adult cardiopulmonary resuscitation -...
Post on 18-Aug-2018
218 Views
Preview:
TRANSCRIPT
Terminology
CPR – Cardiopulmonary Resuscitation
BLS – Basic Life Support CPR without the help of medical devices
EBLS – Extended Basic Life Support CPR with easy to use tools or devices (special
expertise not needed) (NPT / OPT, BVM + O2, automated defibrillator)
ALS – Advanced Life Support CPR with devices for the qualified personnel
ROSC – Return Of Spontaneous Circulation
Response? (vocal and tactile stimulus)
Call for help!
Open the airway
Head tilt
Chin lift
Foreign body removal
Check vital signs
Breathing? (see / hear / feel!)
(Normal: RR≥2/10 sec, noticeable
chest/abdominal movement with
audible and sensible airflow without
pathological noises)
(Circulation / pulse?)
Monitor? (Pulse oxymetry /capnography
/ECG /IBPM)
Vital signs / open airways
CPR 30:2Until defibrillation /
monitoring is
available
Provide a patent airwayLook for vital signs
Call for paramedicsor Medical Emergency Team
Cardiac arrest
Calling the ambulance:
Your name
What has happened
Where did it happen
How to get there
Stay calm and follow
the advices
Chest compression Right („high quality”) technique:
Firm surface
Proper posture
Extended straight arms
Position of the hands: lower half of the sternum
Compression / ventilation rate
30:2 (adult)
15:2 (pediatric)
In the case of a primary cardiac cause COCPR (Compression Only CPR) is allowed in the first 3 minutes (?)
In the case of a secured patent airway (ETT) continuous compression without disruption
Depth:
Approx. 5, max. 6 cms (adult)
1/3rd of the chest (pediatric)
Frequency: 100-120 / min (metronome?)
Duty cycle 1:1; allow complete recoil
(Compression feedback devices?)
Avoid:
fatigue (→change)
> 5 (10) sec disruption (→planning)
Rescue breaths (BLS and EBLS)
Technique:
Mouth-to-mouth/ Mouth-to-nose
BVM (bag-valve mask) ventilation
NB: patent airway!
Head tilt + chin lift
jaw thrust (Esmarch-Heiberg)
NPT / OPT
Foreign body removal(→ FBAO protocol)
Normal blow in
Vt: approx. a normal breath intake (6-8 ml/ttkg)
Approx. 1 sec duration
30:2 (compressions:breaths)
Avoid:
Hyperventilation
→ hypocapnia → cerebral vasoconstriction → cerebral ischaemia
High pressures
→ abdominal insufflation → risk of aspiration
CPR 30:2Until AED or manual
defibrillator is applied
Rhythm
analysis
Shockable(VF/ pulseless VT)
Non-shockable(PEA/Asystole)
Patent airway
Vital signs
Call for
resuscitation
team
Ventricular Fibrillation
(VF)
Pulseless Ventricular
Tachycardia
(pulseless VT)
Rhythm
analysis
Shockable
(VF/ pulseless VT)
1 Shock150-360 J biphasic
or 360 J monophasic
Immediately resume
CPR 30:2
for 2 minutes
Shockable rhythm(VF)
Irregular wave
No recognizeable QRS complex
Ever changing frequency and amplitude
coarse / fine
NB: artefacts
movement
electric interference
Shockable rhythm(pulseless VT)
Monomorphic pulseless VT
widened QRS complex
high frequency
No QRS morphologic changes
Polimorphic pulselessVT
Torsades de pointes
(Precordial thump)
For immediate treatment of a witnessed VF/VT
Monitored patient
If defibrillation is not a prompt option
BUT: according to the 2015 ERC guidelines, it is NOT RECOMMENDED!
Defibrillators AED
Manual
Diagnostic / monitor function
ECG (monitor +/- 12 lead)
(+/- rhythm analysis)
NIBP
Pulse oxymetry
Capnography
Therapeutic options
Defibrillation
SCV (synchronized
cardioversion)
Transcutaneous pacing
Defibrillation energy
Factory recommendation / device learning
Monophasic: 1x360 J
Biphasic: 1x150-360 J (escalating)
If not sure, use the highest possible energy (don't waste time)!!!
(3 shock strategy?: witnessed VF/pulselessVT)
„Good” defibrillation
Efficient
Time !!!
Biphasic wave
Provide contact:
– Adhesive electrodes
– Defibrillator paddles
Contact gel or gel pad
Compression of the paddles
Shock during exhalation
(ventilated patients!)
Anterolat. vs. anteropost. vs. bilat.
position
Safe
Adhesive electrodes
Adequate communication
Correct manipulation (NB:
moving, contact, charging)
Avoidance of wet circumstances
O2 flow and NTTS removal from
defibrillation area
PM / ICD avoidance (>15 cm)
If VF/VT remains
Second shock and after:
150 - 360 J biphasic
360 J monophasic
Minimize the delay between the CPR
and a shock (< 10 s)
Adinistration of medication mustn’t
delay the shock
First 1 mg of Adrenaline + 300 mgs of
Amiodarone after the third shock
Repeat 1 mg Adrenaline if needed in
every 3-5 minutes
Repeat 150 mgs of Amiodarone if
needed once more
Third shock
Fourth shock
CPR for 2 minutes
Adrenaline 1mg iv.
+ Amiodarone 300 mgs iv.
Recheck:
if VF/VT remains
After the shock Immediately continue CPR for 2 minutes
Stop only if the patient shows clear vital signs (breaths,
coughs, opens his/her eyes, moves limbs, regains
consciousness)
After 2 minutes of CPR reassess ECG rhythm:
VT / pulseless VT: keep on with shockable algorithm
Any other electrical activities (compatible with circulation):
ROSC: continue with postresuscitation care
No signs of circulazion (PEA): swap to non-
shockable algorithm
Asystole: swap to non-shockable algorithm
Asystole (Asy)
Pulseless Electrical
Activity (PEA)
Rhythm
analysis
Non-shockable
(PEA/Asystole)
Immediately
resume
CPR 30:2
For 2 minutes
Non shockable rhythmAsystole
No ventricular activity (QRS)
Atrial activity is possible (P-wave asystole – PM indicated)
Rarely straight line (look out: electrical contact!)
Fine VF => treat as asystole
Pulseless Electrical Activity
During CPR:
Exclude / treat reversible causes
Adrenaline 1 mg iv in every 3-5 minutes
(Atropine 3 mg iv., in case of PEA with frequency below 60 / min)
During CPR:
• Maintain high quality chest compressions → change as frequently as needed
• Shortest possible disruption of CPR → planning
• Mechanical chest compression devices if available or needed. (CPR in or on the
way to the catheterization laboratory, fibrinolysis with CPR, hypothermic patient, etc)
• Ventilation with 100 % FiO2
• Route of administration (iv., io.)
• Adrenaline in every 3-5 minutes
• Advanced airway management
• Continuous compressions after securing airways
• Capnography (tube position? effectiveness? ROSC?)
• Reversible causes (4H/4T) and treatment
• Check devices, positions, functions regularly
Airway and ventilation Secured Airway:
ETT (gold standard)
LMA / iGel
LT
ETC, etc.
After a secured airway
Continuous chest compressions!
BVM/mechanical ventilation
FiO2: 100 % !!!
Avoid hyperventilation
Vt: 6-8 ml/bwkgs
RR: approx. 10/min
Route of administration
Peripheral?
Veins on the upper limbs
external jugular vein
Central?
Femoral vein
Internal jugular vein
Subclavian vein
4H Hypoxia (asphyxia)
Hypovolemia (absolute, eg. bleeding / relative, eg. anaphylaxis)
Hypo/hyperkalemia & metabolic changes (acidosis, hypoglycaemia)
Hypo/hyperthermia
4T Thrombosis (ACS, PE)
Tension PTX
Tamponade (cardiac)
Toxin / Tablets (side effects)
Dg: Heteroanamnesis
Medical documentations
Physical examination
Blood gas analysis
Emergency Ultrasound (EUS)
THINK!!!
Potentially reversible causes
After ROSC (postresuscitation care)
ABCDE approach
Advanced monitoring - ECG, BGA, laboratory tests
Imaging (X-Ray, US, CT – HRCT; skull, thorax, abdomen)
Consider coronarography +/- PCI
Causal (4H-4T) treatment ASAP
Supportive therapy: provide tissue oxygenation
Augmentation of the cardiac function (DO2)
O2, NIV, invasive ventilation (normoxia, normocapnia)
Katecholamines, PDE inhibitor drugs, Ca-sensitizers
IABP, ECMO (failing all else)
Decreasing metabolic demand (VO2)
Mechanical ventilation
Analgo-sedation, seizure prophylaxis
(Neuromuscular blockade???)
Targeted Temperature Management (TTM) → 32-36 ⁰C, avoid fever
top related