Cardio Pulmonary Resuscitation

Cardio Pulmonary Resuscitation
The short what to do guide

Author : Dr F Malan
June 2012
Introduction
Why do CPR?
Basic Life Support Principels
Advance Cardiac Life Support Algorhythms
AED vs. Defib
Airway Management Devices
Drugs
Information and Graphics adapted from the BLS and ACLS Guidelines of the American Heart
Association 2010 and the South African Resuscitation Guidelines 2012
Why do CPR?
Blood flow stops = no oxygen or substrate delivery to cells
Ischemic cell injury follows
If condition persists, cell death occurs
CNS very fragile = cell death after 3-5 minutes =
permanent neurological damage
Cardiac muscle stops contracting after 1 minute but only
dies after 40-60 minutes

What happens during cardiac arrest?
Generates blood flow = less tissue ischemia
Improves survival and lessens neurological deficit
Buys time to reverse treatable conditions
The sooner CPR is started and the first shock delivered, the
better the chances of ROSC and thus survival (time = brain
+ heart)
No drug has been proven to increase survival!!

Why must we start Chest compressions as soon
as possible?
Why do CPR?
In-hospital cardiac arrest has an average survival rate of
21%
80% of patients with ROSC after cardiac arrest that are
admitted to ICU die before discharge
Survival rate is very poor for cardiac arrest associated with
rhythms other than VF/VT unfortunately >75% of in-
hospital arrests are due to non-VF/VT rhythms

Scary Statistics
Why do CPR?
80% of patients who had a cardiac arrest had abnormal
vitals for up to 8 hours prior to arrest
Only 44% of patients urgently admitted to ICU before
cardiac arrest die before discharge
Why do CPR?
Even Scarier Statistics

Prevent Cardiac Arrest Rather
than Treating it!

Very Important!!

What are the danger signs of a possible
cardiac arrest?
Threatened airway
Respiratory rate <6 or >30
Heart rate <40 or >140
SBP <90mmHg
Symptomatic hypertension
Significant fall in urine output
Decrease in GCS/Unexplained agitation/Seizure

And the Patient arrests.
I am alone!
What now?
Basic Life Support Principels
Step 1
Check responsiveness
Check for absent/abnormal breathing
Step 2
Get Help!!
Send for AED/Defib
Step 3
Check the carotid pulse for 5-10 seconds
If no pulse (or unsure of pulse) = start chest compressions
If pulse present = Give rescue breaths at 1 breath every 5-6 seconds and check pulse every
2 minutes
Step 4

Shock if needed
Follow each shock immediately with CPR, beginning with compressions
Check pulse and rhythm after 2 minutes

Step 1:

Check responsiveness
Are you all right
At the same time check for absent/abnormal
breathing
scan the chest for movement for 5-10 seconds

Step 2:

Get help
code blue team
Send for AED/Defib
Step 3:

Check the carotid pulse for 5-10 seconds
If no pulse (or unsure of pulse) = start chest compressions
Compress the lower half of the sternum at a rate of 100/min at a
depth of at least 5cm
Allow complete chest recoil after each compression
Minimize interruptions in compressions (10 seconds or less)
Switch compression providers every 2 minutes
Give breaths at a rate of 2 breaths for every 30 compressions if no
advanced airway is in place or at a rate of 1 breath every 5-6
seconds (8-10 breaths per minute) if advanced airway is in place
AVOID EXCESSIVE VENTILATION!
If pulse present = Give rescue breaths at 1 breath every 5-6
seconds and check pulse every 2 minutes

Step 4:

- No pulse = check for shockable rhythm with
an AED or Defib as soon as it arrives
- Shock as indicated
- Follow each shock immediately with CPR,
beginning with compressions
- Check pulse and rhythm after 2 minutes
T
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B
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Important Points
Compressions Must be Started First!
PUSH HARD AND PUSH FAST, ALLOW FULL CHEST RECOIL
Defibrillation (if indicated) must be done ASAP!
Avoid interruption of chest compressions
Work in 2 minute cycles
If in doubt = COMPRESSIONS!!!
BLS = CAB AND NOT ABC

I have started CPR, the Defib and help
has arrived.

The patient still has no pulse!!

What next?
Advanced Cardiac Life Support
The Team
Airway
Breathing
Circulation
Differential diagnosis
The universal ABCDs
A = Airway
Is the airway
patent?
Maintain airway patency in the
unconscious patient
Is an advanced
airway
indicated?
Use advanced airway if needed
Placement of an advanced airway
device can be deferred till later if bag-
mask ventilation is adequate
Is proper
placement of
airway device
confirmed?
Confirm placement of airway
- Secure the airway
-Monitor airway placement with
continuous quantitative waveform
capnography
Is the tube
secured and
placement
reconfirmed?
Assess
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of the
airway device confirmed?
Is the tube secured and
placement reconfirmed?
Action
Maintain airway patency in
unconscious patients
Head tilt-chin lift/jaw thrust
OPA
NPA
Use advanced airway if
needed
ET-tube
Laryngeal mask
Laryngeal tube
Esophageal-tracheal tube
A = Airway
Assess

Action

If bag-mask ventilation is
adequate then the
placement of an advanced
airway device can be
deferred till ROSC or till
initial CPR and defibrillation
attempts fail. Placement
must be weighed against
the adverse effects of
interrupting compressions
A = Airway
Assess

Action

Confirm proper integration
of CPR and ventilation
Confirm placement of
advanced airway
Secure the device to
prevent dislodgment
Monitor airway placement
with continuous
quantitative waveform
capnography
A = Airway
PETCO
2

A-line
PETCO
2

A-line
Example of
Good CPR
Example of
Poor CPR
A
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v
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C
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c

L
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S
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p
p
o
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t

A

=

A
i
r
w
a
y

B = Breathing
Are ventilation and
oxygenation adequate?
Give supplemental oxygen when indicated
Are quantitative
waveform capnography
and oxyheamoglobin
saturation monitored?
- Monitor adequacy of ventilation and oxygenation
- Avoid excessive ventilation
Asses
Are ventilation and
oxygenation adequate?
Are quantitative waveform
capnography and
oxyheamoglobin saturation
monitored?
Action
Give supplementary oxygen
when indicated
Cardiac arrest = 100% O2
Other = titrate O2 delivery to
achieve SATS >94%
Monitor adequacy of
ventilation and oxygenation
Clinical = chest rise and
cyanosis
Quantitative waveform
capnography
Pulse oxymetry
Avoid excessive ventilation
B = Breathing
C = Circulation
Are chest
compressions
adequate?
Monitor CPR quality
What is the
cardiac
rhythm?
Attach defib/monitor and check rhythm
Is cardioversion
or defibrillation
indicated?
Provide defibrillation/ cardioversion
Obtain IV/IO access
Has IV/IO
access been
established?
Is ROSC
present?
C = Circulation (continued)
Is the patient
with a pulse
stable?
Are medications
needed for
rhythm or blood
pressure?
Give fluids if needed
Does the patient
need
volume(=fluid)
for
resuscitation?
Give appropriate drugs
Assess
Are chest compressions effective?
What is the cardiac rhythm?
Is cardioversion or defibrillation
indicated?
Has IV/IO access been
established?
Is ROSC present?
Is the patient with a pulse stable?
Are medications needed for
rhythm or blood pressure?
Does the patient need
volume(=fluid) for resuscitation?
Action
Monitor CPR quality
Quantitative waveform capnography (aim
for Petco2>10mmHg)
Intra-arterial pressure (aim for
diastole>20mmHg)
Feel for central pulse wave during
compressions
Attach monitor/defib for arrhythmias or
cardiac arrest rhythms
VF/pulseless VT
Asystole/PEA
Provide defibrillation/cardioversion
Obtain IV/IO access
Give appropriate drugs
Give IV/IO fluids if needed
C = Circulation
D = Differential Diagnosis
Why did the patient arrest
and is there a reversible
cause?
Search for and treat reversible
causes
(Hs and Ts)
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
Assess
Why did the patient arrest?
Is there a reversible cause
that can be treated?
Action
Search for and treat reversible
cause (=definitive care)
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary
D = Differential Diagnosis
Cardiac Arrest
Rhythms
Shockable
VF Pulseless VT
Unshockable
Asystole PEA
Cardiac arrest rhythms
VF
Shockable Rhythms
Pulseless VT
Shockable Rhythms
Unshockable Rhythms
PEA Asystole
But what if the patient is unstable but
still has a pulse?

Dysrhythmia with pulses
Get help
and the
Defib
ABCDEs
AIRWAY
Open and
maintain
BREATHING
Give
02/Ventilat
e if needed
CIRCULATION
Check
pulse, BP
and
perfusion
Attach
monitors
DRIP and
DIFFERENTIAL
DIAGNOSIS
Obtain IV
access
Treat
underlying
causes
ECG
Get rhythm
strip/12-lead
ECG
Are there
signs of
instability?
What is the
pulse rate?

Dysrhythmia with pulses
What is the
pulse rate?
Fast
(>150/min)
ECG Rhythm?
Narrow
QRS-complex
Broad
QRS-complex
Normal
(50-150/min)
ABCDEs
Slow
(<50/min)
ECG Rhythm?
Bradycardia
with pulses
algorhythm
Tachycardia with pulses
Fast pulse
(>150/min)
Narrow QRS-
complex?
Stable? Unstable?
Wide QRS-
complex?
Unstable? Stable?
Synchronized
cardioversion
Adenosine or
Amiodarone
Vagal
stimulation
Adenosine
Amiodarone
Normal sinus tachycardia
Narrow complex tachycardia (SVT)
Broad complex tachycardia
Bradycardia with pulses
Slow pulse
(<50/min)
Unstable?
Stable?
Atropine
Transcutaneous
pacing or
Adrenaline
ABCDs
Everything went well and the patient
has ROSC. What now?
Drugs
Adrenaline
Atropine
Amiodarone
Adenosine
MgSO4
Bicarb
Ca-chloride/gluconate
Lignocaine

Cardio Pulmonary Resuscitation - Hand Out - v2

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