Lecture 1 Cardio-pulmonary Resusictation

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DEFINITIONS ‡ ‡ ‡ ‡ ‡ ‡

Respiratory arrest = 



 

 Cardiac arrest = 
    

 
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 Biological death = 
 

 
 

   
 

 
  
  
 Cerebral death = 
 

 
 

    
    
   



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 respiratory arrest ? / cardiac arrest ? ‡

There are semnificative differences, related to age, in the incidence of primary respiratory arrest (more frequent in newborns and children) and primary cardiac arrest (more frequent in adults and old persons)

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There are semnificative differences of BLS in primary respiratory arrest and primary cardiac arrest.

understanding physiopathology of cardio-pulmonary arrest

correct CPR efficient CPR
  

RESPIRATORY ARREST

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CARDIAC ARREST ‡

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INDICATIONS of CPR: ‡ Respiratory arrest ‡ Cardiac arrest ‡ Cardio-respiratory arrest   6
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Signs of successful CPR: ± ± ± ±

return of spontaneous circulation hospital admission neurologic improvement hospital discharge

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Phases of CPR: ‡ Basic life support ± First phase of CPR; ± Goals: ‡ ‡ ‡ ‡

Artificial delivery of oxygenated blood to systemic circulatory beds; Prevention of irreversible brain damage; Preservation of chances for successful resuscitation; Return of spontaneous circulation;

± Provided without medical equipment (³with bare hands´);

‡ Advanced life support ± The second/first phase of CPR; ± Goals: ‡ ‡ ‡ ‡

Preservation of vital organ function; Return of spontaneous circulation; Postresuscitation stabilization; Cerebral protection;

± Provided using equipment, drugs and medical devices.

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THE ARMAMENTARIUM of CPR ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡

)    ± airway maneuvers ×
  ± evaluation and support of ventilation     ± evaluation and support of circulation # - IV access and medication (

  

- evaluation of electrical form of cardiac arrest -    

 $ defibrillation .   ± postresuscitation evaluation   
   ± cerebral protection : 
 
 
 ± postresuscitation intensive care O

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Securing the inviroment Evaluation of consciousness Activation of emergency medical system (call 112) Victim positioning Airway maneuvers Assessment of spontaneous breathing (10 seconds) Artificial ventilation (2 ventilation) Assessment of circulation (10 seconds) Chest compresion (100/minute) CPR sequence: 30 chest compressions /2 artificial breath Automatic external Defibrillation

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BLS ALGORHYTHM 1. 2. 3. 4. 5. 6. 7. 8. 9.

Evaluation of consciousness Activation of emergency medical system Victim positioning Airway maneuvers Assessment of spontaneous breathing Artificial ventilation Artificial ventilation Assessment of circulation Chest compresion CPR sequence: 15 chest compressions /2 artificial breath (no matter the number of rescuers)

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for a pulmonary gas exchange (pulmonary blood flow decreased) encrease the intrathoracic pressure decrease the cardiac upload decrease the efficience of chest compresions stomach insuflation (encrease the risk of regurgitation/aspiration, push up the diaphragm and encrease the intrathoracic pressure)

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± CPR performed by trainned medical team ± total time of interupting chest compresions 24-49% of the cardiac arrest duration. ± Any interuption in chest compresions means the decrease of coronary perfusion pressure, which slowly rises when the chest compresions are delivered once again, and so the chances of returning to spontaneous circulation are decreased. ± In the first minutes of cardiac arrest (VF) the artificial ventilation is not so important as the chest compresions because the hipoxy is primary caused by the lack of tissulary perfussion, and there are sufficiently blood O2 rezerves in the first minutes. That is why the rescue person should concentrate in delivering efficient chest compresions. The new recommendations regarding the sequence chest compresions/ventilation 30:2 are made to minimalise the time of chest compresion interuptions.




  
   

 
 
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Y AIRWAY MANEUVERS: ± ± ± ± ±

Should be applyied in case of any unconscious victim; Should preceed assessment of spontaneous breathing; Should be maintained during assessment of spontaneous breathing; Should preceed artificial ventilation; Should be maintained during artificial ventilation;

Y AIRWAY MANEUVERS: DURING BASIC LIFE SUPPORT: ± ± ± ± ± ± ±

Safety position Head tilt Chin lift Head tilt and chin lift Subluxaţia anterioară a mandibulei Subluxaţia anterioară a mandibulei şi deschiderea gurii Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii (tripla manevră Safar); ± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a capului şi deget înfăşurat în pânză)

DURING ADVANCED LIFE SUPPORT: ± Airway devices ± Tracheal intubation

Y AIRWAY MANEUVERS:  
    

   
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 @A ‡ Know the mechanism of injury ± Strangulation ± Cădere de la înălţime ± Deceleration or acceleration s.o.

‡ Traumaticsigns ± ± ± ±

At the cephalic extremity In the cervical region In the region of thorax (the superior 1/3) So, superior to the intermamelonary line

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Y AIRWAY MANEUVERS:  
    

   
 @ BASIC LIFE SUPORT: ± Safety position ± Hiperextension of the had ± Chin lift ± Head tilt and chin lift

± Subluxaţia anterioară a mandibulei ± Subluxaţia anterioară a mandibulei şi deschiderea gurii ± Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii (tripla manevră Safar); ± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a capului şi deget înfăşurat în pânză)

ADVANCED LIFE SUPPORT: : ± Airway devices ± Traceal intubation



 

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 ‡ maintenance of airways patency ‡ protection of airways against the aspiration of gastric content ‡ delivery of machanical ventilation ‡ drug administration ‡ long term access to the airways ‡ endotracheal aspiration

AIRWAY MANEUVERS:

|        ± visualising the endotrachel tube passing through vocal cords ± simetrical thoracic expansions ± equal respiratory sounds on bouth lungs ± water vapors on the inside surface of the endotracheal tube ± the abscence of aeric sounds in epigastric region

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× EVALUATION AND SUPPORT OF VENTILATION: ‡

Assessment of spontaneous breathing ± maintaining MECA ± ³lisen, feel and see´

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Artificiale ventilation ± În SVB ‡ ‡ ‡ ‡ ‡ ‡

Artificial ventilation ³mouth-to-mouth´ Artificial ventilation ³mouth-to-nose´ Artificial ventilation ³mouth-to-tracheostomae´ Artificial ventilation ³mouth-to-mouth and nose´ The exhalated air containe 16-18% O2 Evaluation of the efficience of artificial ventilation: chest movements

± În SVA ‡ ‡ ‡ ‡

Mask and Rueben baloon Trachel tube and Rueben baloon Trachel tube and ventilatory device Mechanical ventilation: ± ± ± ± ±

IPPV (intermitent positive pressure ventilation) Current volume 8ml/kg Frequence: 14-16/min FiO2 1 (O2 100%) PEEP (positive end expiratory pressure) 0


 


 ))O(:8O:8!-B*!&O $O!$*!&O 4 5(;O:/)O:!; ± The rescue person take a normal inspiratory ± Insuflation - 1 second ± Current volume 500-600ml ± Chest rise ± Frecquence 10-12/minute

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 ))O(:8O:8!-*( );:)/ 5(;O:/)O:!;:;85):;)#&/O ± Current volume 6-8ml/kg ± Frecquence 8-10/minute ± Oxigen 100% ± No PEEP ± No interuptions of chest compressions for ventilation

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| CIRCULLATORY EVALUATION AND SUPPORT: ASSESSMENT of CIRCULATION ± Always in the large arteries ± Adult: carotid or femoral artery; infant: brachial artery;

CHEST COMPRESSION ± It is performed during BLS and ALS ± Best achievable results: 25-30% of spontaneous cardiac output ± Chest compression technique: ‡ ‡ ‡ ‡

Victim position Rescuer position Technique Parameters: depth, frequency/min, compression/decompression ratio

± Mechanisms of cardiac output during chest compression: ‡ Cardiac pump theory ‡ Thoracic pump theory

± Evaluation of chest compression efficency: pulse assessmente during CPR ± Options to increase the efficency of chest compression: ‡ ‡ ‡ ‡ ‡ ‡

Maximal values of recommended depth and frequency Concomitantly performed chest compression and artificial ventilation Interposed abdominal compression Kower limb elevation at 60º (not in case of ongoing bleeding or trauma) Active compression/decompression device Internal cardiac massage (only during ALS)

‡ Extracorporeal circulation

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ADULT ‡ Depth of sternal compression 4-6 cm ‡ Frecquence of compressions 100/minute ‡ Duration of compression/Duration of decompression equal ‡ Full chest recoil after each compression ‡ Rithmic compresions ‡ Avoid interupting chest compressions

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High frecquence chest compressions Interpose abdominal compression Internal cardiac massage CPR through Äcoughing´

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Active compression-decompresion device Resistance-level valve device Mechanical Piston device CPR vest Fazic toraco-abdominal compression-decompression manual device ‡ Extracorporeale circulation

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| MEDICATION: ‡ Routes for drug administration ± ± ± ± ±

Peripheral intravenous access ± standard route Central intravenous access Intratracheal administration Intraosseous administration Intracardiac administration

‡ Drugs: ± ± ± ± ± ± ± ± ± ± ±

Oxygen Epinephrine Atropine Lidocaine Vasopresine Sodium bicarbonate Amiodarone Procainamide Magnesium sulphate Dopamine Volume solutions



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‡ Este a doua opţiune de acces venos în RCR. ‡ Oferă acces la un plex venos necolababil, deci, administrarea drogurilor este similară administrării venos centrale. ‡ Există truse dedicate cu toate materialele necesare. ‡ Doza medicamentelor în administrarea intraosoasă este aceiaşi ca în administrarea intravenoasă. ‡ La bolnavul hipovolemic cu acces venos periferic imposibil accesul intraosos oferă o bună alternativă de refacere a volemiei.

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through trachel tube 2-2,5x of intravenous dose diluted in NaCl 0,9% 5-10 ml 5 vigurous ventilations

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 ELECTROCARDIOGRAPHY: ± E     ‡       ‡ "  #  $  ‡ "      # $ ± ± ± ± ±

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’ DEFIBRILAREA: 


    
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’ DEFIBRILLATION: ± Goal ± Defibrillation technique: ‡ ‡ ‡ ‡ ‡ ‡

Patient position Rescuer position Paddles preparation and position ³Clear´ order Energy Checking for efficiency

± Indications ± Differences cardioversion/defibrillation: ‡ ‡ ‡ ‡

Synchronic/asynchronic shock Preparations Energy Indications

 

TEHNICA DEFIBRILĂRII: ± ± ± ± ± ±

Poziţia pacientului Poziţia resuscitatorului Pregătirea şi poziţionarea padelelor Atenţionarea Energia utilizată Verificarea eficienţei

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‡ curent monofazic ± iniţial 360 J şi continuă cu aceiaşi energie la următoarele şocuri. ‡ curent bifazic - iniţial o energie de 200 J, apoi energii crescânde de 300 J şi 360 J. ‡ În fibrilaţia ventriculară/tahicardia ventriculară fără puls recurentă - energia utilizată pentru următorul şoc va fi energia care a convertit ritmul

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‡ Termenul de  #  este utilizat pentru livrarea sincronizată cu complexul QRS a unui şoc electric. Sincronizarea evită livrarea şocului în perioada refractară relativă a ciclului cardiac, perioadă în care şocul electric poate induce fibrilaţie ventriculară. ‡ Termenul de    este utilizat pentru livrarea nesincronizată cu complexul QRS a unui şoc electric.

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PREGĂTIRI PENTRU CARDIOVERSIE ‡ Bolnavul trebuie să aibă monitorizare ECG şi monitorizarea noninvazivă a TA. ‡ Se instituie oxigenoterapia. ‡ Se instituie un acces venos. ‡ Instrumentarul, materialele şi drogurile de resuscitare trebuie să fie pregătite. ‡ Se practică analgezie şi sedare.

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