C ARDIO - P ULMO - ( C EREBRAL) R ESUSCITATION

1. KLINIKA ANESTÉZIOLÓGIE A INTENZÍVNEJ MEDICÍNY LF UPJŠ A FNLP KOŠICE CARDIO - PULMO - (CEREBRAL)RESUSCITATION Jozef Firment Judita Capková Department ofAnaesthesiology & Intensive MedicineŠafárik University Faculty of Medicine, Košice

2. Most frequent causes of out-of-hospital cardiac arrest CA

3. Most common causes of cardiac arrest CA • 1. place IHD...Myocardial infarction (80%) • Hypertension • Valvular disease,.. • Trauma • Poisoning • Drowning • Hypotermia... Ventricular fibrilation

4. Most common causes of cardiac arrest CA 1. place IHD...Myocardial infarction Hypertension Valvular disease,.. Trauma Poisoning Drowning Hypotermia... Electrical defibrillation –only effective treatment for VF Ventricular fibrilation 4

5. Cause of CA in • Trauma • Drowning • Drug overdose Asphyxia • Children Rescue breaths are critical for resuscitation

6. In- hospital arrests are due tu PEA or asystole (60-70%) - early recognition of pp at risk may prevent arrest – „Medical Emergency Teams“ • Overall survival to hospital discharge is 10%

7. Early access to emergency services Early BLS to buy time Early defibrillation to reverse VF Early advanced care to stabilise up to 4 min up to 8 min THE CHAIN OF SURVIVAL

9. Cervical spine injury • Jaw thrust(no for lay rescuer) or chin lift with manual inline stabilisation of head and neck by an assistant

10. AGONAL BREATHING • Occurs shortly after the heart stops in up to 40% of cardiac arrests • Described as barely, heavy, noisy or gasping breathing • Recognise as a sign of cardiac arrest

11. 5-6 cm EXTERNAL CHEST COMPRESSIONS one rescuer 30:2 f : 100-120/min.

12. Effective chest compressions

13. Effective chest compressions

14. Continous chest compression - only

15. Only 1 in 4 patients in CA recieves bystander CPR • transmission of infection: - tuberculosis, SARS, H1N1 – small number, - HIV – never reported

16. Protective devices:

17. Continous chest compression - only • If layman is not able or is unwilling to perform mouth to mouth breathing • f: 100/min without stopping

18. Basic life supportC,A,B • Advanced life supportC, A, B, Drugs, ECG, Fibrilation treatment - defibrilation...

19. In hospital CPR- Advanced life support • One person starts 30:2others call resuscitation team + defibrillator, r. equipments (airway, ambu bag, adrenalin,..) • only one person: leaves the patient, calls resuscitation team starts 30:2

20. A: Oral/nasal airway Tracheal intubation : f: 10/min , Fi02 = 1,0(reservoir bag), VT(tidalvolume) 6-7 ml/kg, (chestcompressions and ventilationscontinueuninterupted) VENTILATION MANAGEMENT ALS –In-hospital CPR

21. Trach Oe 90% Laryngeal mask, laryngeal tube Oe-Trach Combitube

22. O2 FiO2 VT x f l/min % adults: 13 85-100 1000 x 15 - “ - 4 >40 dtto children 5 85-100 300 x 20 - “ - 2 >40 dtto Inlet O2 10 - 13 l/min KLINIKA ANESTÉZIOLÓGIE A INTENZÍVNEJ MEDICÍNY LF UPJŠ A FNSP KOŠICE Campbell B: BAG WITH OXYGEN SUPPLY

23. Advanced life support Self-inflating bag-mask + oropharyngeal airway : C:V= 30:2 Hyperventilationreduces cerebral bloodflowThe quality of chest compressions isfrequently suboptimal, team leader shouldchange CPR providers

24. Ventricular fibrillation Ventricular tachycardia Electro-mechanical disociation (EMD) Pulseless ventricular activity (PVA) Asystole Hearth rhytms associated with CA:

26. DEFIBRILLATION • Paddle positions(sternum, apex), no over the breast tissue • Self- adhesive pads (sparks!!)-the best • Biphasic defibrilators:1. 150-200J2. 150-360J,.... • CPR for 2 min (5 x 30:2)after shock

27. DEFIBRILLATION • Check the rhythm(organised QRS complexes:regular + narrow- feeling for a pulse) • After the third shock give:adrenalin 1mg every 3-5 min. ivamiodaron 300mg iv • Time between CC and shock delivery < 5s • Signs of life return :normal breathing,movement, coughing, puls

28. A precordial thump • Generates a small electrical shock • In witnessed and monitored VF/VT arrests if a defibrillator is not immediately available • The ulnar edge of fist the lower half of sternum from a height of 20 cm • Converting VT to sinus rhytm

30. LIFE-THREATENING CARDIAC RHYTHM DISTURBANCES Cardiac arrest (asystole)Fine VF will not be shocked successfully Pulselesselectrical activity (PEA, EMD)- myocardial contractions are too weak to produce pulse or blood pressure

31. Hypoxia Hypovolemia Hypothermia Hyper/hypoK+andmetabolic disorders H+ions (acidosis) Tension pneumothorax Tamponade Toxic/therap. disturbances Thrombosis coronary Thrombosis pulmonary POTENTIALLY REVERSIBLE CAUSES (5 H’s & 5 T’s):

32. POTENTIALLY REVERSIBLE CAUSES (5 H’s & 5 T’s): • Hypoxia – ventilation with 100% oxygen • Hypovolemia (haemorrhage-trauma, GIT bleeding,rupture of an aortic aneurysm- fluid ( saline or Hartman´s solution + urgent surgery) • Hypothermia (in drowning incident) • Hyper/hypoK+andmetabolic disorders • H+ions (acidosis)

33. POTENTIALLY REVERSIBLE CAUSES (5 H’s & 5 T’s): • Tension pneumothorax- needle thoracocentesis and chest drain • Tamponade – needle pericardiocentesis • Toxic substances – appropriate antidotes • Thrombosis coronary - thrombolysis • Thrombosis pulmonary – trombolytic drug

34. Thoracocentesis

35. Needle pericardiocentesis

36. Thrombosis pulmonary

37. 1. Adrenaline(EPINEPHRINE) 1 mg á 3’- 5 ’(EVERY SECOND LOOP(5x CV 30:2) OF THE ALGORYTHM) alpha adrenergic actions cause vasoconstriction, increases myocardial and cerebral perfusion pressure 2. Bicarbonate50ml 8,4% -pH < 7.1, BE < -10-hyperkalaemia-tricyclic antidepressant overdose & equipment (defibrilator) oxygen Ambu bag face mask F1/1 infusion set plastic IV cannula DRUGS USED CPR 3. Amiodarone 300 mg after a third unsuccessful defibrillation in VF/VT...150 mg (inf. 900mg/24h)lidocaine 1 mg/kg- alternative

38. DRUG DELIVERY ROUTES • Intravenous (central, peripheral + 20 ml sol. F 1/1 + elevate 10-20 s) • Intraosseal – effective concentrations of drugs is achieved very quickly • Tracheal (2-3x more dose + 10 ml water) (adrenaline, lidocaine, atropine) • NEVER IM nor SC !!!

39. EZ-IO AD Proximal Tibial Access Intraosseous Infusion System

40. Automatický intraoseálny injektor

41. Post – resuscitation care • Stable cardiac rhythm, normal haemodynamic function (thrombolysis, percutaneous coronary intervention) • Intubation, ventilation, sedation • Therapeutical hypothermia • Comatose adults after out-of-hospital VF cardiac arrest were cooled to 32-34 oC for 12-24 h. • Improved neurological outcome

42. www.erc.edu www.resus.org. uk Resuscitation (in october 2010) http://www.lf.upjs.sk/kaim/pregradualne_vzdelavanie.html 42

43. Thank you! jcapkova@capko.sk

44. Open chest CPR • better coronary perfusion • Trauma, after cardiothoracic surgery, when chest or abdomen is already open

45. Ectopic rhythm Normal SR 1 2 5 Rhythm disorders at AMI 3 Thrombus development Acute MI 4

46. LIFE-THREATENING CARDIAC RHYTHM DISTURBANCES 1. Ventricular fibrillation,pulseless ventricular tachycardia 2. Cardiac arrest (asystole) 3. Pulselesselectrical activity (PEA, EMD) = circulatoty arrest

47. Basic life support - to buy time for • Advanced life support – to restore circulation 1961: Peter Safar

48. Effective chest compressions