Cardiopulmonary Resuscitation - Prince of Songkla...

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Cardiopulmonary

Resuscitation

���������� ������. ������� ����������������������������������������

�������� ����! ���������

"#$$����%��& ��'& �(�)�*$• 1. ����)� �)��,�������-$��.,)�/�

• 2. ����)� �!'� ventricular fibrillation

• 3. ����,'��� '��,���-$– �������� ���������

– ������������

– ������������������

Cardiopulmonary Cerebral

Resuscitation

CPCR

������������ !� • 1. ��������� : early, effective

ventilation

• 2.�������� : early, effective chest

compression

• 3.������#$������ : early defibrillation

• 4.���������%���&' : early ACLS

The Adult Chain of Survival

��� ()�%� ����� �*#

%���#��������+,-���� . 1.������+,-���� .%���.���/��• Basic Life Support = First A-B-C-D

“Primary ABCD Survey”

2. ������+,-���� .%���.���&' • Advanced Cardiovascular Life Support

(ACLS) = Second A-B-C-D

“Secondary ABCD Survey”

3. ���'����� ����������� : Postresuscitation

care

%���#���*!�����%���#���*!����� Primary ABCD SurveyPrimary ABCD Survey

"��)�������'1��'�"��)�������'1��'� unresponsiveness unresponsiveness unresponsiveness unresponsiveness unresponsiveness unresponsiveness unresponsiveness unresponsiveness!'��������)� '!'��������)� ' call call call call call call call call for for for for for for for for HelpHelpHelpHelpHelpHelpHelpHelp$�,���&2/"3��$�,���&2/"3�� position the victimposition the victimposition the victimposition the victimposition the victimposition the victimposition the victimposition the victim

Preliminary first actionPreliminary first actionPreliminary first actionPreliminary first actionPreliminary first actionPreliminary first actionPreliminary first actionPreliminary first action

Primary survey (BLS)���������� ����!�5�� 5�6��

• A = Airway: �01��� ��*������

• B = Breathing: 0���*�������������

• C = Circulation: ���������������

• D = Defibrillation: ��#$�������2��3++4� �5 VF/pulseless VT

A: Airway

���������� ��������������� ����� ((LayLay rescuersrescuers))

-- �'�����%��" �" '�-�"���'�����%��" �" '�-�"��

-- finger sweepfinger sweep

-- ��8��(�$�,��%��" �" '�' %�9��8��(�$�,��%��" �" '�' %�9 :: ;��$(�)"<�;��$(�)"<� ((IIbIIb))

A: Airway– �,��/�&�� )�����

head tilt-chin lift.

– 1�,)$*1���,2����� �������'

: Jaw thrust

– ����������-$��%)�����')"<�� ��

B: Breathing

• 0���*��������:

• LOOK

• LISTEN

• FEEL

• ���-� 10 ������

• ����&2/"3��;�����-$

• ��������� 2 ��

: ��� ����������%2� 1 �*���

: &� ��#�����!��%� �� ��

• ��23�2���������������$�'0���%� �� CPR

B: Breathing

Breathing

B: Breathing

• ��������������0��0���0��

: 6'2���������3���*���� ���3��&���7���������

• ������������������� �� ��: chest compression only CPR (class IIa)

B: Breathing

• VF ��� 2- 3 ��� ��

: ������� ���&���8������������������

- �� � ���)*����������

- �����!��%� �� : ������ , gasping

B: Breathing

• Reduce pulmonary blood flow

- cardiac output is 25-33% of normal

- decrease total body CO2 production &delivery- excessive hyperventilation

: decrease rate of compression: increase intrathoracic pressure : cumulative perfusion pressure

markedly reduced

B: Breathing• ventilation & compression are

importance

- Prolonged VF sudden arrest

- Asphyxial cardiac arrest

• Progressive chest compression

(after 4 – 10 minutes of CPR)

- atelectasis

- thoracic deformity

B: Breathing

• �� ��� !� ������������������ (hyperventilation)

• �����300����� ������� CPR

• Cardiac output ������� 25-33%

• �.*!������������ �� �� �����2 venous

return ���

tidal volume 6tidal volume 6--7 ml/kg (5007 ml/kg (500--600 ml)600 ml)

B: Breathing• ��04� ��� gastric inflation, aspiration

: �� ��� !� ������������������ : Cricoid pressure

• ��#������������ 8-10 �� #����� ���#2� � �����!��%� �� ��

• synchronize breaths between chest compression

B: Breathing

C = Circulation

• ������ .�(��6'2�����������!�30

3��� � .��#����3�2���� 10%(poor sensitivity)

� � .��#����3�2���3��� 40% (poor specificity)

• �(����1&2/����)� '��%�;"

����;�����-$ -�/�����>6��������-$��.,)�/�

• �$����� ���.��: ���� .� 3����*� 10 �*��� • �5 3������� ��������

C = Circulation

• ����,'�

: ����,'���%��"�����8�����SBP 60-80 mmHg

�MAP at carotid artery > 40 mmHg

��. � .�#����������)*���30&�� ��������

C = Circulation

Survival

Coronary perfusion pressure

Effective chest compression

Cerebral perfusion pressure

ROSC Neurological outcome

• Chest compression

:14 - 22% inadequate(2 rescures)

:40% insufficient depth (JAMA 2005)

C = Circulation

C = Circulation

“ Push hard and fast ”

C = Circulation

• ��8�����,'�

: $�,����'�����1�� 5���1

: &2/����)� ''�2�!/�� (����&2/"3��

• : �(���������� ������'� ��,�1 lower half of sternum (between the nipple)

• : �/�� '!/����%?��,��� ���

• : �/�� '!/����%;��?��,���1�

C = Circulation

�������

: �, @� 11/2-2 �*�� (4-5 )�.)

��� 1/3-1/2 �������� �������2�7� ���

����)� �• compression : relaxation = 50:50

• completely recoil after compression

'��������, = 100/min (class IIa)

C = Circulation

• Compression-Ventilation Ratio

• 30 : 2 (1 or 2 rescuer)

• � ��) �%������1����� '��.,�,'�

• Effective chest compression– Depth

– Rate

– Circulatory-ventilation ratio

– Duty cycle

– Hand position

– Surface underneath the victim

C = Circulation

• Inadequate and interrupted chest compression

• Decreased successful resuscitation

Reduces cardiac output and coronary and cerebral blood flow (Circulation 2002,2004)

Excessive ventilation rates

• Fatiguing effect

: decrease quality/depth of

compression at 1 min. and again at

4-5 min. of CPR

: awareness of fatique after 5 min.

change every 2 min (after 5 cycles)

quickly switch (<5 seconds)

C = Circulation

��������A/'�!'�����,'�

- Fractured ribs & sternum .�����- Pneumothorax

- Hemothorax

- Lungs, heart, spleen, liver laceration

- Ruptured stomach, diaphragm

- Fat embolism

• ���������(��3������ (only healthcare

provider)

: ��#������������ 10-12/min (1 �� �$� 5-6

�*��� )

: ��� ������%2���� 1 �*���

: 0���*�� .������$� 2 ��� (3����*� 10 �*��� )

Definite Pulse � (����$�;,/

DEFIBRILLATION �������.����-$,/��;��B�

D = Defibrillation

���&���8

• VF .�����&$�

• �*> ��?�� !� 0�&*�>*@�. �� electrical defibrillation

• 6�&�������� #������

• VF &���7�0� !���0A� asystole

D = Defibrillation

• ���$��� ����3�2�� 5 ���

• ��( .����� ����3�2�� 2 - 4 ���

• ����#$�������� 3-5 ��� � 6�&�����&' &$�

• ��#������ �*#��� VF ��� 7-10 % #�����

Compression First & Shock First

: Insufficient data� CPR before

defibrillation for all VF.

• CPR first & defibrillation first

: CPR 1.5-3 min before defibrillation�improve return of spontaneous circulation (ROSC) and survival rate.

• ( out-of-hospital VF arrest, JAMA 1999)

• �� 3��� ����/��%2��'���( .�����

• -�/ defibrillator -�/;,/)�*���%�.,

D = Defibrillation

D = Defibrillation

• Monophasic waveform : one polarity– Damped sinusoidal (MDS)

– Trucated exponential (MTE)

• Biphasic waveform– Truncated exponential – Rectilinear biphasic

D = Defibrillation– Monophasic damped sinusoidal

– Monophasic truncated exponential

– Biphasic truncated exponential

– Rectilinear biphasic

.�� ��3++4� : ��#$������ 1 ���5�1. Monophasic waveform : 360 Joules

2. Biphasic waveform

:truncated exponential waveform : 150 - 200 J

:rectilinear biphasic waveform : 120 J

: If unknown � 200 J

: �� 3��� %2��'��0 ���� ������� escalating & non-

escalating energy

D = Defibrillation

• &�&�!�3++4� (Conductive material)

– ��@���B���3++4�%� �� �� (thoracic impedance)

– ��.�� ��3++4�� !��2

– �.*!�6�&�����– Hairy chest : high impedance

D = Defibrillation

D = Defibrillation

%���%� Electrode

: 8-12 cms

: �/'����� 4.3 cm �(�-�/)��, myocardial injury

D = Defibrillation

#������ ���� Electrode

Sternum : closed to clavicle, right border of sternum

Apex : 5th ICS & MAL

�� ��� !� �*��5� !�

* implantable cardioverter

defibrillator (ICD)

* permanent pacemaker

D = Defibrillation

!�5��'����-�/)�� %'�

1. �01���!�

D = Defibrillation

!�5��'����-�/)�� %'�

2. 0��0$D������.�� ��

360 J �� ' 200 J

D = Defibrillation

!�5��'����-�/)�� %'�

3. 0��0$D� “lead select” �0A� “Paddles”

D = Defibrillation

!�5��'����-�/)�� %'�

4. �� EKG gel , cream

3����2 K-Y jelly , ultrasound gel

D = Defibrillation

!�5��'����-�/)�� %'�

5. �� paddles � ��#������ sternum-apex

6. #��&����!�3++4������

D = Defibrillation

!�5��'����-�/)�� %'�

7. �5 VF/pulseless VT

��C��1'� charge

D = Defibrillation

!�5��'����-�/)�� %'�

8. ��0$D� “Charge”

D = Defibrillation

!�5��'����-�/)�� %'�9. ���!���!� charge

.�� ����� ! paddles ��2� #��&��� �

D = Defibrillation

!�5��'����-�/)�� %'�

10. ���� �� paddles 10

kg.

11. ��0$D� ”Discharge” ��� &� %2� .2�����

D: Defibrillation

Oxygen and fire risk

������������������� �� (sparking)

#��&������ Paddle

������#$��������%5� O2-enriched atmosphere

Marquette: monophasic 360 J

Zoll: monophasic 360 J

Nihon Kohden: biphasic 150-270 J

Philips: biphasic 150-200 J

Zoll: biphasic 120 J

CPR #������ 5 cycles ��� 2 min.

Most victims show asystole or PEA for several minutes after defibrillation�CPR can convert to perfused rhythm. (Resuscitation 2002,2003,2005)

�� ��� !� �����������$� ���� �.�!�0���*�� .������!�3++4������

� ������.����-$ 1 ���5�

• #��&����!�3++4������ : shockable rhythm?

• 0F*��#* CPR #�����!� ��%5� charging defibrillator

• �������#$������

• ��',/�� CPR 5 �'1����� � ������.����-$

• �(�A5(�;")� %'�9

� ����� CPR 5 �'1

Automatic External defibrillator (AED)

improve survival rate from out-of-hospital sudden cardiac arrest.

Adult BLS Healthcare Provider Algorithm

�&��2��������������!�5�� 5�6��

Summary��."

Basic life support• Check responsiveness

• Activate emergency response system

• Call for defibrillator: PHONE FIRSTA = Airway

B = Breathing

C = Circulation

D = Defibrillation:1 shock for VF/VT

Within 4 minute

• The American Heart Association. Part 4: Adult Basic Life Support. Circulation 2005;112:IV-18-IV-34.

• The American Heart Association. Part 7.2: Management of cardiac arrest. Circulation 2005;112:IV-57-IV-66.

• The American Heart Association. Part 3: Defibrillation. Circulation.2005;112:III-17-III-24.

• The American Heart Association. Part 3: Overview of CPR. Circulation 2005;112:IV-12-IV-17.

• Hazinski MF, et al. Major changes in the 2005 AHA Guidelines for CPR and Emergency Cardiac Care (ECC). Circulation 2005;112:IV-206-IV-211.

References