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Cardio Pulmonary Resuscitation

The short what to do guide

Author : Dr F Malan

June 2012


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Introduction

Why do CPR?

Basic Life Support Principels

Advance Cardiac Life SupportAlgorhythms

AED vs. Defib

Airway Management Devices

Drugs

Information and Graphics adapted from the BLS and ACLS Guidelines of the American HeartAssociation 2010 and the South African Resuscitation Guidelines 2012


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Why do CPR?

Blood flow stops = no oxygen or substrate delivery to cells

Ischemic cell injury follows

If condition persists, cell death occurs

CNS very fragile = cell death after 3-5 minutes =

permanent neurological damage

Cardiac muscle stops contracting after 1 minute but only

dies after 40-60 minutes

What happens during cardiac arrest?


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Generates blood flow = less tissue ischemia

Improves survival and lessens neurological deficit

Buys time to reverse treatable conditions

The sooner CPR is started and the first shock delivered, the

better the chances of ROSC and thus survival (time = brain

+ heart)

No drug has been proven to increase survival!!

Why must we start Chest compressions as soon

as possible?

Why do CPR?


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In-hospital cardiac arrest has an average survival rate of

21%

80% of patients with ROSC after cardiac arrest that areadmitted to ICU die before discharge

Survival rate is very poor for cardiac arrest associated with

rhythms other than VF/VTunfortunately >75% of in-

hospital arrests are due to non-VF/VT rhythms

Scary Statistics

Why do CPR?


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80% of patients who had a cardiac arrest had abnormal

vitals for up to 8 hours prior to arrest

Only 44% of patients urgently admitted to ICU beforecardiac arrest die before discharge

Why do CPR?

Even Scarier Statistics


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Prevent Cardiac Arrest Ratherthan Treating it!

Very Important!!


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What are the danger signs of a possible

cardiac arrest?

Threatened airway

Respiratory rate 30

Heart rate 140

SBP


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And the Patient arrests.

I am alone!What now?


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Basic Life Support Principels

Step 1

Check responsiveness

Check for absent/abnormal breathing

Step 2

Get Help!!

Send for AED/Defib

Step 3

Check the carotid pulse for 5-10 seconds

If no pulse (or unsure of pulse) = start chest compressions

If pulse present = Give rescue breaths at 1 breath every 5-6 seconds and check pulse every2 minutes

Step 4

Shock if needed

Follow each shock immediately with CPR, beginning with compressions

Check pulse and rhythm after 2 minutes


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Step 1:

Check responsiveness

Are you all right

At the same time check for absent/abnormal

breathing scan the chest for movement for 5-10 seconds


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Step 2:

Get help

code blue team

Send for AED/Defib


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Step 3:

Check the carotid pulse for 5-10 seconds

If no pulse (or unsure of pulse) = start chest compressions

Compress the lower half of the sternum at a rate of 100/min at adepth of at least 5cm

Allow complete chest recoil after each compression Minimize interruptions in compressions (10 seconds or less)

Switch compression providers every 2 minutes

Give breaths at a rate of 2 breaths for every 30 compressions if noadvanced airway is in place or at a rate of 1 breath every 5-6

seconds (8-10 breaths per minute) if advanced airway is in place AVOID EXCESSIVE VENTILATION!

If pulse present = Give rescue breaths at 1 breath every 5-6seconds and check pulse every 2 minutes


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Step 4:

- No pulse = check for shockable rhythm with

an AED or Defib as soon as it arrives

- Shock as indicated

- Follow each shock immediately with CPR,

beginning with compressions

- Check pulse and rhythm after 2 minutes


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Th

e

BLS

survey


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Important Points

Compressions Must be Started First!

PUSH HARD AND PUSH FAST, ALLOW FULL CHEST RECOIL

Defibrillation (if indicated) must be done ASAP!

Avoid interruption of chest compressions Work in 2 minute cycles

If in doubt = COMPRESSIONS!!!

BLS = CAB AND NOT ABC


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I have started CPR, the Defib and help

has arrived.

The patient still has no pulse!!

What next?


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Advanced Cardiac Life Support

The Team


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Airway

Breathing

Circulation Differential diagnosis


The universal ABCDs


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A = Airway

Is the airwaypatent?

Maintain airway patency in theunconscious patient

Is an advancedairway

indicated?Use advanced airway if needed

Placement of an advanced airwaydevice can be deferred till later if bag-

mask ventilation is adequate

Is properplacement of

airway deviceconfirmed?

Confirm placement of airway

- Secure the airway

-Monitor airway placement withcontinuous quantitative waveform

capnography

Is the tubesecured andplacement

reconfirmed?


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Assess

Is the airway patent?

Is an advanced airway

indicated? Is proper placement of the

airway device confirmed?

Is the tube secured and

placement reconfirmed?

Action

Maintain airway patency inunconscious patients

Head tilt-chin lift/jaw thrust

OPA

NPA

Use advanced airway ifneeded

ET-tube

Laryngeal mask

Laryngeal tube

Esophageal-tracheal tube


A = Airway


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Assess Action If bag-mask ventilation is

adequate then the

placement of an advanced

airway device can bedeferred till ROSC or till

initial CPR and defibrillation

attempts fail. Placement

must be weighed against

the adverse effects of

interrupting compressions


A = Airway


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Assess Action Confirm proper integration

of CPR and ventilation

Confirm placement of

advanced airway Secure the device to

prevent dislodgment

Monitor airway placement

with continuousquantitative waveform

capnography


A = Airway


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PETCO2

A-line

PETCO2

A-line

Example ofGood CPR

Example of

Poor CPR

Advanced

Ca

rdiacLife

Support

A=

Airway


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B = Breathing

Are ventilation andoxygenation adequate? Give supplemental oxygen when indicated

Are quantitativewaveform capnography

and oxyheamoglobinsaturation monitored?

- Monitor adequacy of ventilation and oxygenation

- Avoid excessive ventilation


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Asses

Are ventilation and

oxygenation adequate?

Are quantitative waveformcapnography and

oxyheamoglobin saturation

monitored?

Action

Give supplementary oxygenwhen indicated Cardiac arrest = 100% O2

Other = titrate O2 delivery toachieve SATS >94%

Monitor adequacy ofventilation and oxygenation Clinical = chest rise and

cyanosis

Quantitative waveformcapnography

Pulse oxymetry

Avoid excessive ventilation


B = Breathing


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C = Circulation

Are chestcompressions

adequate?Monitor CPR quality

What is the

cardiacrhythm?

Attach defib/monitor and check rhythm

Is cardioversionor defibrillation

indicated?Provide defibrillation/ cardioversion

Obtain IV/IO accessHas IV/IO

access beenestablished?

Is ROSCpresent?


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C = Circulation (continued)

Is the patientwith a pulse

stable?

Are medicationsneeded for

rhythm or bloodpressure?

Give fluids if needed

Does the patient

needvolume(=fluid)

forresuscitation?

Give appropriate drugs


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Assess

Are chest compressions effective?

What is the cardiac rhythm?

Is cardioversion or defibrillation

indicated? Has IV/IO access been

established?

Is ROSC present?

Is the patient with a pulse stable?

Are medications needed forrhythm or blood pressure?

Does the patient needvolume(=fluid) for resuscitation?

Action Monitor CPR quality

Quantitative waveform capnography (aimfor Petco2>10mmHg)

Intra-arterial pressure (aim fordiastole>20mmHg)

Feel for central pulse wave duringcompressions

Attach monitor/defib for arrhythmias orcardiac arrest rhythms VF/pulseless VT

Asystole/PEA

Provide defibrillation/cardioversion

Obtain IV/IO access Give appropriate drugs

Give IV/IO fluids if needed


C = Circulation


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D = Differential Diagnosis

Why did the patient arrestand is there a reversible

cause?

Search for and treat reversiblecauses

(Hs and Ts)

Hypovolemia

Hypoxia

Hydrogen ion (acidosis)Hypo-/Hyperkalemia

Hypothermia

Tension pneumothorax

Tamponade, cardiac

ToxinsThrombosis, pulmonary

Thrombosis, coronary


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Assess

Why did the patient arrest?

Is there a reversible cause

that can be treated?

Action

Search for and treat reversiblecause (=definitive care)

Hypovolemia

Hypoxia Hydrogen ion (acidosis)

Hypo-/Hyperkalemia

Hypothermia

Tension pneumothorax

Tamponade, cardiac Toxins

Thrombosis, pulmonary

Thrombosis, coronary


D = Differential Diagnosis


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Cardiac ArrestRhythms

Shockable

VF Pulseless VT

Unshockable

Asystole PEA


Cardiac arrest rhythms


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VF


Shockable Rhythms


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Pulseless VT


Shockable Rhythms


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Unshockable Rhythms

PEA Asystole


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But what if the patient is unstable but

still has a pulse?


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Dysrhythmia with pulses

Get helpand the

DefibABCDEs

AIRWAY

Open andmaintain

BREATHING

Give02/Ventilate if needed

CIRCULATION

Checkpulse, BP

andperfusion

Attachmonitors

DRIP and

DIFFERENTIALDIAGNOSIS

Obtain IVaccess

Treatunderlying

causes

ECG

Get rhythmstrip/12-lead

ECG

Are theresigns of

instability?

What is thepulse rate?


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Dysrhythmia with pulses

What is thepulse rate?

Fast(>150/min)

ECG Rhythm?

NarrowQRS-complex

BroadQRS-complex

Normal(50-150/min)

ABCDEs

Slow(


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Tachycardia with pulses

Fast pulse(>150/min)

Narrow QRS-complex?

Stable? Unstable?

Wide QRS-complex?

Unstable? Stable?

Synchronizedcardioversion

Adenosine orAmiodarone

Vagalstimulation

Adenosine

Amiodarone


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Bradycardia with pulses

Slow pulse(


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Everything went well and the patienthas ROSC. What now?


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Drugs

Adrenaline

Atropine

Amiodarone

Adenosine

MgSO4

Bicarb

Ca-chloride/gluconate

Lignocaine

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