Lecture 1 Cardio-pulmonary Resusictation

8/14/2019 Lecture 1 Cardio-pulmonary Resusictation

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CARDIO-PULMONARYRESUSCITATION


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2005 AHAGuidelines

for Cardiopulmonary Resuscitationand Emergency Cardiac Care

2005 International Consensus Conference on Cardio- Pulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommandations

andILCOR (International Liaison Committee on Resuscitation)2005 CPR Consensus.

These recommendations replace or complete the 2000 CPR guidelines.

published inCirculation - December 2005


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Gra de 1 Ra ndomized clinica l studies or metaa na lysises with significa ntthera peutic effects

Grade 2 Clinic

al studies with less signific

ant the

rapeutic effects

Gra de 3 Pr ospective contr olled nonra ndomized studies or ca se se r iesGra de 4 Retr ospective nonra ndomized studiesGra de 5 Uncontr olled ca se se r ies

Gra de 6 Exper imenta l a nima l or mecha nica l studiesGra de 7 Theor etica l a na lysisGra de 8 Ra tiona le a nd common pra ctice without evidence ba se

G rading of evidence


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H ierarchy of recommendations depends uponrisk/benefice ratio.

Cla ss Risk/beneficera tio.I benefice>>>r iskIIa benefice>>r isk

IIb benefice >/=r iskIII r isk >/= benefice


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CARDIO-PULMONARY RESUSCITATION

DEFINITIONSRespiratory arrest= the absence of breathing movements.Cardiac arrest= the clinical picture of overall cessation of circulation.Clinical death= coma, apnea and pulselessness in large arteries with cerebral failure still potentially reversible.Biological death= the irreversible absence of body functions due to irreversible structural cell damage.Cerebral death= the irreversible absence of brain and brainstem functions withtemporary presence of respiration and circulation.Persistent vegetative state= absence of motility and reaction to external stimulidue to persistent absence of cerebral activity with preservation of vegetative

functions (respiration, circulation, swallowing).


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CARDIO-PULMONARY ARREST Physiopa thology

respiratory arrest ? / cardiac arrest ?

There are semnificative differences, related to age, in the incidence of primary respiratory arrest (more frequent in newborns and children) and primary cardiac arrest (more frequent in adults and old persons)

There are semnificative differences of BLS in primary respiratory arrestand primary cardiac arrest.

understanding physiopathologyof cardio-pulmonary arrest correct CPR

efficient CPR ma neuver s


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RESPIRATORY ARREST Pathophysiology

Heart and lungs continue the tissue delivery of oxygenated blood until exhaution of alveolar O 2 reserves; pulse is present, altered consciousness;

Delay to cardio-circulatory arrest: variable (seconds-minutes); it depends on:Oxygen reserve in the moment of respiratory arrest (PAO2 i PaO2)Miocardial capacity to sustain hypoxemia

Uncorrected respiratory arrest results in cardiac arrest;

Causes Drowning,, foreign body aspiration, toxic inhalation, epiglotitis, strangulation, etc. Coma of any origin, stroke, etc. Electrocution, trauma, etc.Clinical signs Absence of breathing movements Progressive cyanosis Alterations of consciousness Muscle hypotonyTreatment Artificial ventilation in order to oxygenate the blood and to prevent

secondary cardiac arrest


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CARDIAC ARREST Pathophysiology

Cardiac arrest results in circulatory arrest with the immediate cessation of tissue O 2 delivery; Cessation of brain O 2 delivery:

Depletion of O 2 reserves in 10 seconds Depletion of phosphocreatine reserves in 2 minutes Depletion of glucose and ATP reserves in 5 minutes

For a short time delay ( a lways seconds): agonal respiration (Gasping) (unefficient respiratory efforts withrecruitment of accessory respiratory muscles);

Always cardiac arrest result in respiratory arrest;Causes Myocardial infarction Rhythm disturbances (myocardial infarction, myocardial ischemia electrolyte disturbances,etc.) Hypovolemia (exsanguination, politrauma) Pulmonary embolism Cardiac tamponade

Clinical signs Loss of conscience (10 seconds; izoelectric EEg in 15-30 seconds); Agonic respirations or apneea (10-15 seconds) Pulseless

Midriasis (30-60 secunde) General aspect of death ECG signs

Ventricular fibrillation Pulseless ventricular tachycardia pulseless electrical activitity Asystole

Treatment

Artificial support of ventilation and circulation


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INDICATIONS of CPR:

Respiratory arrestCardiac arrestCardio-respiratory arrest

Primary/secondary - respiratory/cardiac arrest


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DEFINITION= system of standard maneuvers, drugs and techniques indicated in case of cardio-respiratoryarrest in order to artificially deliver the oxygenated blood to systemic circulatory beds at rates that are

sufficient to preserve the vital organ function and at the same time providing the physiologic substrate for the return of spontaneous circulation.


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FACTORS WHICH INFLUENCE THE RESULT OF RESUSCITATION:

Patient related factors:

The cause of cardio-respiratory arrest The functional status in the moment of cardio-respiratoryarrest Co-existing diseases

Resuscitator related factors: Precocity of CPRCorrectness of CPR


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CHAIN OF SURVIVAL

B LS in


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The most important determinant of survival from suddencardiac arrest is the presence of a trained rescuer who isready, willing, able, and equipped to act.

(2005 AHA G uidelines for CPR a nd ECC, Circulation, 2005)

In the 1990s some predicted that cardio-pulmonaryresuscitation (CPR) could be rendered obsolete by thewidespread development of community automated external defibrillator (AED) programs. Cobb noted, however, as moreSeatle first responders were equipped with AEDs, survival rates from sudden cardiac arrest fell. He atributted thisdecline to reduces emphasis on CPR....

(2005 AHA G uidelines for CPR a nd ECC, Circulation, 2005)


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W hat means a successful cardio-pulmonary resuscitation?

Signs of successful CPR: return of spontaneous circulation hospital admission neurologic improvement hospital discharge


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CARDIO-PULMONARY RESUSCITATIONPhases of CPR:

Basic life support First phase of CPR; Goals:

Artificial delivery of oxygenated blood to systemic circulatory beds;Prevention of irreversible brain damage;

Preservation of chances for successful resuscitation;Return of spontaneous circulation; Provided without medical equipment (with bare hands);

Advanced life support The second/first phase of CPR; Goals:

Preservation of vital organ function;Return of spontaneous circulation;Postresuscitation stabilization;Cerebral protection;

Provided using equipment, drugs and medical devices.


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THE ARMAMENTARIUM of CPR A (airway) airway maneuversB (breathing) evaluation and support of ventilation

C (circulation) evaluation and support of circulation D (drugs) - IV access and medication E (electrocardiography) - evaluation of electrical form of cardiac arre F (fibrillation treatment) - defibrillation

G (gauging) postresuscitation evaluation H (human mentation) cerebral protection I (intensive care) postresuscitation intensive care

THIS IS NOT THE PROPER ORDER TO APPLY


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P rimary steps of basic life support

Securing the inviroment Evaluation of consciousness Activation of emergency medical system (call 112)

Victim positioning Airway maneuvers Assessment of spontaneous breathing (10 seconds) Artificial ventilation (2 ventilation) Assessment of circulation (10 seconds) Chest compresion (100/minute) CPR sequence: 30 chest compressions /2 artificial breath Automatic external Defibrillation


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CPR r ecomenda tions200 6 2 esentia l a spects for the success of CPR:Av oid hiper v entilation for a pulmonary gas exchange (pulmonary blood flow decreased) encrease the intrathoracic pressure decrease the cardiac upload decrease the efficience of chest compresions stomach insuflation (encrease the risk of regurgitation/aspiration, push up t

diaphragm and encrease the intrathoracic pressure)

Av oid interupting the chest compresions CPR performed by trainned medical team total time of interupting chestcompresions 24-49% of the cardiac arrest duration.

Any interuption in chest compresions means the decrease of coronary perfusion pressure, which slowly rises when the chest compresions aredelivered once again, and so the chances of returning to spontaneouscirculation are decreased.

In the first minutes of cardiac arrest (VF) the artificial ventilation is not soimportant as the chest compresions because the hipoxy is primary caused bthe lack of tissulary perfussion, and there are sufficiently blood O2 rezervein the first minutes. That is why the rescue person should concentrate indelivering efficient chest compresions. The new recommendations regardinthe sequence chest compresions/ventilation 30:2 are made to minimalise thtime of chest compresion interuptions.


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The a ge

newborn immedia telya fter bir th a nd untilhospita l dischar ge.inf a nt untill thea ge of 1 year .child f r om 1 year until puber ty (12-14 year s).adult f r om puber ty a long


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A AIRWAY MANEUVERS: Should be applyied in case of any unconscious victim; Should preceed assessment of spontaneous breathing; Should be maintained during assessment of spontaneous breathing; Should preceed artificial ventilation; Should be maintained during artificial ventilation;


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A AIRWAY MANEUVERS:DURING BASIC LIFE SUPPORT:

Safety position Head tilt Chin lift Head tilt and chin lift Subluxa ia anterioar a mandibulei Subluxa ia anterioar a mandibulei i deschiderea gurii Hiperextensia capului, subluxa ia anterioar a mandibulei i deschiderea gurii (tripla

manevr Safar); ndep rtarea corpilor str ini solizi (deget crlig) sau lichizi (pozi ie lateral a capului i

deget nf urat n pnz )DURING ADVANCED LIFE SUPPORT:

Airway devices Tracheal intubation


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A AIRWAY MANEUVERS:in pacient with posible cervical spine injury

When to suspect cervical spine injury?

Know the mechanism of injury Strangulation C dere de la n l ime Deceleration or acceleration s.o.

Traumaticsigns At the cephalic extremity In the cervical region In the region of thorax (the superior 1/3) So, superior to the intermamelonary line

Mentain the had in neutral position


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AIRWAY MANEUVERS:

Clinical signs of proper tracheal intubation visualising the endotrachel tube passing through vocalcords

simetrical thoracic expansions equal respiratory sounds on bouth lungs water vapors on the inside surface of the endotracheal tube the abscence of aeric sounds in epigastric region


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CARDIO-PULMONARY RESUSCITATIONB EVALUATION AND SUPPORT OF VENTILATION:

Assessment of spontaneous breathing maintaining MECA lisen, feel and see

Artificiale ventilation n SVB

Artificial ventilation mouth-to-mouth

Artificial ventilation mouth-to-noseArtificial ventilation mouth-to-tracheostomaeArtificial ventilation mouth-to-mouth and noseThe exhalated air containe 16-18% O2Evaluation of the efficience of artificial ventilation: chest movements

n SVAMask and Rueben baloon

Trachel tube and Rueben baloonTrachel tube and ventilatory deviceMechanical ventilation:

IPPV (intermitent positive pressure ventilation) Current volume 8ml/kg Frequence: 14-16/min FiO2 1 (O2 100%) PEEP (positive end expiratory pressure) 0


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Ar tificia l ventila tion

CHARACTERISTICS OF MOUTH-TO-MOUTH VENTILATION The rescue person take a normal inspiratory Insuflation - 1 second Current volume 500-600ml

Chest rise Frecquence 10-12/minute


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VENTILA IA ARTIFICIAL

CHARACTERISTICS OF MECHANICAL

VENTILATION IN SVA IN ADULT Current volume 6-8ml/kg Frecquence 8-10/minute Oxigen 100% No PEEP No interuptions of chest compressions for

ventilation


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CARDIO-PULMONARY RESUSCITATIONC CIRCULLATORY EVALUATION AND SUPPORT:ASSESSMENT of CIRCULATION

Always in the large arteries Adult: carotid or femoral artery; infant: brachial artery;

CHEST COMPRESSION It is performed during BLS and ALS Best achievable results: 25-30% of spontaneous cardiac output Chest compression technique:

Victim positionRescuer positionTechniqueParameters: depth, frequency/min, compression/decompression ratio

Mechanisms of cardiac output during chest compression:Cardiac pump theoryThoracic pump theory

Evaluation of chest compression efficency: pulse assessmente during CPR Options to increase the efficency of chest compression:Maximal values of recommended depth and frequency

Concomitantly performed chest compression and artificial ventilationInterposed abdominal compressionKower limb elevation at 60 (not in case of ongoing bleeding or trauma)Active compression/decompression deviceInternal cardiac massage (only during ALS)Extracorporeal circulation


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CHEST COMPRESSIONS

push hard, push fast, allow full chest recoil after each compression, and minimize

interruptions in chest compression


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CHEST COMPRESSIONS

T he indication for chest compresions is theabsence of pulse in large arteries .

T here are no contraindications for chest

compressions.


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CHEST COMPRESSIONS

ADULT

Depth of sternal compression 4-6 cmFrecquence of compressions 100/minuteDuration of compression/Duration of decompressionequal

Full chest recoil after each compressionRithmic compresionsAvoid interupting chest compressions


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CHEST COMPRESSIONS complica tions

Fra ctur es Ribs f ra ctur esSter na l f ra ctur es

Pa thology of these r osa s

Pneumothora x Hemothora xHemoper icar diumHemoper itoneum

Viscera l injur ies Pulmonar y r uptur eHepa tic r uptur eSplenic r uptur eGa str ic r uptur e

Other complica tions Aspira tion of ga str ic content


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ALTERNATIVE TECHNIQUES OF CARDIAC MASSAG E

High frecquence chest compressionsInterpose abdominal compressionInternal cardiac massageCPR through coughing


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MECHANICAL DEVICES FOR CARDIOCIRCULATORY SUPPORT

Active compression-decompresion deviceResistance-level valve deviceMechanical Piston deviceCPR vest

Fazic toraco-abdominal compression-decompressionmanual deviceExtracorporeale circulation


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CARDIO-PULMONARY RESUSCITATIONC MEDICATION:

Routes for drug administration Peripheral intravenous access standard route Central intravenous access Intratracheal administration Intraosseous administration Intracardiac administration

Drugs: Oxygen Epinephrine Atropine Lidocaine Vasopresine Sodium bicarbonate Amiodarone Procainamide Magnesium sulphate Dopamine Volume solutions


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ACCESUL INTRAOSOS

Este a doua op iune de acces venos n RCR.Ofer acces la un plex venos necolababil, deci, administrareadrogurilor este similar administr rii venos centrale.Exist truse dedicate cu toate materialele necesare.Doza medicamentelor n administrarea intraosoas este aceia ica n administrarea intravenoas .

La bolnavul hipovolemic cu acces venos periferic imposibilaccesul intraosos ofer o bun alternativ de refacere avolemiei.


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CENTRAL VENOUS ACCEESS

Adva nta ges Disa va nta ges

Shor t time of dr ug cir cula tionSa fe a nd longla stinga ccessHiper tonic solutions/ca thecola mines

Temporar y inter uption of car dia cma ss a geLong time for insta la tion

Vita l complica tions possible


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ENDOTRACHEAL DRUG ADMINISTRATION IN CPR

through trachel tube2-2,5x of intravenous dosediluted in NaCl 0,9% 5-10 ml

5 vigurous ventilations


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E ELECTROCARDIOGRAPHY: E lectrical forms of cardiac arrest

Ventricular fibrillation

Pulseless ventricular tachycardia Pulseless electrical activity

E lectromechanical dissociation Pseudo E lectromechanical dissociation Idio-ventricular rhythm

E scape rhythm Bradiasystole Asystole

Identification of the eletrical form of cardiac arrest allowsthe choise of the proper CPR algorhythm


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RESUSCITAREA CARDIO-RESPIRATORIEF DEFIBRILAREA:

Defibr ilar ea este un ter men utiliza t pentr u a desemna livrar ea nesincr oniza t cu complexul QRS a unui ocelectr ic.

ocul elect r ic induce odepolar izar e sincr on ur ma t der epolar izar e sincr on a tutur or fibr elor miocar dice.Deci, dup ocul elect r ic toa te fibr ele miocar dicea jung la un numitor comun: z ero electric . Acest

fenomen per mite intrar ea n func iea centr ului car dia ccu func ie sponta n de p a cema ker , car e va pr elua contr olula ctivit ii electr ice i meca nice a inimii.


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CARDIO-PULMONARY RESUSCITATIONF DEFIBRILLATION:

Goal Defibrillation technique:

Patient positionRescuer position

Paddles preparation and positionClear order EnergyChecking for efficiency

Indications Differences cardioversion/defibrillation:Synchronic/asynchronic shock PreparationsEnergyIndications


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DEFIBRILAREA

TEHNICA DEFIBRIL RII: Pozi ia pacientului Pozi ia resuscitatorului Preg tirea i pozi ionarea padelelor Aten ionarea Energia utilizat Verificarea eficien ei


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ENERG IA UTILIZAT N DEFIBRILARE

curent monofazic ini ial 360 J i continu cuaceia i energie la urm toarele ocuri.

curent bifazic - ini ial o energie de 200 J, apoienergii crescnde de 300 J i 360 J.n fibrila ia ventricular /tahicardia ventricularf r puls recurent - energia utilizat pentruurm torul oc va fi energia care a convertitritmul.


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OCUL ELECTRIC EXTERN

Termenul decardioversie este utilizat pentrulivrarea sincronizat cu complexul QRS a unuioc electric. Sincronizarea evit livrareaocului n perioada refractar relativ a cicluluicardiac, perioad n care ocul electric poate

induce fibrila ie ventricular .Termenul dedefibrilare este utilizat pentrulivrarea nesincronizat cu complexul QRS aunui oc electric.


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CARDIOVERSIA

PREG TIRI PENTRU CARDIOVERSIEBolnavul trebuie s aib monitorizare ECG i monitorizarea

noninvaziv a TA.Se instituie oxigenoterapia.Se instituie un acces venos.Instrumentarul, materialele i drogurile de resuscitare trebuie

s fie preg tite.Se practic analgezie i sedare.


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CARACTERISTICI COMPARATIVE ALE CARDIOVERSIEI I DEFIBRIL RII

PARAMETRU CARDIOVERSIE DEFIBRILARE

Ener gia ini ia l 50 -100 J 200 JSincr onizar ea cu complexulQRS

DA NU

Indica ii TPSV Flutter a tr ia l par oxisticFibr ila ia a tr ia l p ar oxisticTa hicar dia ventr icular cu puls

Fibr ila ia ventr icular

Ta hicar dia ventr icular f r pulsTa hicar dia ventr icular polimor f cu puls


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STATUSUL POSTRESUSCITARE

dup reluarea circula iei spontane

perioad de mari dezechilibre homeostaticegenerate de: leziunile hipoxice

leziuni ischemice leziuni de reperfuzie.


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FIZIOPATOLOG IA STATUSULUI POSTRESUSCITARE

Hemodina mic Disfunc ie miocar dic(pr in ischemia miocar dic globa l i defib r ilar e)

Sindr om de debit car dic sc zutCr e te r e tra nzitor ie a enzimelor miocar diceInsta bilita te hemodina micTulbur r i de r itm

Neur ologic ComIni ia l hiper emie cer ebra l , a poi r educer ea fluxului sa nguin cer ebra le(chiar la va lor i nor ma le a le TAmedii)Hiper temie de or igine centra l

Convulsii

Respira tor Disfunc ie ventila tor ieTulbur r i de oxigenar e sa nguin

Meta bolic Acidoz meta bolicHiper glicemie


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STATUSUL POSTRESUSCITARE

Tulbur r ile pot fi:modeste i cu tendin p r ogr esiv sp r e r ezolu iesever e i pe r sistente

coma persistenthipertermia centralcon v ulsiilesindromul de disfunc ie multipl de organe

f r ecvente la 48-72 or e postr esuscitar epr ognostic nef a vora bil

Lecture 1 Cardio-pulmonary Resusictation

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