Resuscitation

Cardiopulmonary Cerebral Resuscitation

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Introduction

1. The concept of resuscitation 2. Basic life support （ BLS ）

3. Advanced Life Support （ ALS ） 4. Post-resuscitation treatment （ PRT ） 5. General Management Principles for cardiac arrest 6. Summary 2

1.The concept of resuscitation • The concept of resuscitation • The primary concept of resuscitation is to restore a beating heart for a functioning circulation and restore ventilation—CPR The maintenance of normal tissue metabolism relies principally on an adequate delivery of oxygen in a functioning circulation.

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Cer ebral hypoxi a The brain is more sensitive to hypoxia than any other organ. The cerebral cortex is damaged permanently by ischemia of more than 3-4 min duration. Permanent impairment of cerebral function may result if cerebral oxygen delivery is not restored within 3-4 min. 4

CPR TIME LINE 0-4 mins. brain damage unlikely 4-6 mins. brain damage possible 6-10 mins. brain damage probable over 10 mins. probable brain death  

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CORE of ACLS Concepts --Cerebral Resuscitation is the most important goal! Returning the patient to the prearrested level of neurological functioning Cardio-Pulmonary-Cerebral resuscitation (CPCR) – had been proposed to replace CPR

--Focuses on Airway and Ventilation, Basic CPR, Defibrillation of Ventricular fibrillation and Drugs 6

Therefore, when circulatory arrest has occurred, it is essential to start CPR as rapidly as possible. (CPR—CPCR) CPR---CPCP---All management to treat or prevent cardiac arrest or other disorders.

Prevention is the best treatment ！

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2.Basic Life Support Basic Life Support (BLS) establishes a clear airway followed by assisted ventilation and support of the circulation, all without the aid of specialized equipment.

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Check safety when approaching a patient who appears to have suffered a cardiac arrest the rescuer should check that there are no hazards to himself before proceeding to treat the patient. Patients may suffer a cardiac arrest due to electric shocks or toxic substances.

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Causes of pulseless electrical activity Five “H’s” Hypovolemia Hypoxia Hydrogen-acidosis Hypo-/hyperkalemia Hypothermia

Five “T’s” Tablets/drug overdose Tamponade Cardial Tension pneumothorax Thrombosis coronary/ pulmonary Trauma

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• Recovery Position – For unresponsive adult victims who have normal breathing – Should be stable, near a true lateral position, with the head dependent and no pressure on the chest to impair breathing

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Check safety Ch eckin g re sponsi venes s Are you ok?

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How to keep the airway open? Tilt head back Lift chin

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In the unresponsive patient, open the airway by tilting the head back and lifting the jaw forwards. This displaces the most common cause of airway obstruction. In cases of suspected cervical spine injury, the airway should be opened by using the jaw thrust maneuver only whilst maintaining cervical spine immobilization.

Head tilt and neck extension must never be used in this situation. 16

Check for breathing ： Look 、 Listen 、 Feel

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Check for breathing Look – to see if the chest wall is moving or if the abdominal wall is indicating an obstructed airway. Listen–over the mouth for sounds of air movement or for sounds indicating an obstructed airway. Feel – over the mouth with the side of the face for sign of air movement indicating effective breathing. 18

Checking the pulse

Carotid pulse

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Shout for help It is essential to telephone for help as soon as the assessment has been completed. This early call for help decreases the time to the first defibrillation, shortens the time to the delivery of advanced life support, decreases the length of time of performance of basic life support and improves survival .

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If breathing and pulse are absent ， start basic life support.

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Deliver two rescue breaths to minimize high airway pressures ， emphasis is placed on a slow inspiratory phase.

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Allow air to come out

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Mouth to mouth ventilation This is achieved by expired air ventilation. Take a full breath and seal your lips over the patient’s mouth. Blow steadily into the patient’s mouth, watching the chest rise as if the patient was taking a deep breath. Each breath should take approximately 2 s for full inflation. Adequacy of ventilation is judged by each breath producing adequate movement of the chest. 24

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External Chest Compressions When starting external chest compressions: Get the patient on a firm surface •Feel the xiphisternum Chest compressions are performed on the lower third of the sternum place the heel of the second hand on the sternum.

•Put both hands together and depress the sternum 4-5cm in an adult at a rate of 100 compressions per minute.

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Locate rib cage

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Locate sternal notch Position hands - fingers clear of chest

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Keep your elbows straight, and ensure that all the pressure is directed through the sternum and not through the ribs. To perform chest compressions adequately, it is necessary to be above the patient. Stand on a platform if necessary. During a cardiac arrest change the person performing chest compressions regularly, as it is tiring when performed properly.

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Compress chest Above the patient Keep your elbows straight Pressure is directed through the sternum Neonate Infant Child

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The AHA-recommended chest compression rate is 100/min with a depth(≈4-5cm) sufficient to generate a palpable carotid or femoral pulse. A compression/relaxation ratio of 50:50 is advocated. During one-person CPR, the recommended compression /ventilation ratio is 30:2, two-person CPR, it is also 30:2.

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Complications: • fractured ribs • lung contusion • pneumothorax • visceral disruption

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Mechanisms of chest compressions Increases in intrathoracic pressure generate forward blood flow. This is commonly referred to as the thoracic pump mechanism for movement of blood. The valves within the venous system and the heart, most of the blood flows forward through the arteries. A small amount of flow is produced by direct compression of the heart between the sternum and the spine cardiac pump mechanism. 34

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Monitoring CPR Palpation of the carotid or femoral pulse and observation of pupillary size were the standard. Initial pupillary size and changes during CPR are of some prognostic value. Persistently contracted or initially dilated but subsequently contracting pupils are associated with a greater likelihood of successful resuscitation and neurological recovery. 36

Transmission of infection • no documented cases of serious infection after rescue breathing • use a face shield or a face mask when appropriate

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BLS Algorithm C H E C K R E S P O N S IV E N E S S

Shake and shout

O P E N A IR W A Y

Head tilt/Chin lift

C H E C K B R E A T H IN G

2 effective breaths

BR EATH E A S S E S S C IR C U L A T IO N 1 0 s e c o n d s o n ly C IR C U L A T IO N P R E S E N T C o n t in u e R e s c u e B r e a t h in g

Look, listen, and feel

N O C IR C U L A T IO N C o m p re s s C h e s t

Signs of a circulation 100 per minute 15:2 ratio

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Basic life support only provides 10-15% of normal cardiac output and should be regarded as ‘buying time’ until the start of advanced life support.

Time i s life!

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3.Advanced Life Support Advanced life support refers to the use of specialized techniques, in an attempt to rapidly restore an effective rhythm to the heart. The most important components of the advanced life support techniques are direct current defibrillation and efficient BLS.

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There are four underlying disorders associated with cardiac arrest: 1.Ventricular fibrillation

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2.Ventricular tachycardia

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3.Asystole (Ventricular standstill ）

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4.Electromechanical dissociation

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Ventricular fibrillation Ventricular fibrillation is chaotic electrical activity of the myocardium. Early defibrillation (precordial thump ) is recommended and if the first three defibrillation shocks can be delivered quickly, then this initial defibrillation sequence should not be interrupted for basic life support procedures. 45

An initial DC shock at 200 J probably causes minimal myocardial damage and is adequate to achieve success in most recoverable situation. Following two 200 J DC shocks, one defibrillation is attempted at the maximum delivered energy level of 360 J. If all three initial defibrillation attempts (200 J, 200 J, 360 J) are unsuccessful, the prospects of recovery are poor. 46

Defibrillation

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Defibrillation

Ventricular fibrillation Ventricular tachycardia 48

Intubation and Venous access Resuscitation should continue with tracheal intubation and lung ventilation with 100% oxygen. Another member of the ALS team should be cannulating a vein. Peripheral venous access is the simplest to establish and attempts should be made to cannulate a large peripheral vein. Central venous access requires expertise and training but does provide significant advantages over peripheral access. 49

Adrenaline 1 mg (10 ml of 1mg solution ) is the next action. If intravenous access has not been established then 2-3 mg can be given via the tracheal route. This route is definitely second best. Adrenaline is used in resuscitation mainly for it's a-adrenergic receptor stimulant effects: peripheral vasoconstriction, improved coronary perfusion. In addition, adrenaline is believed to ‘harden’ the major vessels leading away from the heart. Adrenaline has a β-adrenergic stimulant activity. 50

Resuscitation in the form of basic life support should not be interrupted for more than 15 s to perform any of the above maneuvers. Therefore in any 2 min cycle of resuscitation three defibrillation attempts (360 J), 1 mg of intravenous adrenaline and 10 cycles of basic life support are applied to the patient. The chance of a successful resuscitation decreases with an increasing number of shocks and with a prolonged resuscitation time. 51

Sodium bicarbonate In prolonged resuscitation the patient may become increasingly acidosic. This is especially so when initial basic life support has been delayed, ventilation has not been performed effectively or chest compressions have not been successful. Where basic life support procedures have been established and the patient’s lungs have been effectively ventilated, any associated acidosis may be reversed by administration of sodium bicarbonate solution.

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Sodium bicarbonate should not be administered without considering that: It does not improve ability to defibrillate the heart It shifts the oxyhaemoglobin dissociation curve and inhibits the release of oxygen . It causes hyperosmolality （高渗透压） and hypernatronemia （高钠血症） It produces paradoxical acidosis （反常酸中毒） Sodium bicarbonate is only recommended routinely in patients with pre-existing metabolic acidosis, hyperkalemia.

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4.Post-resuscitation treatment,PRT For every ten in-hospital resuscitation events, three patients survive the initial resuscitation procedures, two survive the next 24 h, 1.5 survive to discharge from hospital and one patient lives for 1 year after the initial event. Careful monitoring of vital functions should be established. The majority will require further circulatory and respiratory support.

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Cardiovascular system Cardiac output may remain unsatisfactory as a result of cardiogenic shock A low cardiac output may result from: 1.Poor myocardial contractility, e.g. after myocardial infarction or pulmonary embolus 2. Hypovolemia. 3. Arrhythmias. These require treatment if: a. cardiac output is compromised; or b. they are electrically unstable and therefore predispose to a further episode of arrest. 55

Respiratory system Lung dysfunction is produced during resuscitation for reasons which may include inhalation of vomit, lung contusion, fractured ribs and pneumothorax. Pulmonary edema may occur in the presence of heart failure and after head injury, drowning or smoke inhalation. Oxygen therapy for 24 h should follow any episode of circulatory arrest. All Patients should have a chest X-ray and blood gas analysis after resuscitation.

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Central nervous system If efficient resuscitation was started immediately after circulatory arrest occurred and was continued until restoration of an adequate spontaneous cardiac output, the patient should regain consciousness fairly quickly. Recovery tends to be delayed after prolonged arrest or when general anesthesia is involved.

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Patients may fail to recover consciousness for the following reasons: 1. Low cardiac output . 2. Brain damage, which may be present if resuscitation was delayed or if the circulatory arrest was precipitated by hypoxemia.

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Management of brain damage The aim of treatment is to provide optimal conditions for recovery of cerebral cells and prevention of secondary neuronal damage.

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General measures 1.Keep airway open : tracheal intubation. 2.Arterial pressure maintained in the normal range. 3.Haematocrit （血球压积） in the low normal range. 4.Body temperature increases should be avoided. 5.Depth of coma should be assessed regularly.

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Specialized treatment 1.Hyperventilation. Mild passive hyperventilation to a PaCO2 of 4 kPa helps to minimize increases in intracranial pressure. Control of ventilation may be achieved with the aid of muscle relaxants or cerebral depressants. A head-up tilt assists cerebral venous drainage.

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2.Osmotherapy （渗透疗法，脱水治疗） Increasing the plasma osmolality decreases intracranial water content and thus ICP. Mannitol (0.5 g.kg-1 initially) is often used. Mannitol increases the circulating blood volume and may be dangerous in the presence of pulmonry edema or a high CVP. In this situation, frusemide （速尿） may be more appropriate. 3. Steroids. There is no evidence that steroids are beneficial after cardiac arrest. 62

4.Barbiturates and CNS depressants. Thiopentone and diazepam are often used in conventional doses to provide sedation, facilitate control of ventilation and suppress seizures. Both these drugs must be used with care after circulatory arrest. In particular, large loading doses of barbiturates are contraindicated, as they produce profound cardiovascular depression. 5.Hypothermia 63

5.General Management Principles for Cardiac Arrest 1. Establish the safety. 2. Confirm the diagnosis of an arrest 3. Send for help 4. Establish Basic Life Support 5. Aim for early and frequent defibrillation, with regular doses of adrenaline and CPR. 6. If there is doubt about the rhythm, treat adults as being in VF. 64

7. Except for defibrillation, chest compressions should not be interrupted for more than 10 seconds to allow invasive procedures or advanced airway management. 8. Administer drugs intravenously whenever possible. Use a 20-50ml 0.9% saline flush with the peripheral route. 9. Consider and treat any underlying causes 10. Consider antiarrhythmic drugs and sodium bicarbonate

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Questions: why 、 when 、 what how to perform CPR? Summary: concept of resuscitation mouth to mouth ventilation chest compression defibrillation

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The 2005 American Heart Association guidelines for CPR

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Can you save a life? In an emergency, when every second is criticial, would you know what to do?

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The Chain of Survival

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THE ABCDS Interventions described by the letter “ABCD” are vital for successful CPR, For many patient in cardiac arrest, the most important steps are to (3)Provide a patent upper airway (4)Maintain the rate of external compression 100 compressions per minute (5)Minimize interruption in external chest compressions (6)Provide prompt electrical defibrillation. 70

A represents assessment and opening of the airway B represents assessment and aid, if necessary, of breathing C is for circulation (30:2=1 cycle of CPR) D stands for electrical defibrillation In unwitnessed arrest, give five cycles of CPR before checking the rhythm and attempting defibrillation.

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•Push hard, push fast (rate of 100 compressions per minute), allow complete chest recoil between compressions (Do not bend elbows!!) •Compress in the center of the chest at the nipple line (2 fingers width above the xyphoid process) •Compress the chest approximately 11⁄2 to 2 inches, using the heel of both hands •Minimize interruptions in chest compressions

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Time for practice

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