Cardiopulmonary resuscitation

Dr.V.Ravimohan What I learned in the ILS training http://www.mrcogexam.net

Chain of survival
Early recognition and call for help Early cardiopulmonary resuscitation (CPR) Early defibrillation Post resuscitation care

Early recognition
Most in-hospital cardiac arrests are not sudden or unpredictable events Hypoxia or hypotension are either not noticed by staff ,or are recognised but treated poorly. 2 systems early warning scores calling criteria cardiac arrest team Medical emergency team

Medical emergency team calling criteria

Acute change in Airway Breathing Physiology Threatened All respiratory arrests Respiratory rate < 5/ min Respiratory rate >36/min All cardiac arrests Pulse rate <40/min Pulse rate > 140/min Systolic pressure <90 mmHg

Circulation

Neurology

Sudden decrease in level of consciousness Decrease in GCS of > 2 points Repeated or prolonged seizures
Any patient causing concern who doesnt fit the above criteria

Other

Airway obstruction
Treatment
Remove any obstruction unless contraindicated turn the patient to a side Simple airway opening manoeuvres head tilt, jaw thrust or chin lift (remember to give oxygen) Oropharyngeal airway or nasal airway Elective tracheal intubation Tracheostomy Always remember to give oxygen

Breathing problems
Causes
Poor respiratory drive-CNS depression Poor respiratory effort-muscle weakness/nerve damage Lung disorders

Breathing problems
Recognition
Irritability, confusion, lethargy and depressed consciousness(from hypoxia and hypercapnia) High respiratory effort(>30/min) Pulse oxymetry
Non invasive measure of oxygenation but not a measure of ventilation

Blood gas analysis

Circulation problems
Causes
Primary heart problemsarrythmia secondary to ischaemia Secondary heart problems severe anaemia, hypothermia

Acute coronary syndromes

Unstable angina Non ST segment elevation MI ST segment elevation MI
Treatment
O2 high concentration Aspirin 300 mg Nitro-glycerine S/L Morphine

ABCDE approach
A-airway B-breathing C-circulation D-disability E-Exposure

Airway Obstruction
Airway obstruction-sea-saw respirations
complete
no breath sounds at the mouth or nose

Incomplete
noisy

clear the airway Give O2 10 l/min

Breathing
General signs of respiratory distress
Use of accessory muscles of respiration Sweating Cyanosis

Respiratory rate Pulse oxymeter Trachea Percuss listen

Circulation
Colour & temperature of limbs Capillary fill time Finger tip held at the heart level Normal fill time is less than 2 seconds Pulse volume low poor cardiac output high(bounding)-sepsis B.P low diastolic blood pressure arterial vasodilatation anaphylaxis or sepsis narrow pulse pressure-(normal 35-45 mmHg) arterial vasoconstrictionhypovolaemia/cardiogenic shock

Disability
AVPU
A-Alert V-responds to vocal stimuli P-responds to painful stimuli U-unresponsive to all stimuli
Measure blood glucose to exclude hypoglycaemia

Exposure
Exposure to examine the patient properly
Minimise heat loss Respect dignity

collapsed patients
Ensure personal safety Check for patient response
are you alright?
If patient respondsABCDE approach If patient doesnt respondcall for help

Airway Breathing-look feel hear for not more than 10 secs

Pulse
Checking for pulse-can be difficult even for the trained staff If unsure about the pulse dont start delaying CPR
If there is pulse
Still call for help Give O2 Ventilate lungs check for circulation ever 10 seconds Attach monitoring IV access

If there is no pulse or signs of life

Call for help 30 chest compression:2 ventilation 100 compressions/min compression depth 4-5 cm Once the defibrillator arrives apply electrodes to patient and analyse rhythm Minimise interruptions to chest compressions

Advanced life support cardiac rhythm

2 groups of cardiac rhythm
Shock able rhythm
Ventricular fibrillation Pulse less ventricular tachycardia

Non shock able rhythm

Asytole Pulse less electrical activity

Shock able Rhythm

First shock ( biphasic 150-200j or monophasic 360j)

Resume CPR for 2 minutes without assessing for rhythm or pulse

Pause briefly to check rhythm

3 possibilities

VF/VT persists

Organised electrical activity compatible with a cardiac output

Asytole

VT/VF persists
Give a 2nd shock Resume CPR immediately for 2 minutes Briefly check the monitor If VF/VT persists 1 mg adrenaline IV followed immediately by third shock CPR for 2 minutes Briefly check the monitor

VF/VT still persists

Amidarone 300 mg IV followed immediately by a fourth shock

Resume CPR immediately for 2 minutes

Give adrenaline 1mg IV immediately before alternate shocks (approximately every 3-5 minutes)

Give further shocks after each 2 minute period of CPR and after confirming that VF/VT persists

Organised electrical activity compatible with a cardiac output

Pulse or signs of life present

No Pulse or no signs of life present

Start postresuscitation care

CPR & non shock able algorithm

IF Asystole

CPR & non shock able algorithm

Some tips
Lidocaine 100mg IV is an alternative for amidarone but isnt an option if amidarone is already given If there is doubt about whether a rhythm is Asystole or very fine AF
dont defibrillate Very fine VF is unlikely to respond to shock

Precordial Thump
May be useful in VF/VT cardiac arrest which was witnessed and monitored sudden collapse Ulnar edge of a tightly clenched fist From height of about 20 cm Thumb is most likely to be successful in converting VT to sinus rhythm

PULSELESS ELECTRICAL ACTIVITY

Definition: organised electrical activity in the absence of any palpable pulses.

Treatment for PEA

CPR 30:2

Give adrenaline 1 mg IV as soon as possible

Continue CPR 30:2 until airway is secured Recheck rhythm after 2 minutes

3 possibilities

VF/VT persists

Organised electrical activity compatible with a cardiac output

Asystole

If VT/VF persists
Follow shock able side of algorithm

Organised electrical activity compatible with a cardiac output

Pulse or signs of life present

No Pulse or no signs of life present

Start postresuscitation care

CPR & non shock able algorithm

Treatment for asystole and slow PEA(rate <60 min-1)

Start CPR 30:2 Check the ECG leads are attached correctly without stopping CPR

Give adrenaline 1 mg IV as soon as possible

Give atropine 3 mg IV (once only )

Continue CPR until airway secured

Recheck rhythm after 2 minutes

Give adrenaline 1 mg IV every 3-5 minutes

During CPR
Correct reversible causes

Check electrode position & contact

Attempt/verify IV access, Airway & O2
Give uninterrupted compression when airway is secure

Give adrenaline every 3-5 minutes

Consider :amiodarone,atropine,magnesium

Reversible causes
4H Hypoxia Hypovolaemia Hypo/Hyperkalaemia/metabolic Hypothermia Tamponade,cardiac Toxins Thrombosis 4T Tension pneumothorax

4H
Hypoxia 100% oxygen Ensure adequate chest rise & bilateral breath sounds Crystalloid/Colloid Surgery 12 ECG may help in the diagnosis Check for hypoglycaemia

Hypovolaemia Hyperkalaemia Hypothermia

4T
Tension pneumothorax May be a complication of inserting central venous catheter Signs: decreased air entry decreased expansion hyperresonance percussion on affected side Do: needle thoracocentesis Cardiac arrest after penetrating chest trauma 2 reasons:A.hypovolaemia B.cardiac tamponade Do: needle pericardiocentesis or resuscitative thoracotomy

Tamponade cardiac

Toxins Thrombosis Consider thrombolytic therapy

CPR in a pregnant patient

Left lateral tilt(15-30 degrees) of patient Periarrest caesarean section should begin within 4 minutes Sterile preparation is not necessary Moving the patient to operating theatre isnt necessary