Cardio-Pulmonary and Cerebral Resuscitation

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• Cardio-Pulmonary and Cerebral Resuscitation
• Lecture 1
• Department of Anesthesiology and Intensive Care
• The head of a department I.Titov, DrPh.

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Professor Voloshinskij Oleksandr Volodimirovich
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Ass. of prof. Semkovich Michail Yaroslavovich
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Assistant Kindak ?van Romanovich
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?ssistant Golub Volodimir Vasilovich
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?ssistant ?ostirko Roman Bogdanovich
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?ssistant Nestor Igor ?vanovich
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The theme of lecture N 1

• Cardiopulmonary resuscitation. Symptoms of
  clinical death. Safars triple manoeuvre.
  Breathing.
• Cardiopulmonary resuscitation. Chest compression.
  Complications of the CPR.

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Part II. Cardiopulmonary resuscitation

• Life
• For normal functioning all cells of the body
  require oxygen. If oxygen is not provided, death
  of organism appears within 4..5 minutes.
• Brain is the tissue most susceptible to anoxia
  (absence of oxygen).

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Part II. Cardiopulmonary resuscitation

• Process of the death
• Is not a momentary but stepwise process, which
  can take certain time.
• Five steps of the death
• Preagony
  
• Terminal pause
• Agony
• Clinical death (reversible injury)
• Biological death (irreversible injury)

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Part II. Cardiopulmonary resuscitation

• Agony is a stage which precede to the death.
  Function of vital organs is severe disturbed, and
  conditions required for survival of organism
  cannot be met.
• Unconsciousness
• Blood pressure is undetectable
• No pulse on arteries
• Clinical death circulation stops completely and
  that leads to the cessation of breathing and
  nervous system activity.

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Part II. Cardiopulmonary resuscitation

• Symptoms of clinical death
• No pulse on arteries (carotid or femoral)
• Change of skin colour
• Unconsciousness
• Gasping, cessation of breathing
• Dilatation of eye pupils
• Duration of clinical death is 3(5) minutes

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Part II. Cardiopulmonary resuscitation

• Biological death is irreversible condition.
  Metabolism and functioning of vital organs has
  completely ceased. Organ damage is as extensive
  that resuscitation of the body is impossible.
• Evident symptoms of the death
• Rigor mortis
• Death spots on the body
• Drop of body temperature to the level of the
  surrounding

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Part II. Cardiopulmonary resuscitation

• Adult BLS sequence
• Basic life support consists of the following
  actions
• 1. Make sure that the victim, any bystanders, and
  you are safe.
• 2. Check the victim for a response (gently shake
  his shoulders and ask loudly, Sir. Or Ms., are
  you all right?)
• 3 A. If he responds
• Leave him in the position in which you find him
  provided there is no further danger.
• Try to find out what is wrong with him and get
  help if needed.
• Reassess him regularly.

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Part II. Cardiopulmonary resuscitation

• Adult BLS sequence
• 3 B. If he does not respond
• Shout for help, call 911 (USA and Canada) or 03
  (Ukraine and Russian Fed)
• Turn the victim onto his back and then open the
  airway using head tilt and chin lift
• - place your hand on his forehead and gently
  tilt head back.
• - with your fingertips under the point of the
  victims chin, lift the chin to open the airway.

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Part II. Cardiopulmonary resuscitation

• Adult BLS sequence
• 4. Keep the airway open, look, listen, and feel
  for normal breathing.
• Look for chest movement
• Listen at the victims mouth for breath sounds.
• Feel for air on your cheek
• Look, listen and feel for no more than 10 sec to
  determine if the victim breathing normally.

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Opening the airway

• Head tilt
• Chin lift
• If cervical spine injury suspected
• jaw thrust

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Assess Breathing

• Look for chest movement
• Listen for breath sounds
• Feel for expired air
• Assess for 10 seconds before deciding breathing
  is absent

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Rescue breathing(Expired air ventilation)

• If he is not breathing normally
• Ask someone to call for an ambulance.
• Kneel by the side of the victim.
• Pinch the soft part of the victims nose, using
  the index finger and thumb of your hand on his
  forehead.
• Allows his mouth to open, but maintain chin tilt.
• Take a normal breath and place your lips around
  his mouth, making sure that you have a good seal.
  

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Part II. Cardiopulmonary resuscitation

• Blow into his mouth and look on his chest, chest
  must rise take about one second to make his
  chest rise as in normal breathing this is an
  effective rescue breath.
• Maintaining head tilt and chin lift, take your
  mouth away from the victim and watch for his
  chest.
• Take another normal breath and blow into the
  victims mouth once more to give a total of two
  effective rescue breaths.
• Give each rescue breath over 1 sec rather than 2
  sec.

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Assess Circulation

• Check the victims pulse.
• A. If pulse on the carotid artery is not
  palpable begin chest compression.
• Place the heel of one hand in the centre of the
  victims chest.
• Place the heel of your other hand on the top of
  the first hand.
• Interlock the fingers of your hands and ensure
  that pressure is not applied over the victims
  ribs. Do not apply any pressure over the upper
  abdomen or the bottom end of the bony sternum
  (breastbone).

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Part II. Cardiopulmonary resuscitation

• 30 compressions 2 breaths for
• 1-person CPR
• 2-person CPR

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Part II. Cardiopulmonary resuscitation

• Chest compressions
• Depress sternum 4-5 cm
• Rate 100 per minute

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PRECORDIAL BLOW

• Indications
• Confirmed of blood circulation stop

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Continue resuscitation until

• Qualified help arrives and takes over
• The victim shows signs of life
• You become exhausted

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Airway management and ventilation

• Basic airway management and ventilation
• The laryngeal mask airway and Combitube
• Advanced techniques of airway management
• Basic mechanical ventilation

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Safars triple manoeuvre

• Open mouth
• Head Tilt and Chin Lift

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Jaw Thrust
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SUCTION
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Ventilation by mouth through a mask

• Advantages
• Allows to avoid direct contact
• Reduces probability of infected
• Allows to raise O2
• Restrictions
• Tightness maintenance
• Stomach inflating

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Bag-valve-mask
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Ventilation by means of bag ?mbu

• Advantages
• Direct contact allows to avoid
• Allows to increase concentration ?2 - to 85
• Can be used with an obverse mask, L?, Combitube,
  endotracheal tube

• Restrictions
• At use with an obverse mask
• Risk of inadequate ventilation
• Risk of inflating of a stomach
• 4 hands are necessary for optimum use

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Installation L?
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Laryngeal mask

• Advantages
• Speed and simplicity of installation
• Presence of the different sizes
• More effective ventilation in comparison with an
  obverse mask
• Allows to avoid laryngoscopy

• Restrictions
• Does not protect from aspiration
• Does not approach in situations when high
  pressure use on a breath is required
• It is impossible to aspirate from bottom BP

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Choice of an air line of the suitable size
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Simple adaptations for maintenance of BP
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Installation of pharyngo-oral an air line
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Installation of pharyngonasal an air line
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Combitube

• Advantages
• Speed and simplicity of installation
• Allows to avoid laryngoscopy
• It is possible to use, when pressure upon a
  breath the high

• Restrictions
• It is accessible only 2 sizes
• There is a risk of ventilation through a gastric
  gleam
• Damage of cuffs at installation
• Trauma in an installation time
• Only for disposable use

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Ventilation by means of Combitube
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Intubation of tracheas

• Attempt of intubation
• Preoxygenation of the patient
• 30 seconds on each attempt
• Spend a tube through a vocal crack under the
  control of direct sight
• At any doubts or complexities, reoxygenation the
  patient before the subsequent attempts
• Patients are harmed by unsuccessful attempts of
  oxygenation, instead of intubation!

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Installation of endotracheal tube
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Intubation of trachea

• Advantages
• Allows to increase PO2 to 100
• Isolates BP, preventing of aspiration
• Allows aspirated of BP
• Alternative way for introduction of medicine

• Restrictions
• Training and experience are absolutely necessary
• Unfortunate attempt, esophageal intubation
• Risk of deterioration of damage back and a brain
  during laryngoscope

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Confirmation of correct position of ETT in a
trachea

• Direct visualisation during laryngoscope
• Auscultation
• With two sides, on average axillary's lines
• Over epigastrium
• Symmetric movements of thorax during ventilation

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Sellicks manoeuvre

• Pressure on cricoid cartilage on purpose of
  occlusion a gullet about cervical department of a
  backbone

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Sellicks manoeuvre

• Advantages
• Decrease of risk of aspiration and regurgitation
• It can be applied at intubation, and also
  ventilation by means of an obverse mask and LM

• Lacks
• Can complicate intubation
• Can complicate ventilation by means of an obverse
  mask or LM
• Avoid at active vomiting

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Cricothireotomy

• Indications
• Impossibility of maintenance passableness of BP
  in another way
• Complications
• Displacement of cannula
• Emphysema
• Bleeding
• Gullet punching
• Hypoventilation

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DEFIBRILLATION
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Rhythm of a stop of blood circulation

• Fibrillation of ventricles
• Ventricle's tachycardia without pulse
• Asystole
• Electro-mechanical dissociation (EMD)

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Asystole

• There is no activity of ventricles (complex QRS)
• Activity of auricles (wave P) can be
• Seldom straight line
• Possibility of small waves of VF

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The mechanism of DEFIBRILLATION

• Definition
• The termination of fibrillation or absence VF/VT
  in 5 seconds after the discharge
• Depolarized all weight of a myocardium
• Natural pacemeker renew job

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Automatic external DEFIBRILLATOR

• Analyze a heart rhythm
• Make the discharge
• Specificity in recognition of the rhythm in
  subject which is defibrillation comes nearer to
  100

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Automatic external DEFIBRILLATOR

• Attach sticky electrodes
• Follow the sound and visual instruction
• The automatic analysis of an electrocardiogram -
  do not touch the patient
• The automatic discharge at a corresponding rhythm
• /-a manual overload

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Manual DEFIBRILLATION

• It is based on
• The rhythm is recognised by the operator
• The operator puts the discharge
• It can be used for synchronised cardioversion

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Safety of defibrillation

• Never hold both electrodes in one hand
• Charge only when electrodes on a breast of the
  victim
• Avoid direct or indirect contact
• Wipe dry a breast of the patient
• Remove oxygen from a zone of defibrillation

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Manual DEFIBRILLATION (1)

• Diagnostics VF/VT and signs of a stop of blood
  circulation
• Choice of suitable energy of the discharge
• To load condensers (electrodes on the patient)
• The command all to depart
• Visual check of a zone of defibrillation
• To check up the monitor
• The discharge

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Manual DEFIBRILLATION (2)

• Repeatedly to estimate a rhythm
• To hold electrodes on a breast between discharges
• To increase energy
• The assistant makes, or
• To place an electrode on defibrillator and to
  choose energy level independently
• Not to spend BLS between discharges if there is
  no long delay

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The conclusion

• Defibrillation it is unique effective at
  restoration of circulation at patients with VF or
  VT without pulse
• Defibrillation should it is spent quickly,
  effectively and safely
• New technologies increase possibilities of
  equipment and simplify use

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Introduction of medicines in time of ??R
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The central venous access

• Internal jugular vein
• Subclavian vein

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Complications of catheterization the central
veins

• Artery puncture
• Hematoma
• Hemothorax
• Pneumothorax
• Air embolism
• Damage of surrounding fabrics
• ?rrhythmias

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Intatracheal introductin of medicines

• Preparations which can it is entered into a
  trachea
• Adrenaline
• Lidocaine
• Atropine
• Naloxoni

• Preparations which cannot be entered into a
  trachea
• Amiodaroni
• Sodium bicarbonate
• Calcium

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Adrenaline

• Indications
• Any rhythm at a blood circulation stop
• Bradycardia
• Special circumstances
• Anaphylactic shock

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Adrenaline

• Dose
• 1 mg I\V in 10 110,000 (1 ml 11,000) every
  2-3 min at resuscitation
• 2-3 mg throw E??
• 210 mkg min-1 at bradycardia resistant to
  atropine
• 0.5 ml 11,000 i/m, 3-5 ml 110,000 i/v
• at anaphylactic shock, in depending on weight

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Adrenaline

• Action
• a-agonist
• - arterial vasoconstriction
• ????
• a cerebral and coronary blood-groove
• b-agonist ? HC
• ? forces of heart reductions
• requirements of a myocardium for
  oxygen (can strengthen an ischemia)

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Atropine

• Indications
• Asystole
• Bradycardia
• EMD (F of HC lt 60 in min)

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Atropine

• Action
• Blockade of effects of nervus vagus
• Strengthening of automatism of sinoatrial node
• Increase ?-? of conductivity

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Atropine

• Dose
• Asystole / EMD (F of HC lt 60 in min)
• 3 mg i/v, unitary
• 6 mg throw E??
• Bradycardia
• 0.5 mg i/v, to repeat at necessity, maximum 3 mg

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Amiodaroni

• Indications
• Refractory VF / VT without pulse
• Hemodynamic stable VT
• Other resistant tachyarrhythmia

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Amiodaroni

• Dose
• Refractory VF / VT without pulse
• 300 mg in 20 ml 5 dextrose, i/v
• Tachyarrhythmia
• 150 mg in 20 ml 5 dextrose during 10 min
• Repeat 150 mg at necessity
• 300 mg in 100 ml 5 dextrose during 1 hour

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Amiodaroni

• Action
• Increases duration of potential of action
• Extends interval Q-T
• Weak negative inotropic action - can call a
  hypotension

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Lidocaine

• Indications
• Refractory VF / VT without pulse
• at inaccessibility of amiodaroni
• Hemodynamic stable VT
• as alternative for amiodaroni

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Lidocaine

• Dose
• Refractory VF / VT without pulse
• 100 mg i/v
• after boluses 50 mg, max 200 mg
• Hemodynamic stable VT
• 50 mg i/v.
• after boluses 50 mg, max 200 mg
• To lower a dose at elderly and at hepatic
  insufficiency

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Sodium bicarbonate

• Indications
• Heavy metabolic acidosis (pH lt7.1)
• ? K in blood
• Special circumstances
• Poisoning by energizers

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Sodium bicarbonate

• Dose
• 50 mmol (50 ml 8.4 solution) i/v

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Sodium bicarbonate

• Action
• Alkaline agent (increase pH)
• But can call
• Increase in loading ??2
• Reduction of liberation ?2 in fabrics
• Decrease contractility of myocardium
• Increase Na in blood
• Co-operates with adrenaline

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Calcium

• Action
• It is necessary for normal reduction of a
  myocardium
• Surplus can call arrhythmia
• The trigger of  destruction of cages ischemic
  myocardium
• Surplus can break brain restoration

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Calcium

• Indications
• EMD calling by
• ? K in blood
• ? Ca in blood
• Overdose of calcium blocker
• Dose
• 10 ml 10 Ca Cl (6.8 mmol\l)
• Not to enter at once before or after bicarbonate
  sodium

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Naloxoni

• Indications
• Overdose of opiates
• Oppression of breath after appointment of opiates

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Naloxoni

• Dose
• 0.2 - 2.0 mg i/v
• It can be demanded repeatedly, possible to 10 mg
• Infusion can be demanded

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• To make 3 discharges if it is necessary, in a
  current of 1 minute
• Not to interrupt defibrillation for BLS
• After the discharge, palpate pulse on carotids,
  only if on an electrocardiogram a rhythm
  corresponding to job of heart

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During ??R Correction of the reversible
reasons If it is not made To check up
electrodes, an arrangement and contact To provide
/ to check up - Passableness BP and O2 -
Venous access Adrenaline each 3 mines To
consider amidaroni, atropine / pacing buffers
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Compression, respiratory ways and ventilation

• Passableness of respiratory ways
• Endotracheal tube
• LM
• Combitube
• After maintenance of passableness of BP do not
  interrupt a compression for ventilation

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Venous access and preparations FV/VT

• The central or peripheral vein
• Adrenaline of 1 mg i/v or 2-3 mg endotracheal
• To consider amiodaroni 300 mg if FV/VT present
  after 3rd category
• Alternatively - lidocaine of 100 mg
• To consider magnesium 8 mmol

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False asystole

• When monitoring with paddle-gel pads
• More likely with increasing number of shocks and
  high chest impedance
• Displays apparent asystole
• Confirm rhythm with monitoring leads