Cardio-Pulmonary Cerebral Resuscitation

Senior Consultant

Critical Care & Pulmonology

2010 BLS AHA Guidelines

• Lay rescuers begin CPR if the adult victim is unresponsive and not breathing normally (ignoring occasional gasps) without assessing the victim’s pulse.

• Following initial assessment, rescuers begin CPR with chest compressions rather than opening the airway and delivering rescue breathing.

Recognition of Cardiac Arrest

• Healthcare providers cannot reliably determine the presence or absence of a pulse, so CPR should not be delayed if a pulse is not immediately found in the unresponsive adult victim who is not breathing normally.

• All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest.

• A strong emphasis on delivering high-quality chest compressions remains essential:– push hard to a depth of at least 2 inches (5 cm)

at a rate of at least 100 compressions per minute,

– allow full chest recoil after each compression, and minimize interruptions in chest compressions.

• Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2.

Diagnosis of Cardiac Arrest

• Unresponsiveness (not moving & not breathing)

• No looking for pulse• Absence of pulsation in major arteries

(carotid, femoral) – maximum 10 secs• Absence of respiratory effort• Absence of Heart Sounds• Generalized pallor• Pupillary Dilatation

C – Chest Compression (BLS)

• Thump on Chest• External Cardiac Compression

-Pressure to be applied on lower part of sternum (not on ribs, upper abdomen or bottom of stern.)-Depress the sternum at least 4-5cm-Rate 100/min-Ratio 30:2 compression to breaths

• Push hard, push fast, allow complete chest recoil, minimize interruptions in chest compression

Chest Compression

• Immediate CPR is required in all cases of cardiac arrest

• CPR started immediately after collapse from VF doubles/triples the chances of survival

• CPR also prevents degeneration of VF into asystole

• CPR should be continued till a defibrillator is available

Chest Compression

• During CPR, CO is reduced to 25-33%• Low TV & RR can maintain effective oxygenation &

ventilation during CPR• O2 level in blood remains high for the initial few minutes

after cardiac arrest (FiO2 in dead space 14%)• O2 delivery to brain & myocardium is reduced due to

decreased Cardiac Output• Hence Chest compressions are more important than

rescue breaths in the first several minutes after VF & cardiac arrest

• For victims of prolonged cardiac arrest ventilation & compression are of equal importance

Chest Compression

• Rescuer fatigue – relieve every 2 minutes

• Once advanced airway is placed provide 8-10 breaths/min without interrupting chest compression at the rate of 100/min

• 5 cycles (2 min) of CPR should be given immediately after shock to minimize the no flow time

End-tidal CO2• The use of end-tidal CO2 (ETCO2) monitoring

is a valuable adjunct for healthcare professionals. When patients have no spontaneous circulation, the ETCO2 is generally ≤ 10 mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in compressions for pulse checks become unnecessary.

Three Pillars of Cardiocerebral Resuscitation

1. CCC (compression-only cardiopulmonary resuscitation) by anyone who witnesses unexpected collapse with abnormal breathing (cardiac arrest).

2. Cardiocerebral resuscitation by emergency medical services (arriving during circulatory phase of untreated ventricular fibrillation [e.g.>5 min])

Cardiopulmonary Resuscitation• a. 200 CCCs (delay intubation, second person applies

defibrillation pads and initiates passive oxygen insufflation).

• b. Single direct current shock if indicated without post-defibrillation pulse check.

• c. 200 CCCs prior to pulse check or rhythm analysis.• d. Epinephrine (intravenous or intraosseous) as soon as

possible.• e. Repeat (b) and (c) 3 times. Intubate if no return of

spontaneous circulation after 3 cycles.• f. Continue resuscitation efforts with minimal interruptions

of chest compressions until successful or pronounced dead.

Cardiocerebral Resuscitation

3. Post-resuscitation care to include mild hypothermia (32°C to 34°C) for patients in coma post-arrest. Urgent cardiac catheterization and percutaneous coronary intervention unless contraindicated.

Interruptions of Chest Compression

• < 10 secs

• Rhythm recognition

• ET intubation

• Defibrillation

• Fatigue

Compression only CPR

• Better than no CPR• Rescue breathing is not essential in the

first 5 min of VF & SCA in adults• Open airway, passive chest recoil & some

gasps provide some gas exchange• The best method of CPR is chest

compression coordinated with ventilation• CPR should be continued till defibrillator

arrives

FIRST RESPONDER• The closest healthcare personnel who

discovers the need for resuscitation– Starts CPR as per protocol– Scene Safety – Shakes and Shouts-Are You Okay?– Calls for Help- “CODE BLUE ROOM”– Start Chest compression at 100/min – Open Airway – Two Rescue Breaths

SECOND RESPONDER

• The one who has heard the call

• Call CODE BLUE CONTROL ROOM

• Bring the crash cart

• Switches to oral airway, AMBU bag and Oxygen

• Assist in CPR

ARRIVAL OF “CODE BLUE TEAM”• Team leader, Code Blue nurse -

Prepares for and secure Advanced Airway, while CPR is being continued

• First Responder- continue Cardiac Compressions

• 1st Floor Nurse- Attach ECG, leads of defibrillator• 2nd Floor Nurse-Get IV line and Give drugs as per

order• Team Leader- Decides for further Action

depending upon the patient status

How Long to continue CPR

• Flat ECG for at least 30min despite optimal CPR & Drugs

• A sensitive test of effective CPR is decrease in size of pupils

Who should be resuscitated ?

• Reverse sudden unexpected death resulting from reversible disease processes

• Resuscitation is unlikely to benefit patients experiencing cardiac arrest despite maximal medical therapy for progressive cardiogenic or septic shock

Respiratory Arrest

• Careful assessment of vital signs, SpO2, air movement & work of breathing will indicate that respiratory impairment is present

• Tachypnea, progressing to bradypnea, paradoxical abdominal breathing & progressively decreasing alertness may herald imminent respiratory arrest

Warning signs of a severely ill patientParameter Values

• Blood pressure Systolic <90 or mean <70 mmHg

• Heart Rate >120 or <50/min• Respiratory rate >30 or <8 breaths/min• Conscious GCS <12/change of 2 points • Oliguria <0.5 ml/kg/hr• Blood sugar <50mg% or > 300mg%• Worried Nurse Concerned experienced nurse• Sodium <120 mmol/l or >150 mmol/l• Potassium <3 mmol/l or > 6 mmol/l• pH <7.2• Bicarbonate <18

Q.1:The first step in ‘Circulation’ is

a) Side to side chest compression

b) External cardiac compression

c) Thump on the chest

d) Abdominal compression

 

Q.1:The first step in ‘Circulation’ is

a) Side to side chest compression

b) External cardiac compression

c) Thump on the chest

d) Abdominal compression

 

Q.2: The goal of CPR is to

a) Make the patient get up and walk

b) Restore adequate cerebral and coronary blood flow

c) Restore renal blood flow

d) Restore blood flow to all organs

 

Q.2: The goal of CPR is to

a) Make the patient get up and walk

b) Restore adequate cerebral and coronary blood flow

c) Restore renal blood flow

d) Restore blood flow to all organs

 

Q.3: The sternum is to be depressed during chest compression by

a) 2-3 Cm

b) 4-5 Cm

c) 10 Cm

d) 15 Cm

Q.3: The sternum is to be depressed during chest compression by

a) 2-3 Cm

b) 4-5 Cm

c) 10 Cm

d) 15 Cm

Q.4: Chest compression are to be done at a rate of

a) 120/min

b) 60/min

c) 72/min

d) 100/min

Q.4: Chest compression are to be done at a rate of

a) 120/min

b) 60/min

c) 72/min

d) 100/min

Q.5: Compression Ventilation ratio for one operator is

 a) 15:2

b) 15:1

c) 30:2

d) 30:4

Q.5: Compression Ventilation ratio for one operator is

 a) 15:2

b) 15:1

c) 30:2

d) 30:4

D – Defibrillation (ALS)

• As soon as possible• VF:Monophasic 360 Joules 1 shock - CPR• Apply jelly on the paddles• Place on sternum & apex• Persons are asked to stay clear of the bed• Defibrillate once followed by immediate chest

compression

Post Defibrillation

• After defibrillation, asystole or Pulseless electrical activity (PEA) is often noted for several minutes & perfusion is inadequate. CPR is needed after defibrillation, till a perfusing rhythm is restored

• Although defibrillation often restores a perfusing rhythm, yet it does not sustain the circulation & hence advanced life support is required

A – Airway (BLS)

• Clear Airway

• Head tilt, Chin lift

• Head tilt, neck lift

• Head tilt, Jaw thrust

• Oropharyngeal/Nasopharyngeal airway

• Endotracheal tube

Assess Airway

Elevate Mandible

Elevate Mandible&

Open Mouth

Oral Airway

Who should Intubate

• If no good trauma resuscitation in Casualty shift the patient to ICU

• Any patient bleeding significantly should be shifted to OT

• Trauma patients who can be intubated without drugs almost invariably die

• Those adequately trained & experienced in advanced airway management (use of drugs, LMA, cricothyrotomy)

Where to Intubate

• 95% of secondary insults occur before admission to ICU

• If the scene of accident is 20min from hospital proceed directly to hospital

• Most experienced must be available for intubation as patients reserve are diminished & problems occur quite unpredictably

Persons who can intubate

Training for Intubation

• 20 intubations in OT

• 50 intubations under supervision

• At least one/month to maintain currency

• The best technique is the technique the operator is used to, has practiced, & does well

Rapid Sequence Intubation

• Preoxygenation• Manual inline immobilisation of Cervical Spine

with removal of anterior part of cervical collar• Cricoid pressure• Induction drugs & Neuromuscular Blockade• Direct laryngoscopy without extension of the

atlanto-occipital joint

In-line Immobilization

B – Breathing (BLS)

• Mouth to mouth/Mouth to nose (16%O2)

• Ambu Bag & Mask – all providers should know

• Ambu Bag & Endotracheal Tube

• The 30 compressions are now recommended to precede the 2 ventilations, which previous guidelines had recommended at the start of resuscitation.

Breathing

• Blow steadily into the mouth for 1 sec. Chest should rise & then fall as in normal breathing

• Up to 5 attempts should be made to achieve 2 effective breaths

• Bag mask with O2 delivered over 1 sec & chest should rise

• Rapid or forceful breaths are avoided. Hyperventilation increases intrathoracic pressures, decreasing venous return & CO

• Large TV causes gastric inflation & complication• High proximal airway pressure is caused by large TV,

high inspiratory pressure, short inspiratory time, incomplete airway opening & decreased lung compliance

Adult Basic Cardiac Life Support

D – Drugs (ALS)

• Adrenaline-1mg IV. Repeat every 3 min

• Vasopressin 40u – instead of Adrenaline

• Atropine-3mg IV stat in peri-arrest brady

• Sodibicarb-1-2ml/Kg if arrest > 10min

• Xylocaine- 1-2mg/Kg IV stat in resistant arrhythmias

• None are better than a good CPR & Defibrillation

Changes for dysrhythmia

• For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents (eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy to transcutaneous pacing when atropine fails;

• As noted above, transcutaneous pacing for asystole is no longer recommended; and

• Atropine is no longer recommended for routine use in patients with pulseless electrical activity or asystole.

Documentation

• Team Leader with Nurse- Documents all events and orders, Obtain history from patient’s relative, direct team members in their actions, appropriate drug treatment, Defibrillation.

EQUIPMENT FOR CODE BLUE

• Crash Cart• Drug Tray• Defibrillator/AED• Pacemakers• Airway• Bag and Masks• Endo tracheal tubes• Laryngoscopes with extra bulbs, all size blades, extra

batteries• ECG leads• IV cannulas, fluid pints• Central line tray

RECORDING OF EVENTS DURING CARDIAC ARREST

• All events during a cardiac arrest are recorded including date, time, location, patient data, first, second, third responder, the time of each responder, activation of code blue by initial response team and activities of response teams. All interventions made in chronological order, medicines given, life support provided, vitals recording including ECG recording etc., basic disease of patient and the outcome of code blue activities. This also includes the problems encountered in the various activities during CPR.

• This recording is done and compiled by staff nurse on duty attending the CPR.

Post-cardiac arrest care

• Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally recommended for adult survivors of cardiac arrest who remain unconscious, regardless of presenting rhythm. Hypothermia should be initiated as soon as possible after return of spontaneous circulation with a target temperature of 32°C-34°C.

Post-cardiac arrest care• Urgent cardiac catheterization and

percutaneous coronary intervention are recommended for cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute myocardial infarction regardless of neurologic status. There is also increasing support for patients without ST-segment elevation on ECG who are suspected of having acute coronary syndrome to receive urgent cardiac catheterization.

Post-cardiac arrest care

• Hemodynamic optimization to maintain vital organ perfusion, avoidance of hyperventilation, and maintenance of euglycemia are also critical elements in post-arrest care.

Cardiac Arrest

E – ECG (ALS)

• Monitor for asystole, ventricular fibrillation, electro-mechanical dissociation (PEA)

• EtCO2 can be an indicator of Cardiac Output during chest compression

Pulseless Electrical Activity

6 Hs

• Hypovolemia

• Hypoxia

• H+ (acidosis)

• Hyper/hypo kalemia

• Hypothermia

• Hypoglycaemia

Pulseless Electrical Activity

5 Ts

• Tablets (drug overdose)

• Tamponade (cardiac)

• Tension Pneumothorax

• Thrombosis (coronary)

• Thrombosis (pulmonary)

F – Fluids (ALS)

• IV Fluids

• Vascular access – large peripheral vein

- bolus followed by 20ml flush

- should not interfere CPR & Defibrillation

G – Gauging (PLS)

• Assess severity of insult

• State of consciousness

• Cranial nerve reflexes

• Ultimate long term outcome in terms of patients performance, capability, & quality of life

H – Human Mentation (PLS)

• Cerebral Resuscitation

-maintain BP, PaO2, PCO2,

-Decrease cerebral oedema

I - Intensive Care (PLS)

• Intensive monitoring, nutrition, ventilation etc till patient fit for discharge

Prognosis

Predict poor neurological outcome

• Absent corneal reflex at 24 hous

• Absent pupillary response at 24 hours

• Absent withdrawal response to pain at 24h

• No motor response at 24 hours

Leaders Role

• Evaluation

• Airway management

• Chest Compression- 30:2

• Attach ECG monitor

• Obtain IV assess

• Administer medicines as requested

Defibrillation

• Synchronized –PSVT,Atrial flutter(50-100J)

- Atrial fibrillation (100-200J) - Monomorphic VT(100-200-300-360)

• Unsynchronized - Ventricular fibrillation

- Pulseless VT - Unstable Polymorphic irregular VT