kiblboeck aktuelle guidelines der kardiopulmonalen reanimation · cardio-cerebral resuscitation –...
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Aktuelle Guidelines derkardiopulmonalen ReanimationDaniel KiblböckERC Advanced Life Support Instructor
Abteilung Interne II – KardiologieKrankenhaus der barmherzigen Schwestern Linz
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• Algorithmus Adult Advanced Life Support
• Ursachen einer kardiopulmonalen Reanimation
• Post-Resuscitation Care Syndrome
• Prognose nach CPR
• Porto 2010 - neue ERC-Guidelines
Themenübersicht
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ERC - ALS Guidelines 2005
Nolan JP et al. European Council Guidelines for Resuscitation 2005. Resuscitation (2005) 67S1, S39-S86
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Der reglose Patient
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Adult Advanced Life Support
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Notfallcheck (1)
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Notfallcheck (2)
• EigenschutzHandschuhe, überprüfen der Umgebung
• BewußtseinskontrolleAnsprechen – Berühren – Schmerzreiz
• Atemwege überprüfenAtemwege gegebenfalls freimachen
• Kontrolle der Atmung u. des Carotispulsesgleichzeitige Durchführung
Cave: Schnappatmung = Zeichen des Herz-Kreislauf-Stillstandes
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Atemwegsobstruktion
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Basic Life Support – CPR 30:2 (1)
• Position:Mitte des Brustkorbsin der Körpermittellinie
• Drucktiefe: 4-5cm
• Kompressionsrate: 100/min
CPR 30 : 2
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Basic Life Support – CPR 30:2 (2)
• Beatmungszeit: 1 sec.
• Beatmungsfrequenz: 10 / min
• Erfolgskontrolle: sichtbare Hebung des Brustkorbs
CPR 30 : 2
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Monitoring – Rhythmusanalyse
• Kammerflimmern
• pulslose ventrikuläre Tachykardie
• Asystolie
• pulslose elektrische Aktivität
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Defibrillierbare Rhythmen
Kammerflimmern
Pulslose ventrikuläre Tachykardie
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Defibrillation – bi- vs. monophasisch
• 1. Schock: 150 – 200 J biphasisch
• alle weiteren Schocks: 200 – 360 J biphasisch
• alle Schocks: 360 J monophasisch
Effektivität des ersten Schocks bei VF/VT:
• biphasisch 86 - 98%
• monophasisch 54 – 91%
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ALS - Defibrillierbarer Rhythmus
• 1. Schock: 150 –200 J biphasisch
• weitere Schocks: 200 - 360 J biphasisch
• vor 3. Schock: Adrenalin 1mg i.v.
• vor 4. Schock: Amiodaron 300mg i.v. (einmaliger Bolus)
• vor 5. Schock: Adrenalin 1mg i.v.
• vor 7. Schock: Adrenalin 1mg i.v. (alle 3-5min)
etc.
• CPR 30 : 2 für 2 min fortsetzen
• Rhythmuskontrolle
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Präkordialer Faustschlag (1)
Indikation:
beobachteter u. monitorüberwachterHerz-Kreislauf-Stilstand
+ VT / VF
+ kein Defibrillator sofort verfügbar
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Präkordialer Faustschlag (2)
Energie:
40 – 50 Joule
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Monitoring – Rhythmusanalyse
• Kammerflimmern
• pulslose ventrikuläre Tachykardie
• Asystolie
• pulslose elektrische Aktivität
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Nicht-defibrillierbare Rhythmen (1)
Asystolie
Pulslose elektrische Aktivität (PEA)
= elektromechanische Dissoziation (EMD)
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• CPR 30 : 2 für 2 min fortsetzen
• Rhythmuskontrolle
• Adrenalin 1mg i.v. sobald als möglich
• Atropin 3mg i.v. (einmaliger Bolus)bei Asystolie od. PEA < 60/min
• Adrenalin 1mg i.v. (alle 3-5min)
Nicht-defibrillierbare Rhythmen (2)
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Atemwegsmanagement
Oro- / nasotracheale Intubation- bester Aspirationsschutz- Beachtung der sicheren
Intubationskriterien (Stimmritze, Kapnometrie)
Cave:Patient verstirbt nicht, weil er nicht intubiert wurde, sondern an der Hypoxie.
Kontinuierliche CPR nach Intubation!
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Alternative Atemwegssicherung
Larynxmaske
Combi-Tubus
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Hyperventilation (1)
38/min
11/min
Aufderheide TP et al. Hyperventilation-induced Hypotension during cardiopulmonary resuscitation. Circulation 2004;109;1960-1965
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Hyperventilation (2)
Aufderheide TP et al. Hyperventilation-induced Hypotension during cardiopulmonary resuscitation. Circulation 2004;109;1960-1965
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Hyperventilation (3)
Aufderheide TP et al. Hyperventilation-induced Hypotension during cardiopulmonary resuscitation. Circulation 2004;109;1960-1965
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Intraossärer Zugang – proximale Tibia
„If you can‘t get an i.v., think about an i.o.!“
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Intraossärer Zugang – distale Tibia
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Intraossärer Zugang – Devices
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Ursachen einer CPR
Pell JP et al., Presentation, management, and outcome of out of hospital cardiopulmonary arrest:comparison by underlying aetiology. Heart 2003;89:839—42.
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4 H + HITS
H Hypoxie
H Hypo-/Hyperkaliämie, metabolische Urs.
H Hypovolämie
H Hypothermie
H Herzbeuteltamponade
I Intoxikation
T Thrombose koronar/pulmonal
S Spannungspneumothorax
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ROSC – was nun ?!
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Post Resuscitation Care
A Airway: Atemwege überprüfen
B Breathing: Beatmung
C Circulation: EKG-Monitoring, RR,Blut-Gas-Analyse
D Disability: neurologische Beurteilung, Glasgow Coma Scale
E Exposure: Untersuchung, Exploration
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„Die richtige Sedierung“
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Post cardiac arrest syndrome
Herz-Kreislauf-Stillstand
Kardiopulmonale Reanimation
ROSC
Reperfusions-Schädenoxidativer Stress
SIRSHypoxische Hirnschädigung
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Hypothermie nach CPR
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Hypothermie – neurologisches Outcome
NEJM 2002;346:549-556
NEJM 2002;346:557-563
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Hypothermia after cardiac arrest (HACA-Trial)
NNT 6-7
NEJM 2002;346:549-556
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Präklinische Hypothermie
U. Kreimeier, M. Holzer et. al, ERC Leitlinien 2005 – Umsetzung im klinischen Bereich, Notfall Rettungsmed 2008;11:91-98.
• Zieltemperatur: 32 – 34°C
• Ringerlaktat 30ml/kg KG 4°C
• Auflegen von Cool-packs
Kontraindikation:
• Lungenödem
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„Alternative“ präklinische Kühlung
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Milde therapeutische Hypothermie
Milde therapeutische Hypothermie:
Kühlung des Patienten auf 32 – 34°C auf der Intensivstation für 12 – 24h
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Prognose nach CPR
M. Ringh et al, Out of hospital cardiac arrest outside home in Sweden, change in chararcteristics, outcome and avialibity for public access defibrillation, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2009
1992 2005
out of hospital cardiac arrest (n) 2609 2800
bystander CPR 47% 58%
survival to ward 20% 26,9%
survival to 1 month 8,1% 14,1%
survival to 1 month pts. found with VFib 15,3% 27%
survival to 1 month pts. not found in VFib 2,2% 5%
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Porto 2010 – neue Guidelines
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Cardio-Cerebral Resuscitation – CCR (1)
modifiziert nach: Ewy GA, Kern KB (2009) Recent advances in cardiopulmonary resuscitation: cardio-cerebral resuscitation. J Am Coll Cardiol 53:149-157
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Cardio-Cerebral Resuscitation – CCR (2)
Kellum MJ et al. Cardiocerebral resuscitation improves neurological intact survival of patients with out-of-hospital cardiac arrest.Ann Emerg Med 2008;52:244-52
Neurologically intact survival
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Minimal interrupted cardiac resuscitation
Survival to hospital discharge
Bobrow BJ et al. Minimally interrupted cardiac resuscitation by emergency medical services providers for out-of-hospital cardiac arrest. JAMA 2008;229:1158-65
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Chest compression only – survival is similar
Bohm K et al. Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonaryresuscitation. Circulation 2007;116;2908-2912
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Intravenous drug administration during cardiac arrest
Olasveengen TM et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trialJAMA 2009;302(20):2222-2229
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Porto 2010 – neue Guidelines
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Zusammenfassung
• CPR 30 : 2
• Defibrillation bei VFib/VT
• no-flow time kurz halten
• Intubation zur Atemwegssicherung
• Hyperventilation vermeiden
• Medikamente- VFib/VT: Adrenalin, Amiodaron- Asystolie: Adrenalin, Atropin
• prä- u. innerklinische Hypothermie
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Herzlichen Dank für die Aufmerksamkeit
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Pharmakologische Interventionen nach CPR
- Thiopental, BRCT I; N Engl J Med 1986;314:397
- Glucocorticoids, BRCT I; JAMA 1989;262:3427
- Nimodipine, Roine RO; JAMA 1990;264:3171
- Lidoflazine, BRCT II; N Engl J Med 1991;324:1225
- Magnesium, Longstreth WT; Neurology 2002;59:506
- Diazepam, Longstreth WT; Neurology 2002;59:506
- Coenzyme Q10, Damian MS; Circulation 2004;110:3011
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Prognosebeurteilung nach CPR
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Cardiocerebral Resuscitation – CCR (1)
Ewy GA, Kern KB (2009) Recent advances in cardiopulmonary resuscitation: cardio-cerebral resuscitation. J Am Coll Cardiol 53:149-157