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CARDIAC CARDIAC ARRESTARREST

By By Gamal faheim, MDGamal faheim, MD

Associate professor of cardiovascular Associate professor of cardiovascular medicinemedicine

DEFINITIONSDEFINITIONS

CARDIAC ARREST: Abrupt CARDIAC ARREST: Abrupt cessation of cardiac pump function cessation of cardiac pump function which may be reversible by a rapid which may be reversible by a rapid intervention but will lead to death intervention but will lead to death in its absence.in its absence.

DEATH: Irreversible cessation of DEATH: Irreversible cessation of all biologic functionsall biologic functions

MECHANISMS OF CARDIAC MECHANISMS OF CARDIAC ARRESTARREST

50-80%: VF and PULSLESS VT50-80%: VF and PULSLESS VT

20-30%: Asystole, severe 20-30%: Asystole, severe bradycardia and pulseless bradycardia and pulseless electrical activityelectrical activity

BackgroundBackground

USA - 250 000 to 330000 estimated USA - 250 000 to 330000 estimated annual SCA deaths per yearannual SCA deaths per year

Survival < 6% worldwide averageSurvival < 6% worldwide average Trials - short term outcomesTrials - short term outcomes - underpowered, small- underpowered, small - not randomized- not randomized - design limitations- design limitations Informed consentInformed consent

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Decision to start CPRDecision to start CPR::

Decision to start CPR is made if a victim is Decision to start CPR is made if a victim is unresponsive and not breathing normally.unresponsive and not breathing normally.

Pulse check is no longer required, and is Pulse check is no longer required, and is NOT recommended for NOT recommended for lay personslay persons..

Pulse check has been shown to be Pulse check has been shown to be unreliable, with unacceptably high rates of unreliable, with unacceptably high rates of false positives and negatives.false positives and negatives.

Cardio-pulmonary resuscitation Cardio-pulmonary resuscitation (CPR) is a means to provide (CPR) is a means to provide temporary support to the temporary support to the coronary and cerebral coronary and cerebral circulation, till normal cardiac circulation, till normal cardiac output is restoredoutput is restored

Adult Basic Adult Basic LifeLife Support Support

PERSON COLLAPSES

Check if he is unresponsive.

Call Emergency number.

Get AED (automatic Electric Defibrillator)

Begin the ABCD’s

Adult Basic Adult Basic Life Life SupportSupport

Basic life support consists of the following sequence of actions:Basic life support consists of the following sequence of actions: Make sure the victim, any bystanders, and you are safe.Make sure the victim, any bystanders, and you are safe. Check the victim for a response.Check the victim for a response. Gently shake his shoulders and ask loudly, ‘Are you all right?’Gently shake his shoulders and ask loudly, ‘Are you all right?’

If he responds:If he responds:– Leave him in the position in which you find him provided there is Leave him in the position in which you find him provided there is

no further danger.no further danger.– Try to find out what is wrong with him and get help if needed.Try to find out what is wrong with him and get help if needed.– Reassess him regularly.Reassess him regularly.

If he does not respond:If he does not respond:– Shout for help.Shout for help.– Turn the victim supine aligned position or stable side position.Turn the victim supine aligned position or stable side position.

CONFIRM LOSS OF CONFIRM LOSS OF CONSCIOUSNESSCONSCIOUSNESS

Shout Loudly!Shout Loudly!Shake Shake Gently!!Gently!!

Adult Basic Adult Basic LifeLife Support Support

START THE ABCD’sSTART THE ABCD’s

Airway:Airway: Open Airway.Open Airway.

Breathing: Breathing:

(Look, Listen &Feel)(Look, Listen &Feel)

Circulation:Circulation:..

Monitor and check Monitor and check

the pulse.the pulse.

Check Circulation

Circulation

Arrest

Check Breathing

Breathing

Non Breathing

Adult Basic Adult Basic LifeLife Support Support

Defibrillator: Defibrillator:

An important advance in An important advance in providing BLS is the providing BLS is the availability of AED, which availability of AED, which can be used to deliver can be used to deliver defibrillation. improving defibrillation. improving survival outcomes in survival outcomes in cardiac arrest cases. cardiac arrest cases.

Open airway – signs of Open airway – signs of life?life?

Head tilt / chin liftHead tilt / chin lift Check breathing Check breathing

and pulse for 10 secand pulse for 10 sec If no breathing & no If no breathing & no

pulse or unsure of pulse or unsure of pulse assume pulse assume cardiac arrestcardiac arrest

Caution of agonal Caution of agonal breathingbreathing

Adult Basic Adult Basic LifeLife Support Support

BBreathing:reathing:Keeping the airway open, Keeping the airway open, look, listenlook, listen, and , and feelfeel for normal breathing. for normal breathing.

• • Look Look for chest movement.for chest movement.

• • ListenListen at the victim's mouth for breath sounds. at the victim's mouth for breath sounds.

• • FeelFeel for air on your cheek. for air on your cheek.

In the first few minutes after cardiac arrest, a victim may be barely In the first few minutes after cardiac arrest, a victim may be barely breathing, taking infrequent, noisy, gasps. Do not confuse this with breathing, taking infrequent, noisy, gasps. Do not confuse this with normal breathing.normal breathing.

Look, listen, and feel for Look, listen, and feel for no more no more than than 10 sec 10 sec to determine if the victim to determine if the victim is breathing normally. If you have any doubt whether breathing is is breathing normally. If you have any doubt whether breathing is normal, act as if it is normal, act as if it is not not normal.normal.

Pocket mask vs bag-valve Pocket mask vs bag-valve maskmask

If signs of life presentIf signs of life present

Signs of life...Signs of life... Normal breathingNormal breathing CoughingCoughing MovementMovement Palpable pulsePalpable pulse

Assess ABCDEAssess ABCDE Call expert help Call expert help

immediatelyimmediately

Adult Basic Adult Basic LifeLife Support Support

If he is breathing normally:If he is breathing normally: Turn him into the recovery position.Turn him into the recovery position. Send or go for help, or call for an ambulance.Send or go for help, or call for an ambulance. Check for continued breathing.Check for continued breathing.

If he is not breathing normally:If he is not breathing normally:

• • Ask someone to call for an ambulance or, if you are Ask someone to call for an ambulance or, if you are on your own, do this yourself; you may need to leave on your own, do this yourself; you may need to leave the victim. the victim.

Start chest compression as follows:Start chest compression as follows: Kneel by the side of the victim.Kneel by the side of the victim. Place the heel of one hand in the centre of the victim’s chest.Place the heel of one hand in the centre of the victim’s chest.

Adult Basic Adult Basic LifeLife Support Support

Place the heel of your other hand on top of the first hand.Place the heel of your other hand on top of the first hand. Interlock the fingers of your hands and ensure that pressure isInterlock the fingers of your hands and ensure that pressure is

not applied over the victim's ribs. Do not apply any not applied over the victim's ribs. Do not apply any pressurepressure

over the upper abdomen or the bottom end of the bonyover the upper abdomen or the bottom end of the bony

sternum (breastbone).sternum (breastbone). Position yourself vertically above the victim's chest and, withPosition yourself vertically above the victim's chest and, with

your arms straight, press down on the sternum 4 - 5 cm.your arms straight, press down on the sternum 4 - 5 cm. After each compression, release all the pressure on the chestAfter each compression, release all the pressure on the chest

without losing contact between your hands and the without losing contact between your hands and the sternum.sternum. Repeat at a rate of about 100 times a minute (a little less thanRepeat at a rate of about 100 times a minute (a little less than

2 compressions a second).2 compressions a second). Compression and release should take an equal amount of time.Compression and release should take an equal amount of time.

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Chest compressionsChest compressions

Place hands on the Place hands on the center of the chestcenter of the chest, rather , rather than the ‘rib margin’ method.than the ‘rib margin’ method.

100/min for 100/min for allall victims (except newborns). victims (except newborns). Allow chest to recoil to normal position after Allow chest to recoil to normal position after

each compression. each compression. Use equal compression and relaxation times.Use equal compression and relaxation times. Limit interruptions in chest compressions, Limit interruptions in chest compressions,

even for rhythm check, shock delivery, even for rhythm check, shock delivery, advanced airway, or vascular access.advanced airway, or vascular access.

30 chest compressions30 chest compressions

Heel of hand in Heel of hand in centre of chestcentre of chest

Interlock fingersInterlock fingers Keep arms straightKeep arms straight Compress 4-5 cm Compress 4-5 cm

depthdepth Rate of 100 min-1Rate of 100 min-1 Allow chest to recoilAllow chest to recoil

Adult Basic Adult Basic LifeLife Support Support

Combine chest compression with rescue breaths:Combine chest compression with rescue breaths: After 30 compressions open the airway again using head tilt and chin After 30 compressions open the airway again using head tilt and chin

lift.lift. Pinch the soft part of the victim’s nose closed, using the index finger Pinch the soft part of the victim’s nose closed, using the index finger

and thumb of your hand on his forehead.and thumb of your hand on his forehead. Allow his mouth to open, but maintain chin lift.Allow his mouth to open, but maintain chin lift. Take a normal breath and place your lips around his mouth, making Take a normal breath and place your lips around his mouth, making

sure that you have a good seal.sure that you have a good seal. Blow steadily into his mouth whilst watching for his chest to rise; take Blow steadily into his mouth whilst watching for his chest to rise; take

about one second to make his chest rise as in normal breathing; this is about one second to make his chest rise as in normal breathing; this is an effective rescue breath.an effective rescue breath.

Maintaining head tilt and chin lift, take your mouth away from the victim Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as air comes out.and watch for his chest to fall as air comes out.

Adult Basic Adult Basic LifeLife Support Support

Take another normal breath and blow into the Take another normal breath and blow into the victim’s mouth once more to give a total of two victim’s mouth once more to give a total of two effective rescue breaths. Then return your hands effective rescue breaths. Then return your hands without delay to the correct position on the without delay to the correct position on the sternum and give a further 30 chest sternum and give a further 30 chest compressions.compressions.

Continue with chest compressions and rescue Continue with chest compressions and rescue breaths in a ratio of 30:2.breaths in a ratio of 30:2.

Stop to recheck the victim only if he starts Stop to recheck the victim only if he starts breathing breathing normallynormally; otherwise ; otherwise do not interrupt do not interrupt resuscitation.resuscitation.

Adult Basic Adult Basic LifeLife Support Support

If your rescue breaths do not make the chest rise as in If your rescue breaths do not make the chest rise as in normal breathing, then before your next attempt:normal breathing, then before your next attempt: Check the victim's mouth and remove any visible obstruction.Check the victim's mouth and remove any visible obstruction. Recheck that there is adequate head tilt and chin lift.Recheck that there is adequate head tilt and chin lift. Do not attempt more than two breaths each time before Do not attempt more than two breaths each time before

returning to chest compressions.returning to chest compressions. If there is more than one rescuer present, another should If there is more than one rescuer present, another should

take over CPR about every 2 min to prevent fatigue.take over CPR about every 2 min to prevent fatigue. Ensure the minimum of delay during the changeover of Ensure the minimum of delay during the changeover of

rescuers.rescuers.

Adult Basic Adult Basic LifeLife Support Support

Chest-compression-only CPR:Chest-compression-only CPR:

If you are not able, or are unwilling, to give rescue If you are not able, or are unwilling, to give rescue breaths, give chest compressions only.breaths, give chest compressions only.

If chest compressions only are given, these should If chest compressions only are given, these should be continuous at a rate of 100 a minute.be continuous at a rate of 100 a minute.

Stop to recheck the victim only if he starts Stop to recheck the victim only if he starts breathing breathing normallynormally; otherwise do not interrupt ; otherwise do not interrupt resuscitation.resuscitation.

Adult Basic Adult Basic LifeLife Support Support

Continue resuscitation until:Continue resuscitation until:

Qualified help arrives and takes over,Qualified help arrives and takes over, The victim starts breathing normally, orThe victim starts breathing normally, or You become exhausted.You become exhausted.

RECOVERY POSITIONRECOVERY POSITION

Adult Basic Life Support

HIGH QUALITY CPRHIGH QUALITY CPR RATE - push hard, push fast 100/minRATE - push hard, push fast 100/min

DEPTH - 1.5 TO 2 inches DEPTH - 1.5 TO 2 inches

COMPLETE CHEST RECOILCOMPLETE CHEST RECOIL

MINIMISE INTERRUPTIONSMINIMISE INTERRUPTIONS

CHANGE REGULARLYCHANGE REGULARLY

Restore Coronary & Cerebral Blood FlowRestore Coronary & Cerebral Blood Flow

Technique of CPRTechnique of CPR

Push Hard and Push FastPush Hard and Push Fast

Complete Chest RecoilComplete Chest Recoil

Minimal Interruptions <10sMinimal Interruptions <10s

Change RegularlyChange Regularly

The Shocking FactsThe Shocking Facts

Bundle Branch Reentrant VT

Ventricular FlutterSpontaneous conversion to NSR (12-lead ECG)

VF with Defibrillation (12-lead ECG)

Torsades de Pointes Torsades de Pointes Spontaneous conversion to NSR Spontaneous conversion to NSR

(continuous lead II monitor strip)(continuous lead II monitor strip)

Wide QRS Irregular Tachycardia:Wide QRS Irregular Tachycardia:Atrial Fibrillation with antidromic conduction in Atrial Fibrillation with antidromic conduction in

patient with accessory pathway – Not VTpatient with accessory pathway – Not VT

37AED was turned on and attached. The rhythm is labeled “coarse VF.

ECG shows negative effect of ECG shows negative effect of delaying chest compressions after delaying chest compressions after

shock delivery. shock delivery. (From an AED record). (From an AED record).

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•Shock is advised and delivered, 22 sec after pads were attached. •The shock eliminates the VF; the initial post-shock rhythm is asystole.•The AED then analyzes the rhythm after the first shock.

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Post-shock rhythm through the next 21 sec. Asystole is present, and the AED is analyzing the rhythm so no CPR is provided and there is no blood flow.

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• Re-fibrillation 25 sec after the first shock eliminated VF. • No CPR performed during the 25 sec. • AED then analyzes rhythm and recommends shock. • Shock is delivered, asystole follows, and the AED then analyzes those rhythms. • CPR is finally recommended and begins a total of 1:17 min after the first shock. • The victim survived…

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Thank

You

Thank

You