C.P.R

Cardio Pulmonary Resusciation

Presented by H. Hosseini MD

Sudden cardiac arrest is the sudden, unexpected loss of heart function, breathing and consciousness. Sudden cardiac arrest usually results from an electrical disturbance in heart that disrupts its pumping action, stopping blood flow to the rest of the body .

Sudden cardiac arrest

Sudden cardiac death (SCD) is an unexpected death due to cardiac causes occurring in a short time period (generally within 1 h of symptom onset) in a person with known or unknown cardiac disease. Most cases of SCD are related to cardiac arrhythmias. Approximately half of all cardiac deaths can be classified as SCDs.

Sudden cardiac death

EPIDEMIOLOGY AND SURVIVAL — Sudden cardiac arrest (SCA) is a leading cause of death in both the United States and Canada ,outranked only by cancer. Approximately 400,000 people in the United States and 700,000 people in Europe ,suffer SCA each year. The most common etiology of SCA is ischemic cardiovascular disease resulting in the development of lethal arrhythmias. Resuscitation is attempted in up to two-thirds of people who sustain SCA

Coronary heart diseaseApproximately 60–70% of SCD is related to coronary heart disease.[Among adults, ischemic heart disease is the predominant cause of arrest with 30% of people at autopsy showing signs of

myocardial infarctionNon ischemic heart diseaseA number of other cardiac abnormalities can increase the risk of SCD including: cardiomyopathy,cardiac rhythm disturbances, hypertensive heart disease,[congestive. Hert failure[

Non–cardiacSCDs is unrelated to heart problems in 35% of cases. The most common non–cardiac causes: trauma, non-trauma related bleeding (such as gastrointestinal bleeding, aortic rupture, and

intracranial hemorrhage), overdose, drowning and pulmonary embolism

causes

Basic life support consists of cardiopulmonary resuscitation and, when available, defibrillation

using automated external defibrillators (AED) .

Phases of resuscitation  Electrical phase: 

 —The electrical phase is defined as the first four to five minutes of arrest due to ventricular fibrillation (VF). Immediate DC cardioversion is needed to optimize survival of these patients. Performing excellent chest compressions while the defibrillator is

readied also improves survival. :Hemodynamic phase 

 —The hemodynamic or circulatory phase, which follows the electrical phase, consists of the period from 4 to 10 minutes after SCA, during which the patient may remain in VF. Early defibrillation remains critical for survival in patients found in VF. Excellent chest compressions should be started immediately upon recognizing SCA and continued until just before cardioversion is performed (ie, charge the defibrillator during active compressions, stopping only briefly to confirm the rhythm and deliver

the shock). Resume CPR immediately after the shock is delivered .Metabolic phase 

 —Treatment of the metabolic phase, defined as greater than 10 minutes of pulselessness, is primarily based upon post-resuscitative measures, including hypothermia therapy. If not quickly converted into a perfusing rhythm, patients in this phase generally do not survive

 —Rapid recognition of cardiac arrest is the essential first step of successful resuscitation. According to the AHA 2010 Guidelines,① the lay rescuer who witnesses a person collapse or comes across an apparently unresponsive person should check to be sure the area is safe before approaching the victim and then confirm unresponsiveness by tapping the person on the shoulder and shouting: “are you all right?” . If the person does not respond, the rescuer calls for help, activates the emergency response system, and initiates excellent chest compressions. Lay rescuers should not attempt to assess the victim’s pulse and, unless the

patient has what appear to be normal respirations, should assume the patient is apneic .The AHA 2010 Guidelines emphasize that even well-trained professionals can have difficulty determining if breathing is adequate or pulses are present in unresponsive adults. After assessing responsiveness,② health care providers should quickly check the patient’s pulse. While doing so, it is reasonable for the healthcare provider to visually assess the patient’s respirations. It is appropriate to assume the patient is in cardiac arrest if there is no breathing or abnormal breathing (eg, gasping) or if a pulse cannot be readily palpated within 10 seconds. The key point is not to delay CPR

Recognition of cardiac arrest 

The AHA 2010 BLS Guidelines recommend that untrained rescuers begin CPR immediately, without a pulse check, as soon as they determine a patient is unresponsive. Healthcare providers must not spend more than ten seconds checking for a pulse, and should start CPR immediately if no pulse is felty

CPR

1-BLS(Basic Life Support)

2-ACLS(Advance cardiac Life Support)

The AHA 2010 Guidelines recommend that CPR be resumed for two minutes, without a pulse check, after any attempt at defibrillation, regardless of the resulting rhythm. Data suggest that the heart does not immediately generate effective cardiac output after defibrillation

Chest compressions

-Maintain a rate of at least 100 compressions per minute

-Compress the chest at least 5 cm (2 inches) with each down-stroke

-----Allow the chest to recoil completely after each down-stroke (eg, it should be easy to pull a piece of paper from between the rescuer’s hand and the patient’s chest just before the next down-stroke)

-Minimize the frequency and duration of any interruptions-

The following goals are essential for performing excellent chest compressions:

-Give 2 ventilations after every 30 compressions for patients without an advanced airway

-Give each ventilation over no more than one second

-Provide enough tidal volume to see the chest rise - Avoid excessive ventilation

-Give 1 asynchronous ventilation every 8 to 10 seconds (6 to 8 per minute) to patients with an advanced airway in place

Proper ventilation for adults includes the following:

 —When ①multiple trained personnel are present, the simultaneous performance of continuous excellent chest compressions, airway protection, and proper ventilation is recommended by the AHA for the management of sudden cardiac arrest (SCA). The importance of ventilation increases with the duration of the arrest.

However, if② a sole lay rescuer is present or multiple lay rescuers are reluctant to perform mouth-to-mouth ventilation, the AHA 2010 Guidelines encourage the performance of CPR using excellent chest compressions alone. The Guidelines further state that lay rescuers should not interrupt excellent chest compressions to palpate for pulses or check for the return of spontaneous circulation, and should continue CPR until an AED is ready to defibrillate, EMS personnel assume care, or the patient wakes up. Note that CO-CPR is not recommended for children or arrest of noncardiac origin (eg, near

drowning) .

Compression-only CPR (CO-CPR) 

Interruptions in CPR (eg, for subsequent attempts at defibrillation) should occur no more frequently than every two minutes, and for the shortest possible duration.

defibrilation

• In witnessed arrest defibrillation should be used as soon as posible.

• In unwitnessed arrest, rescuers may give 5 cycle of CPR (~2mints) befor checking the rhythm and attempting defibrillation.

• With monophasic defibrilator 360j and biphasic 120-200j(for VT-VF) give one shock

• Survival rate after VF cardiac arrest7-10%with every passing mint. if adequate chest compression are provided this improves to 3-4%/1mint. delay.

• In children 2j/kg → 4j/kg

Automated External Defibrilator (AED)

— Asystole is defined as a complete absence of demonstrable electrical and mechanical cardiac activity. Pulseless electrical activity (PEA) is defined as any one of a heterogeneous group of organized electrocardiographic rhythms without sufficient mechanical contraction of the heart to produce a palpable pulse or measurable blood pressure. By definition, asystole and PEA are non-perfusing rhythms requiring the initiation of excellent CPR immediately when either is present

Asystole and pulseless electrical activity 

Interavenous access

Most desirable rout CVP

Peripheral site

Drugs:

Epinephrine: profound vasoconstriction

in non cerebral non oronary vascular beds

dose 1 mg IV Q 3-5 mint (high dose 0.1 mg/kg)

Vasopresin 40U –IV/IO

Amiodarone 300 mg IV/OS once then 150mg then

1mg/mint for 6 hours and 0.5/mint for 18 hours

Lidocaine 1-1.5 mg/kg(maximum 3mg/kg)

Magnesium 1-2g

Sodium bicarbonate:(metabolic acidosis or hyper

kalemia)

1 meq/kg IV -0.5 meq/kg every 10 mint

antiarrhythmic drugs Amiodarone( 300 mg IV with a repeat dose of 150 mg

IV as indicated ) may be administered in VF or , pulseless VT unresponsive to defibrillation

, CPR and epinephrine .

Lidocaine( 1 to 1.5 mg/kg IV, then 0.5 to 0.75 mg/kg every 5 to 10 minutes ) may be used if

amiodarone  i s unavailable.

Magnesium sulfate( 2 g IV, followed by a maintenance infusion ) may be used to treat

polymorphic ventricular tachycardia consistent with torsade de pointes.

Cardiac arrest:

VF OR VT

Asystole

Pulseless electrical activity(PEA)

Asystole:

EP 1 mg q 3-5 mint

Atropine

Intubation

HCO3 1 meq/kg

Pace

Pulsless electrical activity(PEA):

Organized EKG activity without pulse:

CPR, IV access, intubation

consider underlyind cause:

- hypovolemia(give volume)

- Tension pneumothorux(relive pressure)

- Cardiac tamponad (pericardio centesis )

- Hypokalmia(give K+)

Metabolic acidosis(bicarbonate)

Drug overdose (treatment appropriate to

substance)

Massive MI (heparine-thrombolysis-IABP)

EP 1/10000 IV q 3-5

POST-RESUSCITATION CARE - Optimizing cardiopulmonary function and perfusion of vital organs

-Managing acute coronary syndromes

-Implementing therapeutic hypothermia

-Implementing strategies to prevent and manage organ system dysfunction