CPR &

ELECTRICAL
THERAPIES
BAGIAN ANESTESI
FK UNISSULA SEMARANG
CARDIAC ARREST
The cessation of cardiac mechanical
activity, as confirmed by the absence of
signs of circulation.
SUDDEN CARDIAC ARREST
Circumstances
Witnessed
Unwitnessed
Settings
Out of hospital
In hospital
A single approach to resuscitation is not practical,
but a core set of actions provides a universal
strategy for achieving successful resuscitation.
Chain of Survival
CONCEPTUAL FRAMEWORK FOR CPR
Rescuer : everyone can be a lifesaving
rescuer for a cardiac arrest victim. CPR
skills and their application depend on the
rescuers training, experience, and
confidence.
The 30 : 2 ratio in adults is based on a
consensus among experts and on
published case series.
CONCEPTUAL FRAMEWORK FOR CPR
When VF is present for more than a few
minutes, the myocardium is depleted of
oxygen and metabolic substrates.
A brief period of chest compression can
deliver oxygen and energy substrates and
unload the volume-overloaded right
ventricle, increasing the likelihood that a
perfusing rhythm will return after shock
delivery.
5 CHAIN OF SURVIVAL
AHA 2010
SURVIVAL RATES
Survival rates from witnessed VF SCA
decrease 7% to 10% if no CPR is
provided.
When these links are implemented in an
effective way, survival rates can aprroach
50% following witnessed out of hospital VF
arrest.

BASIC LIFE SUPPORT
BLS care in the out of hospital setting is
often provided by laypersons.
The first 3 BLS links in the adult Chain of
Survival : recognition and activation, early
CPR, and rapid defibrillation (when
appropriate).
ADVANCED LIFE SUPPORT
ACLS in the chain of survival that include
interventions to prevent cardiac arrest,
treat cardiac arrest, and improve
outcomes of patients who achieve ROSC.
For the treatment of cardiac arrest, ACLS
interventions build on the BLS + increase
ROSC with drug therapy, advanced airway
management, and physiologic monitoring.
1. Immediate Recognition of
SCA (ERS)
Check for response based on assesing
unresponsiveness while looking at the
patient to determine the absence of normal
breathing (the victim is not breathing or
only gasping). Suspect cardiac arrest if
victim is not breathing or only gasping.

2. Look, Listen, and Feel has
been removed
Performance of these steps is inconsistent
and time consuming. For this reason the
2010 AHA Guidelines for CPR and ECC
stress immediate activation of the
emergency response system and starting
chest compressions for any unresponsive
adult victim.
3. Hands only CPR
Only about 20 30% of adults with out-of-
hospital cardiac arrest recieve any
bystander CPR.
Hands-Only CPR (compression-only) for
the untrained lay rescuer. Hands-Only CPR
is easier to perform by those with no
training and can be more readily guided by
dispatcher over the telephone.
3. Hands only CPR
If a bystander is not trained in CPR, then the
bystander should provide Hands-Only (chest
compression only) CPR, with an emphasis
on push hard and fast.
How can bystander CPR be effective without
rescue breathing? Initially during SCA with
VF, rescue breaths are not as important as
chest compressions because the oxygen
level in the blood remains adequate for the
first several minutes after cardiac arrest.
4. C A B rather than
A B C
A change in the 2010 AHA Guidelines for
CPR and ECC is to recommend the
initiation of chest compression before
ventilation (rescue breath).
5. Minimal Interruption in
Chest Compressions
Limiting the frequency and duration of
interruptions in chest compressions may
improve clinically meaningful outcomes in
cardiac arrest patients.
Health care providers continue effective
chest compression / CPR until ROSC or
termination of resuscitative efforts.
5. Minimal Interruption in
Chest Compressions
Vascular access, drug delivery and
advanced airway placement should not
cause significant interruptions in chest
compression or delay defibrillation.
During CPR, a goal to limit interruptions to
no more than 10 seconds.
6. Increased high-quality CPR
Compressions of adequate rate and depth,
allowing full chest recoil between
compressions, minimizing interruptions in
chest compressions.
The adult sternum should be depressed at
least 2 inches (5 cm).
It is reasonable for lay rescuers and
healthcare providers to perform chest
compressions at a rate of at least
100x/min.


7. Cricoid Pressure isnt
Recommended
CP is a technique of applying pressure to
the victims cricoid cartilage to push the
trachea posteriorly and compress the
esophagus againts the cervical vertebrae.
2005 : CP can prevent gastric inflation &
reduce the risk of regurgitation & aspiration
during BVM ventilation.
7. Cricoid Pressure isnt
Recommended
New RCT : CP can delay prevent the
placement of advanced airway & the
aspiration can occur despite application of
CP.


8. Precordial Thump
Precordial thump may be considered for
termination of witnessed monitored unstable
ventricular tachyarrythmias when a
defibrillator is not immediately ready for use,
but should not delay CPR and shock
delivery.
In 3 case series : VF / pulseless VT was
converted to a perfusing rhthm by a PT.
There is insufficient evidence to recommend
for againts the witnessed onset of asystole.
CHEST COMPRESSION
1. Care should be taken to minimize
interruptions in chest compressions when
placing, or ventilating with an advanced
airway.
2. Because delay in chest compressions
should be minimized, the HP should take
no more than 10 seconds to check for a
pulse, and if the rescuer does not definitely
feel a pulse within that time period the
rescuer should start chest compressions.


CHEST COMPRESSION
3. Incomplete recoil during BLS CPR is
associated with intrathoracic pressure
significantly hemodynamics ( coronary
perfusion, cardiax index, myocardial
blood flow & cerebral perfussion).
4. It is reasonable to switch chest
compressors approximately every 2
minutes to prevent decreases in the quality
of compressions.
COMPRESSION :
VENTILATION
When an advanced airway (ET, combitube or
LMA) is in palce during 2 person CPR,
continuous chest compressions (there should
be no pause in chest compressions for
delivery of ventilations). Performed at a rate
of at least 100/min without pauses and give 1
breath every 6 8 seconds without
attempting to synchronize breaths between
compressions (this will result in delivery of 8
to 10 breaths/minute).
VENTILATION
Studies in anesthetized adults (normal
perfusion) suggest that a tidal volume of 8
10 ml/kg maintains normal oxygenation and
elimination of CO2.
During CPR, cardiac output is 25 33% of
N oxygen uptake from the lungs and CO
2

delivery to the lungs are also reduced. As a
result, a low minute ventilation (lower than
normal TV and respiratory rate) can maintain
effective oxygenation and ventilation.
VENTILATION
For that reason during adult CPR tidal
volumes of approximately 500 600 mL (6
7 ml/kg) should suffice. This is
consistent with a tidal volume that
produces visible chest rise.
VENTILATION
Excessive ventilation is unnecessary &
can cause gastric inflation and its resultant
complications, such as regurgitation and
aspiration.
Excessive ventilation can be harmful
increase intrathoracic pressure
decrease venous return to the heart
diminishes cardiac output and survival.
VENTILATION
Bag mask ventilation : the rescue should
use an adult (1 to 2 L) bag to deliver
approximately 600 mL TV for adult victims.
Deliver by squeezing a 1 L adult bag about
two thirds of its volume.
The HP should use supplementary oxygen
(O
2
concentration >40%, at minimum flow
rate of 10 12 L/min) when available.
DROWNING
The duration and severity of hypoxia
sustained as a result of drowning.
There is no evidence that water acts as an
obstructive foreign body. Manuevers to
relieve FBAO are not recommended for
drowning victims because such manuevers
arent necessary and they can cause injury,
vomiting, aspiration & delay CPR.
DROWNING
When rescuing a drowning victim of any
age, it is reasonable for the lone HP to
give 5 cycles of CPR before leaving the
victim to activate the EMS system.
DROWNING
As soon as the unresponsive victim is
removed from the water open the airway
check for breathing if theres no
breathing give 2 rescue breaths that
make the chest rise check the pulse if
theres no pulse begin chest
compressions.
Dry the chest area before applying the
defibrillation pads and using the AED.
HYPOTHERMIA
Body temperature : mild (> 34
o
C), moderate
(30-34
o
C), severe hypothermia (< 30
o
C).
If the victim is unresponsive with no normal
breathing, lay rescuer should begin chest
compressions (CPR) immediately.
Do not wait to check the victims
temperature and do not wait until the victim
is rewarmed to start CPR.
HYPOTHERMIA
To prevent further heat loss, remove wet
clothes from the victim; insulate from wind,
heat or cold; and if possible, ventilate the
victim with warm, humidified oxygen.
If VF is detected, emergency personnel
should deliver shocks using the same
protocols of CPR.

FBAO
If the adult victim with FBAO becomes
unresponsive, the recuer should carefully
support the patient to the ground,
immediately activate (or send someone to
activate) EMS, and then begin CPR
(without a pulse check).
Each time the airway is opened during
CPR, the rescuer should look for an object
in the victims mouth and if found, remove
it.
FBAO
Simply looking into the mouth should not
significantly increase the time needed to
attempt the ventilations and proceed to the
30 chest compressions.
No studies have evaluated the routine use
of the finger sweep to clear an airway in
the absence of visible airway osbtruction
case report documented harm to the
victim or rescuer.
PREGNANCY
Patient positioning has emerged as an
important strategy to improve the quality of
CPR and resultant compression force and
output.
Left lateral tilt is used to improve maternal
hemodynamics during cardiac arrest.
PREGNANCY
Chest compressions
should be performed
slightly higher on the
sternum than normally
recommended.
Defibrillation : use of
an AED on a pregnant
victim has not been
studied but is
reasonable.
VASOPRESSOR
A vasopressor can be given as soon as
feasible with the primary goal of increasing
myocardial and cerebral blood flow during
CPR and achieving ROSC.
Epinephrine iv/io dose : 1 mg every 3 5
minutes.
Vasopressin iv / io dose : 40 units can
replace epinephrine.


VASOPRESSOR
Three RCTs and a meta-analysis of the trials
demonstrated no differences in outcomes
(ROSC, survival to discharge or neurologic
outcome) with vasopression 40U iv VS
epinephrine 1mg as a first-line vasopressor in
cardiac arrest.
Because the effects of vasopressin havent
been shown to differ from those of
epinephrine in cardiac arrest, 1 dose of V 40
units may replace either the first/second dose
of E in cardiac arrest.


ANTIARRHYTMIC AGENT
Amiodarone is the first-line AAA given
during cardiac arrest because it has been
clinically demonstrated to improve the rate
of ROSC and hospital admission in adults
with refractory VF/pulseless VT.
Amiodarone iv/io : first dose : 300 mg bolus,
second dose : 150 mg bolus.
If it is unavailable, lidocaine may be
considered, dose : 1 1,5 mg/kg iv bolus.
SULFAS ATROPINE
Atropine sulfate reverses cholinergic-
mediated decrease heart rate and
atrioventricular nodal conduction.
No prospective controlled clinical trials have
examined the use of atropine in cardiac
arrest.
For this reason atropine is no longer
recommended for routine use in the
management of PEA / asystole & has been
removed from the cardiac arrest algorithm..

OVERVIEW
Early defibrillation is critical to survival from
sudden cardiac arrest (SCA).
The most frequent initial rhythm in out of
hospital witnessed SCA is ventricular
fibrillation (VF) all BLS providers should
be trained to provide.
If bystanders provide immediate CPR, many
adults in VF can survive with intact
neurologic function, especially if defibrillation
is performed within 5 10 minutes after
SCA.
OVERVIEW
Rapid defibrillation is the treatment of
choice for VF (witnessed out of hospital
cardiac arrest or for hospitalized patients
whose heart rhythm is monitored).
Performing chest compressions while
another rescuer retrieves and charges a
defibrillator improves the probability of
survival.
OVERVIEW
Electrical therapies (AHA 2010) are
manual defibrillator, AED, synchronized
cardioversion and pacing.
AED may be used by lay rescuers and HP
as part of basic life support.
Manual defibrillation, cardioversion and
pacing are advanced life support
therapies.
When Defibrillator is Performed
First provider should start CPR and second
provider should get or turn on the
defibrillator, place the adhesive pads or
paddles, and check the rhythm.
Rhytm checks should be brief, and if an
organized rhythm is observed (included VT)
by manual defibrillator or cardiac monitor, a
pulse check should be performed.
If there is any doubt about the presence of a
pulse, chest compression should be resumed
immediately.
AUTOMATED EXTERNAL
DEFIBRILLATOR
AED are sophisticated, reliable
computerized devices that use voice and
visual prompts to guide lay rescuers & HP.
Some devices are programmed to detect
spontaneous movement by the patient.
AUTOMATED EXTERNAL
DEFIBRILLATOR
In studies in which EMS call-to-arrival
intervals were 4 5 minutes or longer, 11/2
3 minutes of CPR before defibrillation
increased the rate of initial resuscitation
(ROSC), survival to hospital discharge, and
1 year survival when compared with
immediate defibrillation for VF SCA.
MANUAL DEFIBRILLATOR
The recommended energy dose of biphasic
defibrillator is 200 J for terminating VF.
The recommended energy dose of
monophasic defibrillator is 360 J for
terminating VF.
In pediatrics : initial monophasic doses of 2
J/kg are effective in terminating 18% - 50%
of VF.

MONOPHASIC VS BIPHASIC
Biphasic waveform shock has been
reported to be safer and more effective
than a monophasic waveform shock.
A biphasic defibrillator has lower energy
requirements and is smaller and lighter in
weight than a monophasic defibrillator.
Almost all defibrillators currently available
commercially are biphasic defibrillator.
MONOPHASIC VS BIPHASIC
A study in Japan 2005 2007 hypotesis : the
survival of patients at 1 month with minimal
neurological impairment who recieved
defibrillation shock with the BD is better than
the survival of patients who received
defibrillation shock with the MD.
Minimal neurological impairment was defined
as Glasgow-Pittsburgh cerebral performance
category 1 (good) or 2 (moderate disability).
MONOPHASIC VS BIPHASIC
Results : no significant difference was
observed between the patients who were
shocked with a biphasic defibrillator or with a
monophasic defibrillator.
Discussion : BD have several advantages
compared with MD, including a lower burden
for EMS personnel because of their lower
weight and greater portability.
ROSC
When a rhythm check using a manual
defibrillator or cardiac monitor reveals an
organized rhythm, a pulse check is
performed.
If a pulse is detected ROSC it is
important to begin post-cardiac arrest care
immediately to avoid re-arrest and optimize
the patients chance of long term-survival with
good neurologic function.
ROSC
The treatable causes of cardiac arrest : The
H5 and T5
Hypoxia - Toxins
Hypovolemia - Tamponade
Hydrogen ion (acidosis) (cardiac)
Hypo/hyperkalemia - Tension
Hypotermia pneumothorax
- Thrombosis
(pulmonary)
- Thrombosis
(coronary)

TREAT H5 & T5
1. Hypoxemia placement of an advanced
airway to achieve adequate oxygenation
or ventilation.
2. Hypovolemia administer iv/io
crystalloid or blood transfusion.
3. Pulmonary embolism fibrinolitic
therapy.
4. Tension pneumothorax needle
decompression.
5. Etc
RECOVERY POSITION
Applied for out of hospital cardiac arrest.
Used for unresponsive adult victims who
clearly have normal breathing and
effective circulation.
RP is designed to maintain a patent airway
and reduce the risk of airway obstruction
and aspiration.
The victim is placed on his or her side with
the lower arm in front of the body.
RECOVERY POSITION
No single position is perfect of for all
victims.
The position should be stable, near a true
lateral position, with the head dependent
and with no pressure on the chest to
impair breathing.
TERMINATION OF
RESUSCITATIVE EFFORTS
BY TIME
Basic Life Support Asystole 10
minutes.
Advanced Life Support 20 minutes.

T
E
R
I
M
A K
A
S
I
H