Pneumology - Ventilation perfusion-ratio-and-clinical-importance
What is the ideal chest compression:ventilation ratio? Ventilation : Perfusion Match Good CPR ~1/4 -...
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What is the ideal chest compression:ventilation ratio? Ventilation : Perfusion Match• Good CPR ~1/4 - 1/3 of normal
cardiac output• alveolar ventilation ~1/4 - 1/3 of
normal• Additional breaths
– “dead space” ventilation– Increase IT pressure
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CPR ratios
Babbs, Resuscitation 2004;61
Mathematical model
Lay rescuers - adultvictims
50:2 “best”
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1
Guidelines 2005- Ventilation
• Compression/Ventilation Ration 30:2• Deliver each rescue breath over 1 second• Give enough volume to produce visible chest rise• Avoid rapid and forceful breaths• Advanced Airway- give 1 breath every 6-8 seconds
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Chest Compressions Only Continuous chest compression (CCPR)
Shock First or CPR First
• Emphasis
effective chest compression defibrillation
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Survival From Simulated CPR Survival From Simulated CPR
Ewy et al: Circulation 2005;111:2134-42Ewy et al: Circulation 2005;111:2134-42
00
4040
8080
24 h
r C
NS
NO
RM
24 h
r C
NS
NO
RM
CC Only IDEAL CPR NO CPR
73% 70%
7%
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Wik, L. et al. JAMA 2003;289:1389-1395.
Probability of Survival to Hospital Discharge
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0
10
20
30
40
50
60
ROSC Hosp DC 1 YR
Defib
CPR
Defibrillation or CPR First
Wik, JAMA 2004
%
surv
ival
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Phases of VF Cardiac Arrest
Metabolic PhaseMetabolic PhaseGLOBAL ISCHEMIA-INJURYGLOBAL ISCHEMIA-INJURY
Electrical PhaseMINIMAL ISCHEMIA
Hemodynamic PhaseLOCAL ISCHEMIA
RIGHT HEART V-P
JAMA 2002;288:3035
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Phases of VF Cardiac Arrest
Metabolic PhaseMetabolic PhaseNOVEL THERAPIES NEEDEDNOVEL THERAPIES NEEDED
Electrical PhaseEARLY DEFIBRILLATION CRITICAL
Hemodynamic PhaseCORONARY-CEREBRAL PERFUSION PRESSURE
CRITICAL
JAMA 2002;288:3035
DEFIBRILLATION
4MINS
CHEST COMPRESSIONHDE
4-10MINS
HYPOTHEMRIACONTROLLED REPERFUSION
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Guidelines 2005- CPR before Defibrillation
• Immediate defibrillation is the treatment of choice for VF of short duration
• OOH unwitnessed (EMS) VF, may give period CPR before rhythm check
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• Emphasis
effective chest compression defibrillation
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Single or Stacked Shocks
Pulse Check
Rhythm Check
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Single shock
Followed by immediate CPR
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Major Recommendations
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1st Shock delivered
22 seconds after pads placed
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RE-VF 25 seconds after the 1st shock
(No Chest Compressions yet)
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2nd Shock delivered 34 sec after re-VF
(Still No Chest Compressions)
CPR finally begun after 1 min 17 sec from 1st shock
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N Waveform Energy
1st 2nd 3rd
54 BTE
150, 150,15096% 96% 98%
48 MTE
200, 200, 36054% 60% 67%
13 MDS
200, 200, 36077% 77% 77%
Monophasic vs Biphasic WaveformShock Efficacy VF
No waveform consistently related to ROSC or Hospital Discharge
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Defibrillation Success Out-of-Hospital Cardiac Arrest
First Shock Results (N=21/61)
Remained in VF- 19% Shocked into Non-VF 81%Perfusing rhythm 0%
Kern Circulation 2002
@TIME RESUME CPR – 45 SECONDS
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Prompt CPR after AED
0
10
20
30
40
50
60
ROSC 48-Hour Good Neuro
STD AED Prompt CC
Per
cent
‘p’ <0.05
3/18
3/18 3/18
10/189/18 9/18
Kern
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Will CPR Do Harm Post-Shock
• Most ‘post-shock” PEA is “pseudo-PEA” -some pressure generated (~10/5 or 20/10 mmHg) -undetectable as a palpable pulse (Aufderheide/Monday)
• Chest Compressions during post-shock organized rhythms does not precipitate re-VF (Hess & White)
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Guidelines 2005- CPR after Defibrillation
• Resume CPR immediately following shock (and while charging)
• No pulse or rhythm check for 5 cycles CPR (@ 2 minutes)
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• Emphasis advanced airway
• Recommendation Intraosseous access
Emphasis ET
drug administration
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ACLSMajor Recommendations
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ACLS PRIORITIES2 MINUTE CYCLES- TEAM DYNAMICS
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ECC – New Course Emphasis
• Team Dynamics and Leadership
• Outcome is determined by success of team and not the individual
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• Amiodarone – Lidocaine
either
• Epinephrine- Vasopressin
ET discouraged
• Atropine 0.5 mg - ACS
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ACLSMajor Recommendations
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Summary ACLS• Emphasis on High-Quality CPR• Simplified Algorithms
– Recommend expert consultation
• Use IV / IO Access– limit ET administration
• Limit, defer Advanced Airway Use – Especially endotracheal tube
• Primary confirmation of ET- dual method
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Key studies- AmiodaroneKey studies- Amiodarone
ARREST TRIAL Kudenchuck 1999ARREST TRIAL Kudenchuck 1999Patient Patient groupgroup
nn Survival to Survival to admissionadmission
Odds ratio for Odds ratio for admissionadmission
Survival to Survival to dischargedischarge
AmiodaroneAmiodarone 246246 44 %44 % 1.61.6 13.4 %13.4 %
PlaceboPlacebo 258258 34 %34 %
(p = 0.03)(p = 0.03) (p = 0.02)(p = 0.02)
13.2 %13.2 %
(p = ns.)(p = ns.)
amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)
Patient groupPatient group nn Survival to Survival to admissionadmission
Survival to Survival to dischargedischarge
AmiodaroneAmiodarone 180180 22.8 %22.8 % 5 %5 %
LidocaineLidocaine 167167 12.0 % 12.0 %
(p = 0.009)(p = 0.009)
3 %3 %
(p = 0.34)(p = 0.34)
ALIVE TRIAL Dorian 2002ALIVE TRIAL Dorian 2002
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Lindner 1997Lindner 1997
GroupGroup nn ROSCROSC Survival Survival
admissionadmissionSurvivalSurvival
≥ ≥ 24 h24 hSurvivalSurvival
dischargedischarge
VasopressinVasopressin 2020 80 %80 % 70 %70 % 60 %60 % 40 %40 %
EpinephrineEpinephrine 2020 55 %55 %(p = 0.18)(p = 0.18)
35 %35 %(p = 0.06)(p = 0.06)
20 %20 %(p = 0.02)(p = 0.02)
15 %15 %(p = 0.16)(p = 0.16)
Vasopressin-Epinephrine
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Vasopressin-EpinephrinePatient groupPatient group
(all rhythms)(all rhythms)
nn Survival to 1 Survival to 1 hourhour
Survival to Survival to dischargedischarge
VasopressinVasopressin 104104 39 %39 % 12 %12 %
EpinephrineEpinephrine 9696 35 %35 %(p = 0.66)(p = 0.66)
14 %14 %(p = 0.67)(p = 0.67)
PEAPEA
n = 95n = 95
Survival Survival
to 1 hourto 1 hour
Survival Survival
dischargedischarge
VasopressinVasopressin 33 %33 % 9 %9 %
EpinephrineEpinephrine 29 %29 % 10 %10 %
Stiell 2001
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Stiell 2001Stiell 2001
VF/VTVF/VT
(n = 42)(n = 42)
Survival Survival
1 hour1 hour
SurvivalSurvival
dischargedischarge
VasopressinVasopressin 54 %54 % 25 %25 %
EpinephrineEpinephrine 61 %61 % 33 %33 %
Wenzel 2004Wenzel 2004
VF/VTVF/VT
(n = 188)(n = 188)
ROSCROSC Survival Survival admissionadmission
Survival Survival dischargedischarge
VasopressinVasopressin 36.8 %36.8 % 46.2 %46.2 % 17.8 %17.8 %
EpinephrineEpinephrine 42.6 %42.6 %(p = 0.20)(p = 0.20)
43.0 %43.0 %(p = 0.48)(p = 0.48)
19.2 %19.2 %(p = 0.70)(p = 0.70)
Vasopressin-Epinephrine
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Patient group Patient group (all rhythms)(all rhythms)
nn ROSCROSC Survival Survival admissionadmission
Survival Survival dischargedischarge
VasopressinVasopressin 589589 24.6 %24.6 % 36.3 %36.3 % 9.9 %9.9 %
EpinephrineEpinephrine 597597 28.0 %28.0 %(p = 0.19)(p = 0.19)
31.2 %31.2 %(p = 0.06)(p = 0.06)
9.9 %9.9 %(p = 0.99)(p = 0.99)
Subgroup Subgroup
with PEAwith PEA
n = 186n = 186
N=18N=1866
ROSCROSC Survival Survival admissionadmission
Survival Survival dischargedischarge
VasopressinVasopressin 104104 20.2 %20.2 % 33.7 %33.7 % 5.9 %5.9 %
EpinephrineEpinephrine 8282 20.7 %20.7 %(p = 0.93)(p = 0.93)
30.5 %30.5 %(p = 0.65)(p = 0.65)
8.6 %8.6 %(p = 0.47)(p = 0.47)
Vasopressin-Epinephrine
Wenzel 2004
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Summary BLS HCP
• Lone HCP- Tailor Sequence Actions
• Check for Adequate Breathing
• Open airway in trauma patients
• Avoid Excessive Ventilation (too fast, too much)– 1 breath Q 8-10secs
• 30:2 compression ventilation ratio
• Continuous CPR with advanced airway
• Rescuers rotate every two seconds
• Push hard, push fast, allow full chest recoil
• Pulse check >5 10 seconds
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