Cardiopulmonary Resuscitation

Cardiac Arrest

Cardiac arrest is the cessation of all cardiac mechanical activity. It’s clinical diagnosis is confirmed by

UnresponsivenessAbsence of detectable pulseApnea (or agonal respirations )

The Cardiac Arrest Rhythms

The four cardiac arrest rhythms are

Asystole PEA ( Pulseless Electrical Activity ) Pulseless Ventricular Tachcardia (VT) Ventricular Fibrillation (VF)

International Guidelines for CPR 2005

International consensus on the art & science of CPR

Based on the most extensive evidence review of CPR

Recommendations designed to improve survival from sudden cardiac arrest (SCA)

Circulation Volume 112, Issue 24 Supplement; December 13, 2005  

AHA Class of Recommendation Class I excellent evidence

Definitely recommended Class II a good to very good evidence

Acceptable and useful Class II b fair to good evidence

Acceptable and useful Indeterminate no harm and no benefit

Promising, evidence

lacking, immature Class III not acceptable, not useful,

May be harmful: no may be harmful

benefit documented

Chain Of Survival – 4 links

Call for help

Early CPR

Early Defibrillation

Early Advanced Care

BLS

1. Check Responsiveness

2. Call for help with AED defibrillator

3. Open the Airway

Head Tilt –Chin Lift Maneuver

3. Open The Airway

Jaw Thrust Maneuver

4. Check for Breathing

“ Look, Listen and Feel ”

5. Give 2 slow rescue breaths (over 1 second )

“The Chest Must Rise”

6. Check for Pulse (carotid pulse )

7.Start Chest Compressions (if pulse absent)

Site for chest compressions

Locate the margin of the ribs and follow upto xiphoid process

Place hand 2 finger spaces above the xiphoid process

Place other hand over hand on sternum

Chest Compressions A B

C D

“Push hard and Push fast” Minimise interruption of chest compression

• 100 /min.

• 30:2 ratio ( C:V )

• 5 cycles (2 minutes)

• 50% : 50 % ( C/R )

• 1 ½ -2 inches sternal depression

• Arms Straight, elbows locked,

shoulder over hands

• Complete recoil of chest

Attach defibrillator(AED) as soon as available and shock if indicated

D – Early Defibrillation Automated External Defibrillator

(AED)

Single greatest advance in CPR

The survival rate is 90% if the patient is defibrillated within 1 min. and only 10% if it is delayed till 10mins (Circulation 1984;69:943-8.)

Survival rate after cardiac arrest has been reported to go up from 30% to 49% (Ann Emerg Med 1996;28:480-5.)

Biphasic vs Monophasic Defibrillation

Advantages - greater efficacy - low energy produces same effect - less myocardial damage - less incidence of S-T changes ( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )

Energy - Monophasic 360 J - Biphasic 150/200 J

All AEDs are Biphasic

High first shock success of Biphasic defibrillation (84%-95%)

BLS Algorithm ( Primary ABCD )

Step 1. Assess Responsiveness

Step 2. Activate the EMS and call for the defibrillator

 Step 3. Open the airway

Step 4. Assess Breathing (“ look, listen and feel ” )

 Step 5. If Breathing is absent, give two slow rescue breaths

  Step 6. Check for pulse (carotid pulsations)

 Step 7. If pulse is absent initiate “ Chest Compressions ”

  As soon as a defibrillator is available attach and defibrillate if indicated

 

ADVANCED LIFE SUPPORT

A - Airway

Definitive airway should be secured as soon as possible

Tracheal intubation using cricoid pressure (by trained

personnel only)

Laryngeal Mask Airway (LMA) and Esophageal–tracheal

Combitube are accepted alternatives for others

Cricothyrotomy to be performed in an emergency

B. Breathing - Confirm device placement

Primary Confirmation

Direct Visualisation of ETT passing through cords

Chest expansion

5 point auscultation - L and R anterior,

- L and R mid-axillary

- Over stomach

Still in doubt –repeat laryngoscopy

Further confirmation - Exhaled CO2 detector (ETCO2) - Oesophageal detector device

Inflate cuff and secure the tube

B. Breathing – Confirm effective oxygenation and

ventilation

No synchrony between ventilation and chest

compressions once definitive airway is secured

No longer 30 : 2 compression ventilation cycles

COMPRESSION @100/min

VENTILATION @ 6 – 8 breaths/min

C. Circulation

Identify the rhythm

Defibrillation /Pacing

Secure IV line-large easily accessible peripheral veins

Give rhythm appropriate medication

Recognition of Rhythm

Cardiac Arrest (lethal rhythms)

Shockable-VF,Pulseless VT

Non Shockable – Asystole.PEA

Non Cardiac Arrest (non lethal rhythm)

Rate too fast - >120/min

Rate too slow- <60/min

Defibrillation For shockable rhythms – VF / Pulseless VT

Monophasic or Biphasic defibrillators (Biphasic preferred) Monophasic 360 J ~ Biphasic 200 J

Steps of Defibrillation - Mains plugged in or on battery, On Defib mode

- ECG size/gain maximum - Set on leads: Only set on paddles if no leads - Select joules (200,300 & all others 360) - Charge, (“all clear”chant to count of 3 before discharge) - Discharge

Pacing

Disappointing results for asystole, PEA No benefit in post shock asystole

May be indicated for cardiac arrest with narrow QRS complexes

Not useful during terminal wide complex agonal rhythms

Extensive use in pre-arrest bradyarrhythmias Transcutaneous or transvenous

C-CirculationIV Access

Wide bore peripheral upper limb vein Push each bolus with 20cc fluid Raise extremity Urgent central/femoral line only if peripheral

access impossible or difficult & taking a long time to cannulate

C-Circulation Other Drug Delivery Routes

Tracheal - 2-3 times IV dose - Dilute in 10 ml saline - Preferably inject down a suction catheter which

is wedged deep into the bronchus - Rapid bagging

Intracardiac route - Not recommended - Dangerous

can result in refractory VF or convert to nonshockable rhythm

C - Circulation Rhythm appropriate medications

Epinephrine

Indicated in all cardiac arrest rhythms

i.e. VF, Pulse less VT, Asystole and PEA

IV dose is 1mg administered every 3-5 minutes

followed by 20 ml IV saline flush

Adrenaline causes intense cardio-cerebral sparing vasoconstriction CPR generates CO 25% of normal

Beneficial effects outweigh negative effects on the myocardium

Vasopressin Antidiuretic hormone and a powerful vasoconstrictor

when used in the higher doses.

Positive effects of epinephrine with lesser adverse

effects . Effect lasts for 20 minutes

Dose - 40 IU

Drug of choice for all 4 rhythms Pulseless VT , VF, Asystole and PEA

One dose of vasopressin may replace either the first or the second dose of epinephrine

Atropine

First drug of choice in symptomatic bradycardia (class I )

Second drug after epinephrine for asystole and

bradycardic PEA ( class II b ).

Dose is 1mg IV push, repeat every 3-5 minutes up to a

maximum dose of 0.04 mg /kg .

Amiodarone

Persistent or recurrent VF or VT ( class II b )

Dose is 300 mg IV push (150 mg may be repeated after

3-5 minutes ) may be followed by a 24 hour infusion of

1mg / minute for 6 hours and then 0.5 mg/minute for the

remaining 18 hours.

Amiodarone preferred over Lignocaine (class

indeterminate ) in the treatment of persistent or

recurrent VF /VT.

Sodium BicarbonateSpecific indications are as follows

class I if known pre-existing hyperkalemia class II a if known bicarbonate responsive acidosis -

TCA overdose class II b after prolonged resuscitation with

effective ventilation class III hypercarbic acidosis

The dose is 1 meq/kg bolus, repeat half this dose every

10 minutes thereafter

Calcium

Detrimental effect on ischaemic myocardiumImpairs cerebral recovery

NOT TO BE USED ROUTINELY

Indicated in PEA due to Hyperkalaemia Hypocalcaemia Ca channel blocker overdose

Magnesium sulphate

Shock refractory ventricular fibrillation in pr of possible hypomagnesemia

Torsades de pointes VT in pr of possible hypomagnesemia

Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2 min,can be repeated after 10 –15 min

D. Differential Diagnosis Review the most frequent causes ( the 5 H’s and 5 T’s )

Hypovolemia Tablets ( Toxins)

Hypoxia Tamponade - cardiac

Hydrogen ions – acidosis Tension pneumothorax

Hyper / hypokalemia Thrombosis - coronary

Hypothermia Thrombosis - pulmonary

ACLS - Secondary ABCD Survey

A Airway : place airway device as soon as possible

B Breathing : confirm airway device placement by examination plus confirmation device

B Breathing : secure airway deviceB Breathing : confirm effective oxygenation & ventilation

C Circulation : identify rhythm – monitorC Circulation : Defibrillation/PacingC Circulation : establish IV accessC Circulation : give medications appropriate for rhythm and

condition

D Differential Diagnosis : search for and treat identified reversible causes

Monitoring the Victim - To assess effectiveness of rescue

efforts Monitor for signs of circulation and breathing

Check pulse during compression to assess

effectiveness of compression

To determine ROSC after 2 minutes of chest

compression check for pulse

ETCO2

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