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Basic Cardiac Life Support

for Health Care Provider


(AHA, HSF and ERC Guildline 2005)

Ruttonjee & Tang Shiu Kin Hospital


A&E Training Centre

Last update for EBM: 19 April 2006

Sudden Cardiac Arrest (SCA)

Hong Kong: approx 10,000 SCA-deaths per year!

In Hospital CPR quality


Abella, B.S., Alvarado, J.P., Myklebust, H., Edelson, D.P., Barry, A.,
OHearn, N. et al. (2005). Quality of cardiopulmonary resuscitation
during in-hospital cardiac arrest. JAMA. 293(3):305-310.
A prospective observational study of 67 patients who experienced inhospital cardiac arrest at the University of Chicago Hospitals,
Chicago, Ill
28.1% chest compression rates were less than 90/min (Suggestion
100/min)
37.4% Compression depth was too shallow (defined as <38 mm)
60.9% of segments containing a rate of more than 20/min.
(Suggestion: 10-12/min)
27 patients (40.3%) achieved return of spontaneous circulation
7 (10.4%) were discharged from the hospital.

Out Hospital CPR quality


Wik, L., Kramer-Johansen, J., Myklebust, H., Sorebo, H., Syensson
L., Fellows, B. et al. (2005). Quality of cardiopulmonary resuscitation
during out-of-hospital cardiac arrest. JAMA. 293 (3):299-304.
176 adult patients with out-of-hospital cardiac arrest treated by
paramedics and nurse anesthetists in Stockholm, Sweden, London,
England, and Akershus, Norway.
Compression rate: 118-124/min
28% (95% CI, 24%-32%) of the compressions had a depth of 38 mm
to 51 mm (guidelines recommendation),
11 ventilations were given per minute.
61 patients (35%) had return of spontaneous circulation,
5 (2%) patients discharged alive from the hospital had normal
neurological outcomes.

Sudden Cardiac Arrest (SCA) HK data

Every year approx 10,000 people die of SCA!

HK Ambulance at scene within 12min, mostly too late for SCA!


12,
HK Fire Service Ambulance attends to 300 SCA calls/month.
, 300
HK SCA-survival rates (outside hospital) = 1%!
1%!
Time to defibrillation = the weakest link in the chain of survival
=

Calling 999 only = 1% chance of survival


1%

Use of ECG in Cardiac Arrest Patients

Not a must for Initial Diagnosis

Useful for : :

diagnosis of underlying arrhythmias


monitoring progress of CPR

Non-traumatic Cardiac Arrest:Underlying


Cardiac Rhythms (1)
:(1)
Initial Rhythms for Arrest Outside Hospital:
:

Ventricular Fibrillation (VF)


Ventricular Tachycardia (VT)
Pulseless Electrical Activity (PEA)
Asystole

60%
10%
15%
15%

Underlying Cardiac Rhythms:


Ventricular Tachycardia
Ventricular Fibrillation

Non-traumatic Cardiac Arrest:


Underlying Arrthymias (2)
:(2)
In-hospital Cardiac Arrest:
:
VT more common
Not yet deteriorated to VF due to shorter discovery time

Principle of Treatment for Cardiac


Arrest (1)(1)
(1) Basic Life Support (BLS)
Maintenance of airway, breathing & circulation without any ancillary
equipment
,
A
Airway

B
Breathing

C
Circulation

Aim: Produce an artificial cardiac output and maintain cerebral &


coronary oxygen supply while waiting for the definitive treatment
(ACLS) to start the heart again.
:
()

Principle of Treatment for Cardiac Arrest (2)


(2)
Advanced Cardiac Life Support (ACLS)

BLS with equipment


+
D Drugs
E ECG evaluation
F Fibrillation Tx
(Defibrillation)
BLS/ACLS distinction nowadays blurred

(advanced airways)

BLS providers do DF by automatic defibrillators

ACLS just the other end of resuscitation continuum

Approach to ACLS

8 steps/blocks of problem assessment & management


Primary Survey

Airway
Breathing
Circulation
Defibrillation

(open)
(Bag-valve-mask)
(chest compression)
(defibrillator/AED)

Secondary Survey

Airways
Breathing
Circulation
DDx

(advanced airways)
(placement & effectiveness confirmation
(IV access & IV drugs)
(underlying problems)

Principle of Treatment for Cardiac Arrest (3)

(3)
The Brain:
CPR Initial Goal:
* Restarting the heart
CPR Ultimate Goal:
* Restoring neurological function
Therefore the term:
Cardio-pulmonary-cerebral Resuscitation

The Patient & the Cause of Arrest:


Must constantly returning to the overall view? Underlying causes for
the arrest

Principle of Treatment for Cardiac Arrest (4)

(4)
Time:
Probability of survival & neurological recovery decline sharply with
time
Progressive death of brain cells starts 4 minutes after cardiac arrest
,

Post-resuscitation Care:

Patients condition may change rapidly, thus continuous assessment is a must.


,
Investigation :

Arterial Blood Gases Assay, Serum Electrolytes & Cardiac Enzymes

12-Leads ECG

Chest Radiograph

Continuous BP, Pulse Oximeter Monitoring

Ryles Tube and Foley Catheter


,
End-Tidal CO2 monitoring for patient transfer

CHAIN OF SURVIVAL

HEALTHY CHOICES

EARLY RECOGNITION

EARLY ACCESS

EARLY CPR

EARLY DEFIBRILLATION

EARLY ADVANCED CARE ERALY


EARLY REHABILITATION

HEALTHY CHOICES
RISK FACTORS
- Cannot Control

Age

Gender

Family History

Race

HEALTHY CHOICES (CONT)


()
Can Be Control

Lack of Exercise

High Blood Pressure

High Blood Cholesterol

Diabetes

Drinking Too Much Alcohol


Stress

Being Overweight

Smoking

BE AWARE RISK FACTOR

Be

Smoke-free

Be

Physically Active

Control
Eat

Blood Pressure

Healthy

Maintain

Healthy Body Weight

BE AWARE RISK FACTORS (CONT)


()
Manage
Limit

Diabetes

Alcohol

Reduce

Stress

Regularly

Body Check-up

Post-menopause

Female

EARLY RECOGNITION
Warning Signs for Heart Disease & Stroke

Disease

Pain

Shortness of Breath
Nausea

Sweating

Fear

Heart

EARLY RECOGNITION
Stroke

Weakness

Trouble Speaking

Vision Problems

Headache

Dizziness

Early access

2min CPR
(

2min CPR

Early Access
 999 () / 27353355 ()


,


()



Early CPR
CPR (Cardio- Pulmonary resuscitation)

Airway

Clear
Open
Maintain

Breathing

Look
Listen
Feel

Circulation

Push hard and push fast

Airway
Clear
/

/ Magill forcep / (Suction)

Airway
Open

Head tilt chin lift


,
Jaw Thrust

Airway
Maintain

NPA ( Nasal Pharyngeal Airway )


OPA ( Oral Pharyngeal Airway )

Breathing
5-10 (10 )
: /

: ( Noisy Breathing )
() :

Breathing
,
(layman protocol )

1,
500-600 (Tidal volume)

>>>
>>

Breathing

10-125-6
12-20 (3-5

12 :

1001 (), 1002 1003 1004 1005 ()

20 :

1001 (), 1002 1003 ()

EARLY CPR
Responsive
Rest
Medication
Experience Chest Pain
Reassurance

Unresponsive
Begin CPR
Recovery Position
CPR


()
, 30:2 CPR ()
Push hard and push fast , 100

: 1 - 2
,
2 ( 5 30:2)


()
, 30:2 CPR () 15:2 ()
Push hard and push fast , 100

:
: 1/3 1/2
,
2 ( 5 30:2 / 815:2)


()
60,,
30:2 CPR () 15:2 ()
Push hard and push fast , 100
() ()
: ()
: 1/3 1/2
,
2 ( 5 30:2 / 815:2)


, ,

A
B

2

C

,
10 - 12


CPR,
3- 4%
2- 3

ACLS
ET Tube,
LMA, Combi tube CPR

8-10
1,
500-600 (Tidal volume)


Activate

2min CPR

2min CPR

Airway

Head tilt chin lift


,
,

Breathing

10-125-6 12-20 (3-5

Circulation

()
()

1 to 2

1/3 1/2
100

30:2

30:2 () 15:2 ()

CPR AED
CPR

CPR

(75%)

Timely access to AEDs


can improve the chances of survival dramatically!
, !

- Pulseless VT
Pulseless Ventricular Tachycardiac

150

- VF
Ventricular Fibrillation

VT

Polymorphic VT
>
>

120

+-

Monomorphic VT
>
Amiodarone


Medtronic CR Plus

Cardiac Science
Powerheart AED
G3
Laerdal FR2

Laerdal Heartstart 3000

Defibrillation
Monophasic
360J

Defibrillation
Biphasic dose
150-200J for truncated
exponential waveform
(BTE)
120J for
rectilinear biphasic
waveform (RLB)
If unknown , 200J for
ANY biphasic

Automatic External Defibrillation

VF5min,
AED
VF5min,CPR
2min
(CPR AED)

CPR, AED

Automatic External Defibrillation

(8 / 25)
AED

AED Mode of HeartStart XL

AED Mode of HeartStart XL

AED Mode of HeartStart XL

AED Mode of HeartStart XL

1
2

2
2

(
CPR2
ABC)

(CPR
2
ABC)

(AED
2ABC)

EARLY ADVANCED CARE


Ventilation
Set

Up IV

Drugs

Apply

Cardiac

Monitoring

Defibrillation
After

Care

EBM - CPR in Hong Kong


Lau CL , Lai JCH, Hung CY ,Kam CW (2005). Cardiac arrest
(OHCA) to a regional hospital in Hong Kong. Hong Kong j.
emerg. med, 12, 224-227.
1st Jan 2001 31st Dec 2003 (2 year)
A total of 876 cardiac arrests @ TMH
Rhythm
Asystole (n=795)
VF / pulseless VT (n=45)
Pulseless electrical activity (n=22)
Unknown (n=14)
111/876 (12.7%) survived to hospital admission.
4/876 (0.5%) survived to hospital discharge and at one year after
discharge.

EBM - CPR in Hong Kong


AKC Wai , P Cameron, CK Cheung , P Mak , TH Rainer
Out-of-hospital cardiac arrest in a teaching hospital in Hong Kong:
descriptive study using the Utstein style
(Hong Kong J.emerg.med. 2005;12:148-155)

1 July 2002 and 31 December 2002.


A total of 124 patients @ PWH
(mean age 71.9 years).
The majority of cardiac arrests occurred in patients' home.
The overall bystander cardiopulmonary resuscitation (CPR) rate was 15.3%
(19/124).
The overall survival was 0.8% (1/124),
The median defibrillation time was 14 minutes.
The median prehospital time interval from collapse/recognition to arrival at
hospital was 33 minutes.

EBM - CPR in Hong Kong


Leung LP, Wong TW, Tong HK, Lo CB, Kan PG (2001). Out of-hospital cardiac
arrest in Hong Kong. Prehosp Emerg Care, 5(3):308-11.
out-of-hospital cardiac arrest treated in the three A&E of Hong Kong Island
from March 15, 1999, to October 15, 1999.
320 patient @ RH, QMH, PYNEH
The majority of cardiac arrests occurred at patients' homes.
In 57.5% of cases the arrest was not witnessed.
The bystander cardiopulmonary resuscitation (CPR) rate was 15.6%.
The most common electrocardiographic (ECG) rhythm at scene was asystole.
Ventricular fibrillation or pulseless ventricular tachycardia constituted 14.1%.
The average call to dispatch interval was 1.04 minutes.
The average call to CPR interval was 9.82 minutes.
The average total prehospital interval was 27.55 minutes.
The overall immediate survival rate was 14.1%
the rate of survival to hospital discharge was 1.25%.

EARLY REHABILITATION

Healthy Lifestyle Choices

Ready to Face Second Attack


(,/,
: Abdominal thrusts
: 30:2 CPR
(x )
, .


(,/,
:
(x )
,

Defibrillation protocol

Guildline 2005
http://www.americanheart.org/presenter.jhtml?identifier
=3035517

http://ww2.heartandstroke.ca/Page.asp?PageID=33&Articl
eID=4466&Src=heart&From=SubCategory

http://www.erc.edu/index.php/guidelines_download_2005/
en/?

QUESTIONS?