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Adult CPR Update 2005

Adult CPR Update 2005 . Dr Adrian Burger Emergency Medicine Registrar UCT/Stellenbosch. Background. ILCOR vs AHA 36 Months before 2005 Consensus Conference Awareness - limitations of evidence - benefits of CPR Tipping point - major changes

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Adult CPR Update 2005

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  1. Adult CPR Update 2005 Dr Adrian Burger Emergency Medicine Registrar UCT/Stellenbosch

  2. Background • ILCOR vs AHA • 36 Months before 2005 Consensus Conference • Awareness - limitations of evidence - benefits of CPR • Tipping point - major changes - re-affirmed others

  3. Background • USA - 250 000 to 330000 estimated annual SCA deaths per year • Survival < 6% worldwide average • Trials - short term outcomes - underpowered, small - not randomized - design limitations • Informed consent

  4. Method • Critical review of sequence and priorities • Identify factors with greatest impact on survival • Recommendations for interventions that should be performed frequently and well • Emphasis on HIGH QUALITY CPR

  5. So Why Change Then? • Poor survival not inevitable • Lay Rescuer CPR + AED Programs Witnessed VF SCA 49%-74% Survival • Make it all easier

  6. Common Elements of Success • Trained Rescuers • Rapid Recognition • Prompt CPR • Defibrillation < 5 min

  7. The Brief • Simple • Appropriate • All Ages

  8. Simple • “Lay rescuers not be expected to learn, select or perform different sequences of CPR”

  9. Appropriate • Asphyxial and VF SCA • ?Compression alone VF • ?Ventilation + Compression Asphyxial and Prolonged arrest

  10. Age Effective • Infant and Children - Asphyxial Arrests more likely • Adults - VF SCA more likely

  11. Lay Rescuers Infant under 1 year Child 1-8 years Adult 8 and older HCP Infant under 1 year Child 1 year to puberty Adult puberty & older Age Groups

  12. Airway • For Lay rescuers - Head Tilt Chin Lift • For HCP - Jaw Thrust - Head Tilt Chin Lift - Manual C-spine control in CPR • Head Tilt Chin Lift EVEN IN TRAUMA

  13. Breathing • Match Pulmonary Blood Flow & Ventilation • Not excessive ventilations -Initial O2 content adequate in VF SCA -Reduced perfusion 25%-30% of normal -Reduced venous return -Gastric Insufflation

  14. CPR For Lay Rescuers • Check normal breathing • 2 rescue breaths of 1s each • Visible chest rise • Immediate chest compressions (no pulse check) • 2 hands, centre of chest, nipple line, 100/min • AED when arrives

  15. CPR For HCP • “Phone First” for all sudden collapse and if lone rescuer • “CPR First” for unresponsive infants and children, all victims of likely hypoxic arrest and if lone rescuer • Check for adequate breathing • 2 rescue breaths of 1s each • Visible chest rise • Check response • Pulse check • Rescue breathing without compressions 10-12/min • Technique of compressions same as lay rescuers

  16. The Ratios • Universal 30:2 -All Lone Rescuers of Infants (not newborns), Children & Adults -All Lay Rescuer situations -2 Rescuer Adult CPR without advanced airway • 15:2 -2 Rescuer CPR for Infants and Children

  17. Put Simply • 30:2 - All Lone Rescuers (Lay & HCP) for All victims - 2 Rescuers Adults (no advanced airway) • 15:2 - 2 Rescuers for Infants and Children

  18. And if there’s an ETT or LMA? • Breathing rate: 8-10/min • Compression rate: 100/min • Swap roles regularly -objectively <1-2 minutes -subjectively >5 minutes

  19. HIGH QUALITY CPR • RATE - push hard, push fast 100/min • DEPTH - 1.5 TO 2 inches • COMPLETE CHEST RECOIL • MINIMISE INTERRUPTIONS • CHANGE REGULARLY Restore Coronary & Cerebral Blood Flow

  20. Technique of CPR • Push Hard and Push Fast • Complete Chest Recoil • Minimal Interruptions <10s • Change Regularly

  21. The Shocking Facts

  22. Changes • Challenged Defib first to all VF victims, especially > 4 to 5 min • Improved survival for CPR first? • Insufficient data for CPR first to all VF SCA

  23. Consensus Lay Rescuers • AED as soon as available EMS • Witnessed SCA VF: Defib • Not witnessed or > 4 to 5 min: CPR first

  24. Non Consensus • In hospital cardiac arrest • Ideal duration of CPR before defib • Ideal duration of VF to switch to CPR first

  25. Only One Shocker • No specific studies • 1st shock efficacy - termination of VF at least 5s after the shock • Monophasic defib - low 1st shock efficacy • Biphasic defib - average 90% 1st shock efficacy • If 1st shock fails - low amplitude VF, CPR greater value

  26. So the VF is terminated… • Most have a nonperfusing rhythm • PEA/Asystole = CPR • AED rhythm analysis 29-37 seconds Therefore 1 shock immediately followed by CPR for 5 cycles or 2 minutes (+ physicians discretion)

  27. How much? Adults • Biphasic Truncated Exponential Waveform use 150J to 200J • Biphasic Rectilinear Waveform use 120J • Monophasic Waveform use 360J Children • Initial 2J/kg biphasic or monophasic • Subsequent 2-4J/kg • AEDS okay for > 1 year old

  28. Drugs - To Use or not use? • “No Placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases rate of survival to hospital discharge” • Vasopressin vs Epinephrine • No evidence for routine use of any antiarrythmic during cardiac arrest

  29. Drug administration • “LEAN” Lignocaine, epinephrine, atropine, naloxone, and vasopressin • IV or IO preferable to ET • If no IV or IO: 2.5XIV dose in 5-10ml H2O

  30. Predictable drug delivery Predictable drug effect low dose of adrenaline systemically leads to a B -adrenergic effect Vasodilatation Lower coronary artery perfusion pressure & flow Reduced potential of ROSC Pulmonary vasoconstriction IV/IO vs ET

  31. Other drugs in short • NaBic: No evidence for routine use Adverse effects of vasodilatation, alkalosis, CO2 production, catecholamine Specific instances, eg TCA, hyperkalaemia • Calcium: No benefit from routine use Indicated for hypocalcaemia, hyperkalaemia, CCB toxicity • Fluids: Indicated with hypovolaemic arrest Class indeterminate as routine Avoid glucose unless hypoglycaemic

  32. Implications • Deemphasizes drug administration • Reemphasizes BLS • Drug administration during CPR • Co-ordinate - reduced interval increases shock success • AEDS - quicker, during CPR, re-program

  33. Post Resus • Little evidence to support specific Rx • No standardized Rx • Supportive - myocardial, organ function - glucose - avoid hyperventilation - temperature • Therapeutic hypothermia - improved outcome of out-of-hospital adult VF arrest

  34. FBAO • Simplified - mild or severe • Mild - victim coughing: do not interfere • Severe - silent cough - respiratory distress - stridor - unresponsive

  35. Severe FBAO • Activate EMS • Anecdotal evidence • Adults & >1yo : abdominal thrusts first : chest thrusts • Combinations of above most effective • Chest thrusts: obese, pregnant • CPR for unresponsive patients • Look into mouth, but no blind finger sweeps

  36. 18 March 2006 www.resuscitationcouncil.co.za

  37. ?

  38. References • Circulation, 2005; 112 • Currents, winter2005-2006 • JAMA, Feb 9, 2000-Vol 283, No6 p783-790

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