Lecture 1 Cardio-pulmonary Resusictation(some Editions)

CARDIO-PULMONARY RESUSCITATION

2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care 2005 International Consensus Conference on CardioPulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommandations and ILCOR (International Liaison Committee on Resuscitation) 2005 CPR Consensus. These recommendations replace or complete the 2000 CPR guidelines. published in Circulation - December 2005

Grading of evidence Grade 1

Randomized clinical studies or meta-analysis with significant therapeutic effects

Grade 2

Clinical studies with less significant therapeutic effects

Grade 3

Prospective controlled nonrandomized studies or case series

Grade 4

Retrospective nonrandomized studies

Grade 5

Uncontrolled case series

Grade 6

Experimental animal or mechanical studies

Grade 7

Theoretical analysis

Grade 8

Rationale and common practice without evidence base

Hierarchy of recommendations depends upon risk/benefit ratio.

Class

Risk/benefit ratio

I

Benefit >>> risk

IIa

Benefit >> risk

IIb

benefit >/= risk

III

risk >/= benefit

CARDIO-PULMONARY RESUSCITATION DEFINITIONS • • • • • •

Respiratory arrest = the absence of breathing movements. Cardiac arrest = the clinical picture of overall cessation of circulation. Clinical death = coma, apnea and pulselessness in large arteries with cerebral failure still potentially reversible. Biological death = the irreversible absence of body functions due to irreversible structural cell damage. Cerebral death = the irreversible absence of brain and brainstem functions due to definitive neurological damage as a result of known pathological process. Persistent vegetative state = absence of motility and reaction to external stimuli due to persistent absence of cerebral activity with preservation of vegetative functions (respiration, circulation, swallowing).

CARDIO-PULMONARY ARREST Physiopathology respiratory arrest ? / cardiac arrest ? •

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

•

There are significant differences between BLS in primary respiratory arrest and primary cardiac arrest.

understanding physiopathology of cardio-pulmonary arrest

correct CPR efficient CPR maneuvers

RESPIRATORY ARREST •

Pathophysiology – Heart and lungs continue the tissue delivery of oxygenated blood until exhaustion of alveolar O2 reserves; pulse is present, altered consciousness; – Delay to cardio-circulatory arrest: variable (seconds-minutes); it depends on: • Oxygen reserves in the moment of respiratory arrest (PAO2 and PaO2) • Myocardial capacity to sustain hypoxemia – Uncorrected respiratory arrest results in cardiac arrest;

•

Causes – Drowning, foreign body aspiration, toxic inhalation, epiglotitis, strangulation, etc. – Coma of any origin, stroke, etc. – Electrocution, trauma, etc.

•

Clinical signs – – – –

•

Absence of breathing movements Progressive cyanosis Alterations of consciousness Muscle hypotony

Treatment – Artificial ventilation in order to oxygenate the blood and to prevent secondary cardiac arrest

• Pathophysiology – –

– –

CARDIAC ARREST

Cardiac arrest results in circulatory arrest with the immediate cessation of tissue O2 delivery; Cessation of brain O2 delivery: • Depletion of O2 reserves in 10 seconds • Depletion of phosphocreatine reserves in 2 minutes • Depletion of glucose and ATP reserves in 5 minutes For a short time delay (always seconds): agonic respiration (gasping) (inefficient respiratory efforts with recruitment of accessory respiratory muscles); Always cardiac arrest result in respiratory arrest;

• Causes – – – – –

Myocardial infarction Rhythm disturbances (myocardial infarction, myocardial ischemia electrolyte disturbances, etc.) Hipovolemia (exsanguinations, politrauma) Pulmonary embolism Cardiac tamponada

• Clinical signs – – – – –

Loss of consciousness (10 seconds; isoelectrical EEG in 15-30 seconds); Agonic respirations or apnea (10-15 seconds) Pulseless Midriasis (30-60 seconds) General aspect of “death”

• ECG signs – – – –

Ventricular fibrillation Pulseless ventricular tachycardia Pulseless electrical activitty Asystoly

• Treatment –

Artificial support for ventilation and circulation

CARDIO-PULMONARY RESUSCITATION INDICATIONS of CPR: • Respiratory arrest • Cardiac arrest • Cardio-respiratory arrest Primary/secondary - respiratory/cardiac arrest

CARDIO-PULMONARY RESUSCITATION DEFINITION = system of standard maneuvers, drugs and techniques indicated in case of cardio-respiratory arrest in order to artificially deliver the oxygenated blood to systemic circulatory beds at rates that are sufficient to preserve the vital organ function and at the same time providing the physiologic substrate for the return of spontaneous circulation.

CARDIO-PULMONARY RESUSCITATION FACTORS WHICH INFLUENCE THE RESULT OF RESUSCITATION: Patient related factors: • The cause of cardio-respiratory arrest • The functional status in the moment of cardio-respiratory arrest • Co-existing diseases

Rescuer related factors: • Precocity of CPR • Correctness of CPR

CARDIO-PULMONARY RESUSCITATION CHAIN OF SURVIVAL

Early access

Early BLS

BLS in <4 min

Early defibrillation

Early ALS

ALS in <8 min

•

“The most important determinant of survival from sudden cardiac arrest is the presence of a trained rescuer who is ready, willing, able, and equipped to act.” (2005 AHA Guidelines for CPR and ECC, Circulation, 2005)

•

“In the 1990s some predicted that cardio-pulmonary resuscitation (CPR) could be rendered obsolete by the widespread development of community automated external defibrillator (AED) programs. Cobb noted, however, as more Seatle first responders were equipped with AEDs, survival rates from sudden cardiac arrest fell. He attributed this decline to reduces emphasis on CPR....” (2005 AHA Guidelines for CPR and ECC, Circulation, 2005)

What means a successful cardio-pulmonary resuscitation? Signs of successful CPR: – return of spontaneous circulation – hospital admission – neurologic improvement – hospital discharge

CARDIO-PULMONARY RESUSCITATION 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 (“with bare hands”);

• Advanced life support – The second/first phase of CPR; – Goals: • Preservation of vital organ function; • Return of spontaneous circulation; • Post-resuscitation stabilization; • Cerebral protection; – Provided using equipment, drugs and medical devices.

CARDIO-PULMONARY RESUSCITATION THE ARMAMENTARIUM of CPR • • • • • • • • •

A (airway) – airway maneuvers B (breathing) – evaluation and support of ventilation C (circulation) – evaluation and support of circulation D (drugs) - IV access and medication E (electrocardiography) - evaluation of electrical form of cardiac arrest F (fibrillation treatment) - defibrillation G (gauging) – post-resuscitation evaluation H (human mentation) – cerebral protection I (intensive care) – post-resuscitation intensive care

THIS IS NOT THE PROPER ORDER TO APPLY

Steps of basic life support – – – – – – – – – – –

Securing the environment Evaluation of consciousness Activation of emergency medical system (call 991) Victim positioning Airway maneuvers Assessment of spontaneous breathing (10 seconds) Artificial ventilation (2 ventilation) Assessment of circulation (10 seconds) Chest compressions (100/minute) CPR sequence: 30 chest compressions /2 artificial breath Automatic external Defibrillation

CARDIO-PULMONARY RESUSCITATION 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 Assessment of circulation Chest compressions CPR sequence: 15 chest compressions /2 artificial breath (no matter the number of rescuers)

CPR recommendations 2006 – 2 essential aspects for the success of CPR:

• Avoid hyperventilation – – – – –

for a pulmonary gas exchange (pulmonary blood flow decreased) increase the intra-thoracic pressure decrease the cardiac upload decrease the efficiency of chest compressions stomach insufflations (increase the risk of regurgitation/aspiration, push up the diaphragm and increase the intra-thoracic pressure)

• Avoid interrupting the chest compressions – CPR performed by trained medical team – total time of interrupting chest compressions 24-49% of the cardiac arrest duration. – Any interruption in chest compressions means the decrease of coronary perfusion pressure, which slowly rises when the chest compressions 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 compressions because the hipoxie is primary caused by the lack of tissulary perfusion, and there are sufficiently blood oxygen reserves in the first minutes. That is why the rescue person should concentrate in delivering efficient chest compressions. The new recommendations regarding the sequence chest compressions/ventilation 30:2 are made to minimalise the time of chest compression interruptions.

The age • • • •

newborn – immediately after birth and until hospital discharge. infant – until the age of 1 year. child – from 1 year until puberty (12-14 years). adult – from puberty along

CARDIO-PULMONARY RESUSCITATION

A AIRWAY MANEUVERS: – – – – –

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

A AIRWAY MANEUVERS: DURING BASIC LIFE SUPPORT: – – – – – – –

Safety position Head tilt Chin lift Head tilt and chin lift Jaw thrust Jaw thrust and mouth opening Head extension, mouth opening, chin lift (Safar maneuver / triple airway maneuver); – Finger sweep maneuver to remove foreign solid/liquid material in the airway

DURING ADVANCED LIFE SUPPORT: – Airway devices – Endotracheal tube placement

A AIRWAY MANEUVERS: in patient with suspected cervical spine injury When to suspect cervical spine injury? • Know the mechanism of injury – Strangulation – Fall – Deceleration or acceleration s.o.

• Traumatic signs – – – –

At the cephalic extremity In the cervical region In the region of thorax (the superior 1/3) Above the nipple line

Maintain the head in neutral position

A AIRWAY MANEUVERS: in patient with suspected cervical spine injury BASIC LIFE SUPORT: – Safety position – Head extension – Chin lift – Head tilt and chin lift

– – – –

Jaw thrust maneuver Jaw thrust mouth opening maneuver Head extension, mouth opening, chin lift; Finger sweep maneuver to remove foreign solid/liquid material in the airway

ADVANCED LIFE SUPPORT: – Airway devices – Tracheal intubation

Tracheal intubation in CPR - advantages -

• • • • • •

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

AIRWAY MANEUVERS: Clinical signs of proper tracheal intubation – visualizing the endotracheal tube passing through vocal cords – symmetrical thoracic expansions – equal respiratory sounds in both lungs – water vapors on the inside surface of the endotracheal tube – the absence of aeric sounds in epigastric region

CARDIO-PULMONARY RESUSCITATION B EVALUATION AND SUPPORT OF VENTILATION: •

Assessment of spontaneous breathing – maintaining MECA – “listen, feel and see”

•

Artificial ventilation – In SVB • • • • • •

Artificial ventilation “mouth-to-mouth” Artificial ventilation “mouth-to-nose” Artificial ventilation “mouth-to-tracheotomies” Artificial ventilation “mouth-to-mouth and nose” The exhaled air contain 16-18% O2 Evaluation of the efficiency of artificial ventilation: chest movements

– In SVA • • • •

Mask and Rueben balloon Tracheal tube and Rueben balloon Tracheal tube and ventilators Mechanical ventilation: – – – – –

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

Artificial ventilation

CHARACTERISTICS OF „MOUTH-TO-MOUTH” VENTILATION – – – – –

The rescuer takes a normal inspiratory breath Insufflation - 1 second Tidal volume 500-600ml Chest rise Frequency 10-12/minute

Artificial ventilation

CHARACTERISTICS OF MECHANICAL VENTILATION IN ALS IN ADULT – – – – –

Tidal volume 6-8ml/kg Frequency 8-10/minute Oxygen 100% No PEEP No interruptions of chest compressions for ventilation

CARDIO-PULMONARY RESUSCITATION C CIRCULLATORY EVALUATION AND SUPPORT: ASSESSMENT of CIRCULATION – Always in the large arteries – Adult: carotid or femoral artery; infant: brachial artery;

CHEST COMPRESSIONS – 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 efficiency: pulse assessment during CPR – Options to increase the efficiency of chest compression: • • • • • •

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

• Extracorporeal circulation

CHEST COMPRESSION

„push hard, push fast, allow full chest recoil after each compression, and minimize interruptions in chest compression”

CHEST COMPRESSION

The indication for chest compression is the absence of pulse in large arteries. There are no contraindications for chest compression.

CHEST COMPRESSION ADULT • • • • • •

Depth of sternal compression 4-6 cm Frequency of compressions 100/minute Duration of compression/Duration of decompression equal Full chest recoil after each compression Rhythmic compressions Avoid interrupting chest compressions

CHEST COMPRESSIONS complications Fractures

Ribs fractures Sternal fractures

Pathology of the serosas

Pneumothorax Hemothorax Hemopericardium Hemoperitoneum

Visceral injuries

Pulmonary rupture Hepatic rupture Spleen rupture Gastric rupture

Other complications

Aspiration of gastric content

ALTERNATIVE TECHNIQUES OF CARDIAC MASSAGE

• • • •

High frequency chest compressions Interposed abdominal compression Internal cardiac massage CPR through „coughing”

MECHANICAL DEVICES FOR CARDIOCIRCULATORY SUPPORT • • • • •

Active compression-decompression device Resistance-level valve device Mechanical piston device CPR vest Phase thoraco-abdominal compression-decompression manual device • Extracorporeale circulation

CARDIO-PULMONARY RESUSCITATION C MEDICATION: • Routes for drug administration – – – – –

Peripheral intravenous access – standard route Central intravenous access Endotracheal administration Intraosseous administration Intracardiac administration

• Drugs: – – – – – – – – – – –

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

PERIPHERAL VENOUS ACCESS

Advantages

Disadvantages

• Simple technique • Long time of drug circulation • Short time for installation • Easy to lose venous access • No need for the interruption of chest compressions

INTRAOSSEOUS ACCESS

• The second option for venous access in CPR. • Give access to noncolappsed veins, so the intraosseous drugs administration is similar to the central venous administration. • There are dedicated truce for intraosseous access. • Similar drug doses as in intravenous administration. • Offers a good alternative in hipovolemic patients with difficult venous access.

CENTRAL VENOUS ACCEESS

Advantages

Disavantages

• Short time of drug circulation • Temporary interruption of cardiac massage • Safe and longlasting access • Long time for instalation • Hipertonic solutions/cathecolamines • Vital complications possible

ENDOTRACHEAL DRUG ADMINISTRATION IN CPR

• • • •

through tracheal tube 2-2,5x of intravenous doses diluted in NaCl 0,9% 5-10 ml 5 vigorous ventilations after

CARDIO-PULMONARY RESUSCITATION E ELECTROCARDIOGRAPHY: – Electrical forms of cardiac arrest • Ventricular fibrillation • Pulseless ventricular tachycardia • Pulseless electrical activity – – – – –

Electromechanical dissociation Pseudo Electromechanical dissociation Idio-ventricular rhythm Escape rhythm Bradiasystole

• Asystole

Identification of the eletrical form of cardiac arrest allows the choice of the proper CPR algorythm

CARDIO-PULMONARY RESUSCITATION

F DEFIBRILLATION: Defibrillation terms an electrical shock delivered asynchronous with QRS complex. The electrical shock induce a synchronous depolarization followed by a synchronous repolarization of all the myocardic cells.

CARDIO-PULMONARY RESUSCITATION F DEFIBRILLATION: – Goal – Defibrillation technique: • • • • • •

Patient position Rescuer position Paddles preparation and position “Clear” order Energy Checking for efficiency

– Indications – Differences cardioversion/defibrillation: • • • •

Synchronic/asynchronic shock Preparations Energy Indications

DEFIBRILLATION

DEFIBRILLATION TECHNIQUE: – – – – – –

Patient positioning Rescuer positioning Electrode position Clear order Energy Checking for efficiency

DEFIBRILLATION Characteristics

• Precocity of defibrillation • „Shock first versus CPR first” • Shortning the time period between the last chest compression and shock • „1-Shock Protocol” • CPR after shock

ENERGY OF DEFIBRILLATION

• monophasic electrical current – initially 360 J and than the same energy. • biphasic electrical current - initially 200 J, than higher energy 300 J, than 360 J. • In recurrent VF/ pulseless ventricular tachycardia – the energy for the next shock is the energy which last time converted the cardiac rhythm.

EXTERNAL ELECTRICAL SHOCK

• Cardioversion terms the delivery of an electrical shock synchronous with QRS complex. Syncronization avoids the delivery of the electrical shock during relative refractory period of the heart cycle, period during witch the electrical shock may induce VF. • Defibrillation terms the delivery of an electrical shock asynchronous with the QRS complex.

CARDIOVERSION PREPARINGS FOR CARDIOVERSION • The patient should be monitored for EKG and noninvasive blood tension. • Oxygen therapy. • Venous access. • Rescue truce and drugs should be prepared. • Analgesia and sedation.

CARDIOVERSION AND DEFIBRILLATION CHARACTERISTICS

Initial energy Synchronization with QRS complex Indications

CARDIOVERSION

DEFIBRILLATION

50-100 J

200 J

YES

NO

•TPSV •Paroxistic Atrial Flutter •Paroxistic Atrial Fibrillation •Ventricular Tachycardia with pulse

•Ventricular Fibrillation •Pulseless Ventricular Tachycardia •Poliform Ventricular Tachycardia with pulse

MONITORING DURING CPR

• End tidal CO2 • EKG

POSTRESUSCITATION STATUS

• After recovery of spontaneous circulation • A period of great homeostatic disequilibrium • Generated by: – Hypoxic lesions – Ischemic lesions – Reperfusion lesions.

POSTRESUSCITATION STATUS Physiopathology Hemodinamic

Myocardial dysfunction (generated by global myocardial ischemia and defibrillation) Low cardiac output syndrome Transitory raise of myocardial enzymes Hemodinamic instability Cardiac rhythm anomalies

Neurological

Coma Initially cerebral hyperemia, than decreased cerebral blood flow (even at normal blood pressure values) Hyperthermia of central origin Convulsions

Respiratory

Ventilatory dysfunction Blood oxygenation anomalies

Metabolic

Metabolic acidosis Hyperglycemia

POSTRESUSCITATION STATUS

Dysfunctions may be: • Moderate with progressive tendency to resolution • Severe and persistent

Persistent coma Central origin hyperthermia Convulsions Multiple organ deficiency syndrome

Frequently at 48-72 hours post resuscitation Poor prognostic