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Copyright 2008 Society of Critical Care Medicine Reanimación Cardiopulmonar/ Reanimación Cerebral

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  • Reanimacin Cardiopulmonar/ Reanimacin Cerebral

  • ObjetivosIdentificar pacientes que puedan ser beneficiados por la reanimacin. Proponga un proceso para delegar responsabilidades.Discuta temas de tratamiento en paro cardiorespiratorio. Enfatice las metas e intervenciones en la proteccin cerebral y recuperacin.Revise eventos cardiorrespiratorios en pacientes en ventilador.

  • Quien Debe de Ser Reanimado?Cual es el propsito de la reanimacin.?Que pacientes son menos beneficiados por la reanimacin?Como saben los profesionales de la salud si un paciente en paro cardiorespiratorio debe de ser reanimado?Si hay duda, iniciar reanimacin!

  • Caso de EstudioEl Operador anuncia el paro de un hombre de 54 aos de edad en un piso general.Se aplica O2; La enfermera esta intentando medir la presin arterial.Cuales son sus acciones inmediatas?

  • Respuesta PrimariaDetermine si un compaero del cdigo se ha hecho, lider.Asuma el rol de lder si es necesario.Acepte la responsabilidad para un rol delegado.Cuales son los siguientes pasos y si usted es el lder?

  • El Rol del LderValoracin primaria del paciente.

    Delegacin de responsabilidades de la reanimacin.

  • Valoracin PrimariaValore respuesta del paciente.Valore los ABCsAbrir va aereaVentilacinCompresiones TorcicasColoque monitor y determine el ritmo.

  • Delegar Tareas Va aerea con oxigenacin/ventilacin.Compresiones torcicas.Operador de desfibrilador.Acceso venoso.Administracin de medicamentos.Revisar expediente clnico.Notificacin al medico y familia.Retirar equipo no necesario y personal.

  • Continuacin de la Reanimacin Obtener datos crticos de laboratorio. Revisar administracin reciente de medicamentos.Confirmar que la reanimacin sea apropiada.Considere presencia de la familia durante el cdigo?Anticipe traslado a UCI.

  • Reanimacin CerebralRestablezca perfusion al cerebro.Permita o induzca hipotermia moderada.32C34C por 1224 horas.La mejor evidencia en fibrilacin ventricular.Puede ser de beneficio en paro cardiaco sin FV.Tratar convulsiones agresivamente Evite la hperglucemiaEvite la hipertermia.

  • Caso de EstudioPaciente con dificultad para respirar.Intubado y transferido a UCI.Se inicia ventilacin mecnica.1 hora despus, disminucin de la saturacin de O2FC 40/min. con perdida de pulsoCuales son las posibles etiologas de este deterioro?Que pasos deber de usted seguir para optimizar el estado respiratorio del paciente?

  • Paro RespiratorioDesconecte del ventiladorAdministre 100% oxigenoVerifique el tubo endotraqueal.Considere neumotrax a tensin.

  • Revisin de Arritmias

  • Fibrilacin VentricularDesfibrilar una vez e iniciar RCP inmediatamente.Epinefrina 1 mgVasopresina 40 unidades.Agentes Antiarrtmicos AmiodaronaLidocainaMagnesio

  • Actividad Elctrica sin Pulso y AsistoliaBusque las causas reversibles.Epinefrina 1 mgVasopresina 40 u. en lugar de la 1 o 2 dosis de epinefrina.Atropina 1 mg. para asistolia y AESP lenta.

  • BradicardiaMarcapaso TranstoracicoAtropinaDopaminaEpinefrinaMarcapaso transvenoso.

  • Taquicardia con Signos/ Sntomas Serios Cardioversion inmediataUse el modo sincronizadoPremedique si es posible

  • Taquicardia de Complejo Angosto EstableManiobras VgalesMedicamentos para conversin o control de la frecuencia. AdenosinaDiltiazen-BloqueadorDigoxina

  • Taquicardia Estable de Complejo AnchoSe aconseja consulta con experto.Medicamentos:AmioradonaMagnesio (para torsades)Preparese para desfibrilar.

  • Puntos ClaveEste familiarizado con las guas de reanimacin. Preprese para ser un lder del equipo o miembro.Optimice las compresiones torcicas y la ventilacin.Considere al ventilador como un contratiempo en el paciente intubado con ventilador. Monitoree a los pacientes e intervenga en forma temprana para evitar el paro cardiorespiratorio.

    Note that this slide addresses the first objective: who will benefit from resuscitation. Introduce questions for discussion using animation.PurposeReverse sudden, unexpected death from reversible disease processes and iatrogenic complications. This defines who would benefit from resuscitation.Contrast with those unlikely to benefit. Patients who arrest while receiving maximum support for a progressive conditionAsk students for examples. Emphasize that no set of variables predicts outcome from arrest.Examples: patient on maximum vasopressors, severe cardiomyopathyCaregiver guidance for resuscitation.Resuscitation is implied unless patient/family/surrogate has made other wishes known. Mention briefly DNAR orders, living will, durable power of attorney, etc.Stress that it is best to make resuscitation decisions before critical illness develops, although such decisions are often made during critical illness.Reveal last statement.Present case information and reveal question.If students begin to answer with details of patient assessment, direct them to think of the most basic issues.The response can be simplified to Who is in charge? If a team leader has taken charge, the response is What do you want me to do?Confirm basic issues.The response can be simplified to Who is in charge? If a team leader has taken charge, the response is What do you want me to do?After discussion of primary responses, reveal question and discuss. Next slide is used to confirm/review the response.Confirm discussion from prior slide.Ask what is involved in a primary assessment before revealing the bulleted items.Ask additional questions, including rate of ventilation and rate of compressions. Ventilation (8-10/min); compressions (100/min)Ask what should be done if patient is in ventricular fibrillation.Defibrillate 1 time (360 joules with monophasic and 200 joules with biphasic defibrillator) and immediately initiate chest compressions for 2 minutesAsk students what they would do if patient was on mechanical ventilation.Disconnect patient from ventilator and initiate bag-mask ventilationBefore revealing the list, ask what tasks should be delegated to team members during resuscitation.After discussion, ask students additional details about each task as time allows.How long should a team member provide chest compressions?2 minutes, then exchange roles with another individualWhat is the recommended ratio of chest compressions to ventilations if airway is not secured? And if intubation has been accomplished?30:2 for unsecured airway; asynchronous ventilations at 8-10/min if intubatedWhat is the depth of compressions?1.5-2 inchesWhat IV access is preferred?Peripheral IV over central venous catheter; intraosseous route may be used as temporizing measure in children and adults

    Reveal slide and review other aspects of care during resuscitation.Ask students what laboratory tests may be particularly helpful during resuscitation. Note that obtaining blood samples must not distract from resuscitation efforts.Glucose, ABG (assess adequacy of oxygenation/ventilation, metabolic acidosis likely), K, Ca, Mg (may help determine etiology or identify specific interventions needed)Ask students if they have participated in codes where family was present.Ask what issues might be considered if family is to be present.Team knowledge and agreement that family is to be presentAttention to organized team performanceSafety of family and resuscitation team, etcBefore revealing items, ask students to identify the best way to ensure recovery of brain function. Restoration of perfusionAsk for other possible interventions that could benefit the brain.Mild hypothermia. Note that the recommendation for mild hypothermia is based on 2 trials performed in patients with out-of-hospital VF arrests who had return of spontaneous circulation;it is unknown if the same effect is possible with in-hospital arrests or in patients with PEA or asystolic arrests.Ask students if this is likely to be a primary cardiac arrest or a respiratory arrest.Respiratory arrestPoint out that respiratory arrests are often associated with bradycardia, bradypnea, and/or oxygen desaturation. Reveal first question.Ask students to identify some possible etiologies of the respiratory arrest. Discuss only briefly as etiologies will also be discussed in the Respiratory Failure lecture.Airway obstructionVentilator mishapTension pneumothoraxAuto-PEEPWorsening lung processReveal next question about steps to optimize respiratory status. After discussion, use next slide to confirm/review.Ask students how they would check the endotracheal tube.Check ETT for kinks/obstructionPass suction catheterCheck position of ETTPhysical exam, expired CO2 evaluation, direct laryngoscopy (not chest radiograph)Remove ETT if unsure of position and use BVM ventilation until reintubationAsk how they would evaluate for possible tension pneumothorax (not with radiograph).Unilateral chest tympanyAsymmetric chest movementDeviation of the tracheaUnilateral decreased breath soundsJugular venous distension

    Optional slides 13-19 for groups that need or want a brief review of current resuscitation guidelines. Refer to ACLS algorithms in appendix.Ask students to identify depicted rhythm before revealing title of slide.Then ask students the treatment of VF and seek additional details.Examples: How frequently is epinephrine given? 3-5 minHow frequently is vasopressin given? 1 time instead of the first or second dose of epinephrine What is the dose of amiodarone? 300 mg (arrest dose); may give second dose of 150 mg in 3-5 minAsk students to identify rhythm before revealing title of slide. If they say it is bradycardia, ask if they need to know if a pulse is present. Then tell them there is no pulse.Then ask students the treatment of PEA and asystole and seek additional details.Examples: Name potential causes and indicate those that are reversible.Hshypovolemia, hypoxia, hydrogen ion (acidosis), hypokalemia/hyperkalemia, hypoglycemia, hypothermiaTstoxins, tamponade (cardiac), tension pneumothorax, thrombosis (MI or PE),traumaHow frequently is atropine given? 3-5 min(Note: Pacing is no longer recommended in asystole.)Ask students to identify rhythm before revealing title of slide.Second degree AVB (Wenckebach block)Ask if they should initiate any treatment; guide them to determine if patient has symptoms.What symptoms suggest the need for intervention?Chest painPulmonary edema, shortness of breathHypotensionAltered mental statusShockThen ask students the treatment of symptomatic bradycardia and discuss before revealing the listed interventions.Dose of atropine0.5-1 mg while initiating transthoracic pacingDopamine, epinephrine if pacing not effectiveAsk what they would do if the patient does not have serious symptoms.Seek etiology of bradycardiaEvaluate for ischemiaApply oxygen if needed, etcPresent clinical scenario of patient with shortness of breath and BP 88/50 mm Hg. Ask students to identify rhythm and the most appropriate management before revealing title and bullet points.Ask students to list other signs and symptoms that would lead to immediate cardioversion for a tachycardia.Altered mental statusChest painSigns of shockWhat energy level would be appropriate for the defibrillator? Biphasic defibrillator: 100-120 J and titrate up, PSVT may respond to 50 JMonophasic defibrillator: 100 J and 50 J for PSVTPresent scenario of patient with palpitations, normal BP, and no serious signs/symptoms.Ask students to identify the most appropriate management before revealing bullet points. (Includes rhythms such as PSVT, atrial tachycardia, junctional tachycardia, atrial fibrillation/flutter)What is the dose of adenosine and how is it administered?Fast bolus with saline flush using 6 mg of adenosine; if no response, then 2 doses of 12 mgMay ask dose of diltiazem.0.25 mg/kg (~20 mg) bolus over 2 min; if no response, 0.35 mg/kg (~25 mg) after 15 min, then infusion 5-15 mg/h

    Present scenario of patient with palpitations, normal BP, and no serious signs/symptoms.Ask students to identify the most appropriate management before revealing bullet points.May ask dose of amiodarone for this arrhythmia.150 mg amiodarone (nonarrest dose) then initiate continuous infusion.Emphasize the importance of calling for help with stable wide complex rhythms and of preparing for defibrillation in case of deterioration.