Cardiopulmonary resuscitation

Cardiopulmonary resuscitation Dr.V.Ravimohan What I learned in the ILS training http://www.mrcogexam.net Chain of survival • • • • Early recognition and call for help Early cardiopulmonary resuscitation (CPR) Early defibrillation Post resuscitation care Early recognition • Most in-hospital cardiac arrests are not sudden or unpredictable events • Hypoxia or hypotension are either not noticed by staff ,or are recognised but treated poorly. • 2 systems early warning scores calling criteria “cardiac arrest team” “Medical emergency team” Medical emergency team calling criteria Acute change in Airway Breathing Physiology Threatened All respiratory arrests Respiratory rate < 5/ min Respiratory rate >36/min Circulation All cardiac arrests Pulse rate <40/min Pulse rate > 140/min Systolic pressure <90 mmHg Sudden decrease in level of consciousness Decrease in GCS of > 2 points Repeated or prolonged seizures Any patient causing concern who doesn’t fit the above criteria Neurology Other Airway obstruction • Treatment – Remove any obstruction unless contraindicated turn the patient to a side – Simple airway opening manoeuvres head tilt, jaw thrust or chin lift (remember to give oxygen) – Oropharyngeal airway or nasal airway – Elective tracheal intubation – Tracheostomy – Always remember to give oxygen Breathing problems • Causes – Poor respiratory drive-CNS depression – Poor respiratory effort-muscle weakness/nerve damage – Lung disorders Breathing problems • Recognition – Irritability, confusion, lethargy and depressed consciousness(from hypoxia and hypercapnia) – High respiratory effort(>30/min) – Pulse oxymetry • Non invasive measure of oxygenation but not a measure of ventilation –Blood gas analysis Circulation problems • Causes – Primary heart problemsarrythmia secondary to ischaemia – Secondary heart problems severe anaemia, hypothermia Acute coronary syndromes • Unstable angina • Non ST segment elevation MI • ST segment elevation MI – Treatment • • • • O2 high concentration Aspirin 300 mg Nitro-glycerine S/L Morphine ABCDE approach • • • • • A-airway B-breathing C-circulation D-disability E-Exposure Airway Obstruction • Airway obstruction-”sea-saw” respirations – complete • no breath sounds at the mouth or nose – Incomplete • noisy • clear the airway • Give O2 10 l/min Breathing • General signs of respiratory distress – Use of accessory muscles of respiration – Sweating – Cyanosis • • • • • Respiratory rate Pulse oxymeter Trachea Percuss listen Circulation • • Colour & temperature of limbs Capillary fill time – Finger tip held at the heart level – Normal fill time is less than 2 seconds • Pulse volume low – poor cardiac output high(bounding)-sepsis B.P low diastolic blood pressure arterial vasodilatation anaphylaxis or sepsis narrow pulse pressure-(normal 35-45 mmHg) arterial vasoconstrictionhypovolaemia/cardiogenic shock Disability • AVPU – A-Alert – V-responds to vocal stimuli – P-responds to painful stimuli – U-unresponsive to all stimuli • Measure blood glucose to exclude hypoglycaemia Exposure • Exposure to examine the patient properly – Minimise heat loss – Respect dignity “collapsed patients” • Ensure personal safety • Check for patient response – “are you alright?” • If patient responds”ABCDE approach” • If patient doesn’t respondcall for help • Airway • Breathing-”look” “feel” “hear” for not more than 10 secs Pulse • Checking for pulse-can be difficult even for the trained staff • If unsure about the pulse don’t start delaying CPR • If there is pulse – – – – Still call for help Give O2 Ventilate lungs check for circulation ever 10 seconds Attach monitoring IV access If there is no pulse or signs of life • Call for help • 30 chest compression:2 ventilation • 100 compressions/min compression depth 4-5 cm • Once the defibrillator arrives apply electrodes to patient and analyse rhythm • Minimise interruptions to chest compressions Advanced life support cardiac rhythm • 2 groups of cardiac rhythm – Shock able rhythm • Ventricular fibrillation • Pulse less ventricular tachycardia – Non shock able rhythm • Asytole • Pulse less electrical activity Shock able Rhythm First shock ( biphasic 150-200j or monophasic 360j) Resume CPR for 2 minutes without assessing for rhythm or pulse Pause briefly to check rhythm 3 possibilities VF/VT persists Organised electrical activity compatible with a cardiac output Asytole VT/VF persists Give a 2nd shock Resume CPR immediately for 2 minutes Briefly check the monitor If VF/VT persists 1 mg adrenaline IV followed immediately by third shock CPR for 2 minutes Briefly check the monitor VF/VT still persists Amidarone 300 mg IV followed immediately by a fourth shock Resume CPR immediately for 2 minutes Give adrenaline 1mg IV immediately before alternate shocks (approximately every 3-5 minutes) Give further shocks after each 2 minute period of CPR and after confirming that VF/VT persists Organised electrical activity compatible with a cardiac output Pulse or signs of life present No Pulse or no signs of life present Start postresuscitation care CPR & non shock able algorithm IF Asystole CPR & non shock able algorithm Some tips • Lidocaine 100mg IV is an alternative for amidarone but isn’t an option if amidarone is already given • If there is doubt about whether a rhythm is Asystole or very fine AF • don’t defibrillate • Very fine VF is unlikely to respond to shock Precordial Thump • May be useful in VF/VT cardiac arrest which was witnessed and monitored sudden collapse • Ulnar edge of a tightly clenched fist • From height of about 20 cm • Thumb is most likely to be successful in converting VT to sinus rhythm PULSELESS ELECTRICAL ACTIVITY • Definition: organised electrical activity in the absence of any palpable pulses. Treatment for PEA CPR 30:2 Give adrenaline 1 mg IV as soon as possible Continue CPR 30:2 until airway is secured Recheck rhythm after 2 minutes 3 possibilities VF/VT persists Organised electrical activity compatible with a cardiac output Asystole If VT/VF persists • Follow shock able side of algorithm Organised electrical activity compatible with a cardiac output Pulse or signs of life present No Pulse or no signs of life present Start postresuscitation care CPR & non shock able algorithm Treatment for asystole and slow PEA(rate <60 min-1) Start CPR 30:2 Check the ECG leads are attached correctly without stopping CPR Give adrenaline 1 mg IV as soon as possible Give atropine 3 mg IV (once only ) Continue CPR until airway secured Recheck rhythm after 2 minutes Give adrenaline 1 mg IV every 3-5 minutes During CPR Correct reversible causes Check electrode position & contact Attempt/verify IV access, Airway & O2 Give uninterrupted compression when airway is secure Give adrenaline every 3-5 minutes Consider :amiodarone,atropine,magnesium Reversible causes 4H Hypoxia Hypovolaemia Hypo/Hyperkalaemia/metabolic Hypothermia Tamponade,cardiac Toxins Thrombosis 4T Tension pneumothorax 4H Hypoxia 100% oxygen Ensure adequate chest rise & bilateral breath sounds Crystalloid/Colloid Surgery 12 ECG may help in the diagnosis Check for hypoglycaemia Hypovolaemia Hyperkalaemia Hypothermia 4T Tension pneumothorax May be a complication of inserting central venous catheter Signs: decreased air entry decreased expansion hyperresonance percussion on affected side Do: needle thoracocentesis Tamponade cardiac Cardiac arrest after penetrating chest trauma 2 reasons:A.hypovolaemia B.cardiac tamponade Do: needle pericardiocentesis or resuscitative thoracotomy Toxins Thrombosis Consider thrombolytic therapy CPR in a pregnant patient • Left lateral tilt(15-30 degrees) of patient • Periarrest caesarean section should begin within 4 minutes • Sterile preparation is not necessary • Moving the patient to operating theatre isn’t necessary