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Cardio-Pulmonary Cerebral Resuscitation

Cardio-Pulmonary Cerebral Resuscitation. Introduction. Mouth to Mouth Breathing (1744) Jaw Thrust (1378, 1958) External Cardiac Compression (1892, 1960) IPPV + ECC (1961) Defibrillation (1956). Diagnosis of Cardiac Arrest.

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Cardio-Pulmonary Cerebral Resuscitation

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  1. Cardio-Pulmonary Cerebral Resuscitation

  2. Introduction • Mouth to Mouth Breathing (1744) • Jaw Thrust (1378, 1958) • External Cardiac Compression (1892, 1960) • IPPV + ECC (1961) • Defibrillation (1956)

  3. 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

  4. 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

  5. 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

  6. Chest Compression • During CPR, Cardiac Output 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

  7. Chest Compression • Rescuer fatigue – relieve every 2 minutes • Once advanced airway is placed provide 8-10breaths/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

  8. 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.

  9. 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])

  10. 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.

  11. 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.

  12. Interruptions of Chest Compression • < 10 secs • Rhythm recognition • ET intubation • Defibrillation • Fatigue

  13. 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

  14. Electrical therapies • Patients with VF or pulseless VT should receive chest compressions until a defibrillator is ready. Defibrillation should then be performed immediately. • Chest compressions for 1.5-3 minutes before defibrillation in patients with cardiac arrest longer than 4-5 minutes have been recommended in the past, but recent data have not demonstrated improvements in outcome.

  15. 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

  16. 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

  17. A – Airway (BLS) • Clear Airway • Head tilt, Chin lift • Head tilt, neck lift • Head tilt, Jaw thrust • Oropharyngeal/Nasopharyngeal airway • Endotracheal tube

  18. Assess Airway Elevate Mandible Elevate Mandible & Open Mouth

  19. Oral Airway

  20. 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)

  21. 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

  22. Persons who can intubate

  23. 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

  24. 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

  25. In-line Immobilization

  26. 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.

  27. 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

  28. Adult Basic Cardiac Life Support

  29. 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

  30. 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.

  31. 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

  32. 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

  33. 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

  34. 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.

  35. 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

  36. 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.

  37. 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.

  38. 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.

  39. 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.

  40. Cardiac Arrest

  41. E – ECG (ALS) • Monitor for asystole, ventricular fibrillation, electro-mechanical dissociation (PEA) • EtCO2 can be an indicator of Cardiac Output during chest compression

  42. Pulseless Electrical Activity 6 Hs • Hypovolemia • Hypoxia • H+ (acidosis) • Hyper/hypo kalemia • Hypothermia • Hypoglycaemia

  43. Pulseless Electrical Activity 5 Ts • Tablets (drug overdose) • Tamponade (cardiac) • Tension Pneumothorax • Thrombosis (coronary) • Thrombosis (pulmonary)

  44. F – Fluids (ALS) • IV Fluids • Vascular access – large peripheral vein - bolus followed by 20ml flush - should not interfere CPR & Defibrillation

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