilated or subsequently
    dilating pupils.

57
How long to resuscitate
  • Risk of functional impairment in any of the major
    organs is directly related to the duration of the
    ischemic insult.
  • CPR continued for 30min if the time to onset of
    CPR is lt6min.
  • Onset of CPR gt6min CPR can be terminated after
    15min.

58
Predicting neurological recovery
  • Who do not awaken immediately after CPR- most
    important determination is neurologic recovery.
  • Coma gt 24hrs - 10 chance of neurologic
    recovery.
  • Coma gt 72hrs - 5 chance of neurologic recovery.
  • Coma gt 2wks - no chance of full neurologic
    recovery.
  • 72hrs point or GCSlt5 little or no chance of
    neurological recovery.

59
Cardio Pulmonary Resuscitation
  • Cardio Pulmonary - Cerebral Resuscitation (CP-CR)

60
CPR - CPCR
  • Avoid hyperventilation impair ability of chest
    compressions to generate blood flow.
  • As early as possible give DC shock
  • Avoid prolonging CPR beyond a reasonable time
    period.
  • Goal of CPR is a functioning heart in
    functioning person

61
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