CARDIOPULMONARY RESUSCITATION

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CARDIOPULMONARY RESUSCITATION
Department of Anaesthesia Visakha Steel General
Hospital
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Cardio Pulmonary Resuscitation

• Consists of mouth-to-mouth respiration and chest
  compression.
• Allows oxygenated blood to circulate to vital
  organs such as the brain and heart.
• Keep the person alive until more advanced
  procedures (such as defibrillation - an electric
  shock to the chest) can treat the cardiac arrest.

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Cardio Pulmonary Resuscitation

• 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.

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HISTORICAL REVIEW

• 5000 - first artificial mouth to mouth
  3000 BC ventilation
• 1780 first attempt of newborn
  resuscitation by blowing
• 1874 first experimental direct cardiac
  massage
• 1901 first successful direct cardiac massage
  in man
• 1946 first experimental indirect cardiac
  massage and defibrillation
• 1960 indirect cardiac massage
• 1980 development of cardiopulmonary
  resuscitation due to the works of Peter
  Safar

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all cases accompanied with hypoxia
extracardiac
Causes of cardiac arrest
cardiac
Primary lesion of cardiac muscle leading to the
progressive decline of contractility,
conductivity disorders, mechanical factors
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Diagnosis of cardiac arrest
Blood pressure measurement ? Taking the pulse on
peripheral arteries ? Auscultation of cardiac
tones
Loss of time !!!
Symptoms of cardiac arrest

• absence of pulse on carotid arteries a
  pathognomonic symptom
• respiratory arrest may be in 30 seconds after
  cardiac arrest
• enlargement of pupils may be in 90 seconds
  after cardiac arrest

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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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Cardio Pulmonary Resuscitation

• BLS basic life support.
• ACLS advanced cardiac life support.

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Main stages of resuscitation

• A irway ensure open airway by preventing the
  falling back of tongue, tracheal intubation
• Breathing start artificial respiration of lungs
• 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

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A (Airway) ensure open airway
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A (Airway)  ensure open airway
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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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B (Breathing)

• EFFCTIVE RESCUE BREATHS

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Airway management

• Mouth-mouth respiration (pocket face masks).
• Mouth-mouthnose respiration.
• Bag mask ventilation.
• Airways (nasal oral).
• Endotracheal tubes.
• Laryngeal mask airways.
• Combitubes.

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Airways (nasal oral)
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Laryngeal mask airways
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Endotracheal tubes.
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• Closed chest compressions only effective if
  the patient successfully ventilated.

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Algorithm for artificial ventilation
mouth to mouth or mouth to nose respiration
ventilation by a face mask and a self-inflating
bag with oxygen
2 initial resecuebreaths
wait for the end of expiration
10-12 breaths per minute with a volume of app.
800 ml, each breath should take 1,5-2 seconds
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Air way obstruction

• Choking Conscious Infant (lt1 years old)

• Determine if the infant can cry or cough. If not,
  proceed to next step
• Give 5 back blows.
• Give 5 chest thrusts.
• Repeat steps 2 3 above until effective or the
  infant becomes unconscious. If the infant becomes
  unresponsive, perform CPR- if you see an object
  in the throat or mouth, remove it.

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Choking Conscious Child - adult

• Perform an abdominal thrust (Heimlich Maneuver)
  repeatedly until the foreign body is expelled.
• If the adult or child becomes unresponsive
  perform CPR.if you see an object in the throat
  or mouth, remove it.

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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.
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C. Circulation Restore 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 lt10 sec except
  during ET insertion or defibrillation.

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2 mechanisms explaining the restoration of
circulation by external cardiac massage
Cardiac pump
Thoracic pump
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Cardiac pump during the cardiac massage
Blood pumping is assured by the compression of
heart between sternum and spine
Between compressions thoracic cage is expanding
and heart is filled with blood
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Thoracic pump at the cardiac massage

• Blood circulation is restored due to the change
  in intra thoracic pressure and jugular and
  subclavian vein valves
• During the chest compression blood is directed
  from the pulmonary circulation to the systemic
  circulation. Cardiac valves function as in normal
  cardiac cycle.

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ALGORITHM of Cardiopulmonary resuscitation
a
2 breaths (duration 1.5 2 sec.)
palpation of pulse on carotid arteries (5 10
sec.)
in case of absence of pulse initiate external
cardiac massage
2 persons
1 person
a
compression rate 80 100/min. compression/breath
15 2
compression rate 80 100/min compression/breath
5 1
a
2 breaths in 4 7 sec.
breath during 1 1.5 sec. after each 5th
compression
4 cycles 15 compression and 2 breaths
10 cycles 5 compression and 1 breath
check the pulse on carotid arteries (5 sec)
in case of absence of pulse continue resuscitation
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During CPR

• Push hard fast(100/min)
• Compressions to relaxation ration 5050
• Ensure full chest recoil

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During CPR

• Avoid hyperventilation
• Secure airway confirm placement
• Rotate compressors every 2min with rhythm checks
• After an advanced airway is placed, rescuers no
  longer deliver cycles of CPR. Give continuous
  chest compressions without pause for breaths.
  Give 8-10 breaths/min. check every 2min.

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Infant CPR

• Shout and gently tap the child on the shoulder.
  If there is no response, position the infant on
  his or her back

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Infant CPR

• If the baby is NOT breathing give 2 small gentle
  breaths.
• Cover the baby's mouth and nose with your mouth.
• Each breath should be 1 second long.
• You should see the baby's chest rise with each
  breath.

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Child CPR 1-8 years

• CPR for children is similar to CPR for adults.
  The compression to ventilation ratio is 152.
  There are, however, 3 differences.
• 1) If you are alone with the child give two
  minutes of CPR before calling help
• 2) Use the heel of one hand as for adults for
  chest compressions
• 3) Press the sternum approximately one-third the
  depth of the chest

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CPR

• Pushing on the Chest
• Sometimes you may hear a cracking sound.
• The sound is caused by cartilage or ribs
  cracking.
• Even if this occurs the damage is not serious.
• The risk of delaying CPR or not doing CPR is far
  greater than the risk of a broken rib.

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Types of CPR

• Closed Compression CPR.
• ACD-CPR active compression decompression CPR.
• IAP-CPR (Interposed Abdominal Counterpulsation
  CPR).
• Vest-CPR.
• Invasive CPR.

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Search for treat possible contributing factors

• Toxins
• Tamponade,
• Tension pneumothorax
• Thrombosis(coronary or pulmonary)
• Trauma

• Hypovolemia
• Hypoxemia
• Hydrogen ion
• Hypo/hyperkalemia
• Hypoglycemia
• Hypothermia

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Summary of recommended BLS techniques
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Possible arrhythmias

• ventricular tachycardia fibrillation
• bradyarrythmia including electromechanical
  dissociation and asystole
• supraventricular arrhythmia accompanied with
  tachycardia
• supraventricular arrhythmia with normal blood
  pressure and pulse rate

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VENTRICULAR FIBRILLATION OR PULSELESS TACHYCARDIA
Witnessed
Unwitnessed
Precordial thump
Check pulse, if none

• Begin CPR
• Defibrillate with 200 joules
• Establish IV access, intubate
• Defibrillate with 200 joules
• Adrenaline 1 mg push
• Defibrillate with 200 joules
• Amiodarone 300mg IV,followed by 150mg or
  lidocaine 1-1.5mg IV, followed by 0.5 -0.75mg/kg

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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 youre clear
• Three ever body clear
• Apply 25lb of pressure on both paddles
• Press the 2 paddle discharge button
  simultaneously

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• Defibrillation
• Complete depolarisation
• Asystole
• Resumption normal cardiac automaticity

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• A single shock strategy preferable to the
  traditional triple shock strategy

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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
  gt5min ,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
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Energy Requirements Monophasic Shocks
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Operations in case of asystole
Asystole/PEA

• Start CPR
• IV line
• AdrenalineIV 1 mg, each 3-5 min.
• or
• intratracheal 2 - 2.5 mg
• in the absence of effect increase the dose
• Atropine 1 mg push (repeated once in 5 min)
• Na Bicarbonate 1 Eq/kg IV
• Consider pacing

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Drug Administration During CPR

• Cannulation of peripheral veins- does not require
  interruption of CPR.
• Injected as bolus followed by 10-20ml of IV
  fluid.
• If initial drug injection is unsuccessful,
  perform CVP.
• Alternate sites - Intraosseous(I O),ET tube
• Drugs administered through ET tube
  atropine,adrenaline,vasopressin,xylocaine

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Cardiac arrest drugs vasopressors
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Cardiac arrest drugsantiarrhythmic agents
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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.
• CPP gt 15mmof Hg successful outcome.
• End Tidal CO2 indirect indicator of the CO
  generated during CPR.
• Increase in ETCO2 during CPR is predictive of
  successful outcome.

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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 lt6min.
• Onset of CPR gt6min CPR can be terminated after
  15min.

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Predicting neurological recovery

• Who do not awaken immediately after CPR- most
  important determination is neurologic recovery.
• Coma gt 24hrs - 10 chance of neurologic
  recovery.
• Coma gt 72hrs - 5 chance of neurologic recovery.
• Coma gt 2wks - no chance of full neurologic
  recovery.
• 72hrs point or GCSlt5 little or no chance of
  neurological recovery.

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Cardio Pulmonary Resuscitation

• Cardio Pulmonary - Cerebral Resuscitation (CP-CR)

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CPR - CPCR

• Avoid hyperventilation impair ability of chest
  compressions to generate blood flow.
• As early as possible give DC shock
• Avoid prolonging CPR beyond a reasonable time
  period.
• Goal of CPR is a functioning heart in
  functioning person

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Thank You