12.cardiopulmonary resuscitation (88) dr. rahul tiwari

Dr. Rahul TiwariFinal Yr. MDS

OMFS-SIDS

CARDIOPULMONARY RESUSCITATION

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• INTRODUCTION• HISTORY• PHYSIOLOGY• CPR-• BLS• ACLS• CONCLUSION• REFERENCES

CONTENTS

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•

DEFINITION

Cardiopulmonary resuscitation (CPR) is an emergency procedure which is performed in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person in cardiac arrest.

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• BLS ( Basic Life Support) . • ACLS (Advanced Cardiovascular Life Support) .

APPROACH

Support & restore effective oxygenation, ventilation and circulation with return of intact neurological function. Intermediate Goal: Return of spontaneous circulation (ROSC)

GOAL

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MECHANISM

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• It is the sudden and unexpected cessation of ventilation and circulation.

• It may result from pulse less electrical activity, ventricular tachycardia, ventricular fibrillation or ventricular stand still.

• Clinical death occurs at the moment of cardiopulmonary arrest (may be reversed if recognized promptly and effectively managed preventing biological death).

• Biological death follows when permanent cellular damage has occurred primarily from lack of oxygen.

CARDIAC ARREST

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• Brain damage begins 4 - 6 minutes after cardiac arrest.

• Brain damage becomes irreversible in 8 - 10 minutes.

CARDIAC ARREST

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• Absence of ventilation is detected by lack of thoracic or abdominal movements, absence of breath sounds & absence of air movements through nose and mouth.

• Absence of circulation is detected by lack of carotid or femoral pulse. It is confirmed by dilated pupils, unresponsiveness & comatose state.

RECOGNITION

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CHAIN OF SURVIVAL

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HISTORICAL REVIEW 5000 – 3000 BC - first artificial mouth to mouth

ventilation1780 – first attempt of newborn resuscitation by blowing

1874 – first experimental direct cardiac massage1901-first successful direct cardiac massage in man1946 – first experimental indirect cardiac massage and defibrillation

1960 – indirect cardiac massage1980 – development of cardiopulmonary

resuscitation due to the works of Peter Safar

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CardiopulmonaryResuscitation

A - AirwayB - Breathing C - CirculationD- Defibrillation

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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.

CARDIO PULMONARY RESUSCITATION

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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

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• Airway – ensure open airway by preventing the falling back of tongue

• Breathing – start artificial respiration• 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

MAIN STAGES OF RESUSCITATION

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BEFORE BLS

Assess ActionScene safety For you and victim

Check responsiveness Tap/ shake and shout“Are you all right?”

Activate emergency response system and get AED

Alone- shout for help.Activate emergency 108Get AED…if availableReturn to victim ……start CPR

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• CPR and defibrillation within 3-5 minutes can save over 50% of

cardiac arrest victims

• CPR followed by AED saves thousands of lives each year

• In most cases CPR helps keep victim alive until EMS or AED

arrives

CPR SAVES LIVES

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Airway

Head tilt, Chin lift, Jaw thrustKeeping airway open- LOOK, LISTEN, FEEL

LOOK LISTEN FEEL

CHEST MOVEMENTS BREATH SOUNDS AIR FLOW RESP. RATE VOICE QUALITY CHEST

MOVEMENTSCYANOSIS ABNORMAL SOUNDS TRAUMAFLUID/BLOOD /VOMITINGNOT MORE THAN 10 SECONDS

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A (AIRWAY) ENSURE OPEN AIRWAY

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A (Airway) ensure open

airway

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KEEPING THE AIRWAY OPEN, LOOK, LISTEN, AND FEEL FOR NORMAL BREATHING. ……OPEN AIRWAY

2 EFFECTIVE RESCUE BREATHS

• TIDAL VOL. 8-10 ml/kg• Deliver in one sec.• Chest rise/ expand

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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.

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LOOK, LISTEN AND FEEL FOR NORMAL BREATHING

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IF HE IS BREATHING NORMALLY• TURN HIM INTO THE RECOVERY POSITION• SEND OR GO FOR HELP, OR CALL FOR AN AMBULANCE.• CHECK FOR CONTINUED BREATHING.

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IF HE IS NOT BREATHING NORMALLY• Give 2 rescue breaths• Pinch the nose• Take a normal breath• Place lips over mouth• Blow until the chest

rises• Take about 1 second• Allow chest to fall• Repeat

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C. CirculationRestore the circulation, start external

cardiac massage

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C. CIRCULATIONEXTERNAL CARDIAC MASSAGE

• EFFECTIVE CHEST COMPRESSIONS

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• Delivery of oxygenated blood during cardiac

arrest & CPR is dependent on the effectiveness

of chest compressions

• Interruption of chest compression <10 sec

except during ET insertion or defibrillation.

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DURING CPR

• Push hard & fast(100/min)• Compressions to relaxation ration 50:50

• Ensure full chest recoil

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• Patient positioning:Firm and hard surface (ground, table/ hard bed) deflate air/ water mattresses.

• Rescuer's position:Level with patient, elbows vertically straight and locked, shoulders directly above the hands, heel of one palm over the other.

• Site :lower half of sternum in inter-mammary line 1-1 ½ inches above the xiphiod process

• Depth: 1 1/2- 2 inches.• Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.).• Allow complete chest recoil.

CHEST COMPRESSIONS

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CHEST COMPRESSIONS30 CHEST COMPRESSIONS

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Put hand(s) in correct position for chest compressions

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Give 30 chest compressions at rate of 100 per minute

Then give 2 ventilations

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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.

CHEST COMPRESSIONS• Rate: 100/MIN., SITE- Sternal depression -1.5 in.-2 in.•Universal compression-ventilation ratio (30:2) - Recommended for all single rescuers of infant, child and adult victims (excluding newborns)

30:2- ALL ADULTS, 15:2 – Infants and child PURPOSE : PUSH HARD,PUSH FAST

PULSE PRESENT

CONTINUE VENTILATION TILL SPONTANEOUS RESPIRATION

PULSE ABSENT / NOT DETECTED

CHECK FOR SIGNS OF CIRCULATION

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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..

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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.

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•

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 <6min.

• Onset of CPR >6min CPR can be terminated after 15min.

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PROBLEMS AND COMPLICATIONS OF CHEST COMPRESSIONS

1. RIB FRACTURES2. FRACTURE STERNUM3. RIB SEPARATION4. PNEUMOTHORAX5. HEMOTHORAX6. LUNG CONTUSIONS7. LIVER LACERATIONS8. FAT EMBOLI9. INFECTIONS

MANAGE ACCORDINGLY BUT CONTINUE CPR

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Advanced, invasive assessment and management techniques required.

Basic airway adjuncts: OPA, NPAAdvanced Airway interventions:Combitube, LMA, Endotracheal intubation.Advanced circulatory interventions:Drugs to control heart rhythm and blood pressure.

ACLS

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• It is J shaped device used in unconscious pateints when basic procedures fail to maintain open airway.

• This device fits over the tongue to hold it and the soft hypopharyngeal structures away from the posterior wall of pharynx.

OROPHARYNGEAL AIRWAY

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OROPHARYNGEAL AIRWAY/GUEDEL

• Different colours = different sizes

• Neonate to large adult

SIZE COLOUR000 VioletOO BlueO Black1 White2 Green3 Orange4 Red5 Yellow

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OROPHARYNGEAL AIRWAYS

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•

OROPHARYNGEAL AIRWAY/GUEDEL

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The size of the Guedel airway is the distance between the center of the incisors and the angle of the jaw (on the same side!)

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• Clear the mouth and pharynx using pharyngeal suction tip.• Select proper size OPA.• Insert the OPA so that it is turned backward as it enters the

mouth.• When the posterior wall of pharynx is approached rotate it 180

degrees into proper position.

STEPS

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OROPHARYNGEAL AIRWAY INSERTION

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• Indications: To open and maintain an airway in a patient with a depressed level of consciousness

OROPHARYNGEAL AIRWAY/GUEDEL

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PROBLEMS

Patient won’t accept it Risk of vomiting & aspiration

OROPHARYNGEAL AIRWAY/GUEDEL

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• For maintaining airway in “more awake” patients

• Sits in nasopharynx and opens airway

NASOPHARYNGEAL AIRWAY

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• It is soft rubber or plastic uncuffed tube that provides airway between nares and the pharynx.

• Can be used in concsious or semiconscious patients.• It is used when insertion of OPA is difficult or

impossible(strong gag reflex,trismus,trauma around mouth and wiring of jaws).

NASOPHARYNGEAL AIRWAY

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Estimate by comparing to patients little finger

Lubricate

Gently push posteriorly towards ear on same side

NASOPHARYNGEAL AIRWAY

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• Contra-indications:

Base of skull fracture

Serious midline facial fractures

When definitive airway needed

NASOPHARYNGEAL AIRWAY

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NASOPAHRYNGEAL AIRWAY SIZES

• Measure from tip of nose to bottom of earlobe

• Also based on diameter of patient’s nares

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• Select proper size NPA.

• Lubricate the airway with anesthetic jelly.

• Insert the airway through nostril in a posterior

direction,if any resistence is encountered slightly

rotate or attempt placement through other nostril.

STEPS

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NASOPHARYNGEAL AIRWAY INSERTION

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NASOPHARYNGEAL AIRWAY INSERTION

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• Essential component of maintaining airway.

• Prepared to perform when the airway becomes

occluded with secretions,blood or vomit.

• Portable suction devices- -80 to -120mmHg.

• Wall mounted suction devices- -300mmHg.

SUCTIONING

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• Soft flexible used for aspiration of thin secretions

from the oropharynx and nasopharynx,intratracheal

suctioning,suctioning through NPA.

• Rigid for suctioning oropharynx,particularly if there

is thick particulate matter.

SOFT V/S RIGID CATHETERS

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• Most basic piece of “airway” kit• Different types - clear, black - cushion around edge• Won’t maintain airway by self• Needs head tilt/chin lift or jaw thrust• Also needs Positive Pressure Ventilation

MASK

Ventilation of the lungs single most important and most effective step in cardiopulmonary resuscitation of the compromised newborn

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• Cushioned/Non-cushioned• Round/Anatomical shaped• Size 0 or 1

MASKS

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CORRECT POSITION OF MASK

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• Inserted Through Nose or Mouth• Nasal Route Preferred in Awake Patients• Oral Route Preferred in Coma or Uncooperative Patients• Tracheostomy Preferred for Long Term Intubation• Laryngoscope help

ENDOTRACHEAL INTUBATION

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COMPLICATIONS OF INTUBATION

• Epistaxis• Esophageal Intubation• Nasal, Septal Necrosis• Bacteremia• Dental Trauma• Occlusion from Biting on Tube• Laryngeal Damage

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TUBE PLACEMENT

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• Laryngeal mask airway

• Advanced airway

• Useful alternative for “difficult intubation”

• Easy to use

• Sits on larynx - Protects lungs

LMA

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LMA

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• Indications:

Unconscious or anaesthetized patients

AHA Guidelines for adults:

BLS: alternative to ventilation ACLS: Optional/alternative to ventilation, failed ETT

LMA IN EMERGENCY MEDICINE

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• Disadvantages:

Needs adequate training

Risk of aspiration

Limited Paediatric use

Not always successful

LMA IN EMERGENCY MEDICINE

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LMA INSERTION

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COMBITUBE®

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• Advantages: Protect airway from aspiration. Easy to use AHA: alternative to ETT• Disadvantages: Trauma to soft tissues. No availability.

COMBITUBE®

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„Pharyngeal“ lumen No. 1

„Esophago-tracheal“ lumen No. 2

Esophageal - tracheal

COMBITUBE

Oropharyngealballoon

Distalcuff

Perforations

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• Head neutral or slightly flexed• Hold tongue and jaw between thumb & forefinger

and lift • Gently insert Combitube® in a curved back and

downward movement until black markers aligned with teeth

• Inflate (proximal) pharyngeal balloon• Inflate (distal) tracheal balloon• Confirm which one of #1 or #2 tube is in lungs by

using bag ventilator

COMBITUBE®

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COMBITUBE® INSERTION

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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

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DEFIBRILLATION

• Shock should be delivered with in 3min• CA occurs outside the hospital response time is

>5min ,a brief period of CPR followed by shock• Chance of survival declines 7-10% for every min

without defibrillation

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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.

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AED(AUTOMATED EXTERNAL DEFIBRILLATION)

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AED (AUTOMATED EXTERNAL DEFIBRILLATION

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AED (AUTOMATED EXTERNAL DEFIBRILLATION

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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 you are clear• Three every body clear• Apply 25lb of pressure on

both paddles• Press the 2 paddle discharge

button simultaneously

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POSITIONING OF ELECTRODES FOR AUTOMATED EXTERNAL DEFIBRILLATOR

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ANALYSING RHYTHM DO NOT TOUCH VICTIMSHOCK INDICATEDSTAND CLEAR

DELIVER SHOCKIF VICTIM STARTS TO BREATH NORMALLY PLACE IN RECOVERY POSITION

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• The science of cardiopulmonary resuscitation is developing rapidly.

• We as physicians and first responders must stay updated.

• We must also adjust our practice of medicine accordingly.

CONCLUSIONS

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1. Medical emergencies in dental office -Malamed

2. Oral and maxillofacial surgery-laskin.

3. General medicine-Davidson

4. Text book of pharmacology-Tripathi

5. Advanced cardiovascular life support-Manual of

American Heart Association

REFERENCES

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Thank you

Take some time to learn FIRST AID & CPR. It saves lives which is life long. But when a heart stops every second counts.