2.Cpr 2

Cardiopulmonary Resuscitation Chaiyanfen Tianjin Medical University General Hospital Department of Emergency Medicine

OBJECTIVE At the end of the course the student will be able to 1.Define the sudden cardiac arrest, the clinical death and biologic death. CPR defination 2.Master the cardiopulmonary cerebral resuscitation skill, procedure and the method of BLS. 3.Know the complication of CPR. 4.Know the chain of survival .

COURSE CONTENT 1.General Consideration 2.CPR Steps 3.Complications of CPR 4.Monitoring during CPR 5.Terminating Resuscitation

Gerneral Consideration 1. CPR definition 2.History of CPR 3.Anatomy and function of the circulatory system 4.Death concepts 5.The chain of survival

CPR Defination CPR is a technique through mechanical, physiologic and pharmacologic methods to resuscitate the individuals in sudden unexpected death resulting from reversible disease.

The purpose of CPR is To temporarily provide effective oxygenation of vital organs (especially the brain and heart) until appropriate, definitive medical treatment can restore normal cardiac and respiratory activity.

There are three goals of resuscitaition ① Basic life support, providing temporary perfusion of vital tissues. ② Restoration of spontaneous cardiac and respiratory activity and establishment of circulatory self-sufficiency. ③ Correction of the underlying disease, while supporting and protecting all organs and assisting them in recovery to as near prearrest state as possible.

CPR is a key part of emergency medicine.

History of CPR The history of CPR and cerebrial arrest prophylaxis begins in ancient times. 5000 -first artificial mouth to mouth ventilation in 3000 BC 1780 – first attempt of newborn resuscitation by blowing 1874 – first experimental direct cardiac massage 1901 – first successful direct cardiac massage in man 1946 – first experimental indirect cardiac massage and defibrillation 1960 – indirect cardiac massage 1980 – development of cardiopulmonary resuscitation due to the works of Peter Safar

History of CPR Inversion method Silvester’s method of artificial Ventilation

History of CPR There were no immediately effective emergency resuscitation techniques available before 1950s. Modern respiratory resuscitation was pioneered in 1950s safar opening airway 1958, Elam mouth to mouth breath, ), Modern circulatory resuscitation in the 1960s Kouwenhoven ECC,1960 , Therapeuticall promising reseach on brain resuscitation began in 1970.

Anatomy and function of the circulatory system The circulatory system is similar to a city water system: The heart functions as a pump The blood vessels as a network pipes The blood as fluid

Blood picks up oxygen in the lungs ,it goes to the heart ,which pumps the oxygenated blood to rest of the body. The cells of the body absorb oxygen and nutrients from the blood and produce waste products(including carbon dioxide),that blood carries back to the lungs.In lungs ,the blood exchanges the carbon dioxide for more oxygen .Blood then returns to the heart to be pumped out again.

If the heart stop contracting,and no blood is pumped through the blood vessels.Without a supply of blood, the cells of the body will die because they cannot get any oxygen and nutrients and they cannot eliminate waste products.

Death Concepts Death is a physiologic and biologic process, it just occurs after cardiac arrest. Clinical Death Biologic Death Sudden Cardiac Death

Clinical Death Clinical Death has been defined by Negovsky as “the period of respiratory,circulatory,and brain arrest during which initiation of resuscitation can lead to recovery with prearrest central nervous system function.” Clinical Death is a reversible state The duration of clinical death depends on the length of time of the cerebral cortex survives in the absence of circulation and respiration.

Biologic death Biologic death which sets in after clinical death, is an irreversible state of cellular destruction. On normal temperature , the period does not exceed 3-6min from clinical death to biologic death

Sudden cardiac death Sudden cardiac death (also called sudden arrest) is death resulting from an abrupt loss of heart function (cardiac arrest). Sudden cardiac death is clinical death

The victim may or may not have diagnosed heart disease. The time and mode of death are unexpected . It occurs within minutes to 1 hour after symptoms appear. The most common cause of cardiac arrest is coronary heart disease.

Causes of circulation arrest Cardiac 1.Ischemic heart disease (myocardial infarction, stenocardia) 2.Arrhythmias of different origin and character 3.Electrolytic disorders 4.Valvular disease 5.Cardiac tamponade 6.Pulmonary artery thromboembolism 7.Ruptured aneurysm of aorta Extracardiac 1.airway obstruction 2.acute respiratory failure 3.shock 4.Reflective cardiac arrest 5.embolisms of different origin 6.drug overdose 7.Electrocution 8.poisoning

follwing abrupt cessation of effective cardiac output : Loss on consciousness at about 10~15seconds; Pupillary dilation at about 30~45 seconds ; Brain damage begins within 4 ~ 6 minutes after cardiac arrest; Irreversible cerebral cortical damage occurring within 8~10 minutes after cardiac arrest.

Sudden cardiac arrest is reversible in most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation.

Sudden cardiac death － ECG The arrest is usually associated with the lethal arrhythmia of ventricular fibrillation triggered by an acutely ischemic or infarcted myocardium or by a primary electrical disturbance . There several ECG in sudden cardiac arrest: Ventricular fibrillation Pulseless Ventricular tachycardia Asystole Electric –mechanical activity dissociation

Ventricular fibrillation Asystole Electric –mechanical activity dissociation Pulseless Ventricular tachycardia

Epidemiology of Sudden cardiac death Cardiac arrest accounts for between 250 000-350 000 death each year in USA. Expert estimate that the overall survival rate may be beween 3% and 5% , in many large urban areas maybe less than 2% . In China , approximately 1 000 000 - 1800,000 people suffer cardiac arrest every year .Mortality of cardiac arrest is 95%-98% in USA ， and 98%-99% in China 。 Delay Initiation of CPR are the main cause o f low survival rate. .

Chain of Survival Early Access to Medical Care (calling 911 in USA ,and calling 120 in China immediately) Early CPR (within 4 min after cardiac arrest) Early Defibrillation (for an out of hospital sudden cardiac death within 5min,for a in hospital victims within 3min ( In guideline 2005 ) Early Advanced Care including intubation and IV medication(should be initiated within 8min of arrest) In 1991 ， American Heart Association has introduced

Chain of Survival Early Defibrillation Resuscitation success depend on each link in the chain. Early defibrillation has emerged the greatest impact on ultimate survival. When defibrillation alone is added to the BLS regimen,survival increases from 6% to 25% for prehospital VF.

Survival Rates No CPR 0%-2% survive Delayed defibrillation Early CPR 2%-8% survive Delayed defibrillation Early CPR 20% survive Early defibrillation Early CPR 30% survive Very early defibrillation Early ACLS Source: American Heart Association, 1994

Better chance of survival Brain damage starts in 4-6 minutes Brain damage is certain after 10 minutes without CPR

Sudden death is unique. Time constraints are extreme. A victim's chances of survival are reduced by 7 to 10%with every minute that passes without defibrillation

If resuscitative interventions are not begun within 5~7min, there is little likelihood of successful resuscitation and functional survival. Few attempts at resuscitation succeed after 10 minutes .

Most survivors of cardiac arrest are from the group of patients . . . Whose collapse is witnessed by a bystander, Who receive CPR within 4 to 5 minutes, and Who receive advanced cardiac life support (ACLS), e.g., defibrillation, intubation, drug therapy, within the first 10 minutes.

COURSE CONTENT 1.General Consideration 2. CPR Steps 3.Complication of CPR 4.Monitoring during CPR 5.Terminating Resuscitation

CPR Steps 1. Basic Life Support, BLS 2. Advanced Life Support, ALS

Basic Life Support- BLS BLS is the application of artificial ventilation and circulation without special equipment or drugs to prevent brain damage.

BLS Combines rescue breathing and chest compressions Revives heart (cardio) and lung (pulmonary) functioning Use when there is no breathing and no pulse Provides O2 to the brain until ALS arrives

Effective CPR provides 1/4 to 1/3 normal blood flow Rescue breaths contain 16% oxygen (21%)

BLS 1.CALL Check the victim for unresponsiveness 2. BLOW Tilt the head back and listen for breathing . . 3. PUMP If the victim is still not breathing normally, coughing or moving, begin chest compressions. Push .

New BLS process (2005) unresponsiveness opening the airway& check the victim CPR 2:30 until defibrillation or monitoring defibrillation once :360J Continue CPR for 5 groups (2:30)

BLS Recognition of cardiac arrest A-airway control B-breathing support C-circulation support D-defibrillation

1.Recognition of Cardiac Arrest Sudden cardiac death can be confirmed by the absence of detectable pulse, unresponsiveness, and apnea, gasping （喘息） respiration”. Responsiveness Tap shoulder and shout “Are you ok?”

Note: The presence of spontaneous respiration dose not exclude the possibility of cardiac arrest. Normal respiratory motion may persist for approximately 1 minute after loss of cardiac function.

Once unresponsiveness has been determined, assistance obtained and a defibrillator requested. Start ＢＬＳ Immediately

stabilize the cervical spine by maintaining the head ,neck, and trunk in a straight line Positioning the patient supine on a flat, firm surface with arms along the sides of the body, Always be aware of head and spinal cord injuries

2.A – airway control In an unconscious patient, airway obstruction is most commonly due to relaxation of the muscles of the tongue allowing it to rest against the posterior pharyngeal wall.

There are several simple airway maneuver to relieve this obstruction--opening the airway method:

if no concern cervical spine injury . Head-tilt/neck stretch

Head-tilt/chin-lift if no concern cervical spine injury . (2005 guidline new) In patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift

Jaw-thrust T he jaw –thrust is the safest method for opening the airway if there is the possibility of cervical spine injury.

Cleaning the secretion of airway tract or foreign body (such as gastric contents regurgitation , blood clotting or denture in the mouth inspired into the airway) 。 Sweeping out by fingers

3.B-breathing support Check For Breathing After opening the airway ， you should quickly Check For Breathing look the patient’s chest and abdomen movement, listen for sounds of breathing, placing your ear over the patient’s nose and mouth and feel and hear the movement of air No longer than 10 seconds

Once you determine the patient not spontaneous breathing ,you must begin artificial ventilation immediately. mouth-to-mouth mouth-to nose mouth-to-stoma

Pinch the nose- prevent air escape take a deep breath Seal the mouth with yours give two breaths (1 second or longer) If the first two breaths don’t go in, re-tilt and give two more breaths (if breaths still do not go in, suspect choking) mouth-to-mouth mouth-to-mouth

Can’t open mouth Can’t make a good seal Severely injured mouth Stomach distension mouth-to-nose ventilation may be more effective. mouth-to nose

After tracheotomy , the stoma becomes the patient’s airway . mouth-to-stoma

To prevent transmission of disease from the victim to rescuer, a bag –valve mask or other suitable device should be used in place of mouth-to-mouth technique.

Both mouth to mouth and mouth to nose ventilation can provide large volumes ， the concentration of oxygen delivered to the patient is 16%~17% ， may produce an alveolar partial pressure of oxygen of 80mmHg,more than enough to patient’s life. mouth to mask ventilation connected to high flow oxygen ， the concentration of oxygen is up to 55% 。

4.C-circulation (extenal chest compression) Once the airway has been established and the lungs have been ventilated ， If there is not carotid pulse ， external chest compression should be started.

The rescuer positions- bedside the victim’s chest. Locate proper hand position for chest compressions Place heel of one hand on the lower half of the sternum . The fingers interlocked Keeping the arms straght Compression rate 100/min Depth of compressions: 1 .5 to 2 inches(4-5cm)

After 30 chest compressions give: 2 slow breaths ( Ratio of compression-to-ventilations 30:2) Continue until help arrives or victim recovers If the victim starts moving: check breathing

5.D-defibrillation Early defibrillation has emerged as a single element of BLS that appears to have the greatest impact on ultimate survival. When defibrillation alone is added to the BLS regimen, survival increases from 6% to 25% for prehospital VF.

Defibrillation is the definitive treatment for the vast majority of cardiac arrests. It should be delivered as early as possible. At least 50%of patient in cardiac arrest are in VF when the first ECG ,in early 1970s “blind” defibrillation was recommended as soon as a defibrillator was available.

However, current defibrillators with quick-look paddles enable display the rhythm disturbance As soon as ventricular fibrillation is documented, defibrillation should be perform immediately.

The method of defibrillation 1.Precordial thump If an electrical defibrillator is not immediately available, a precordial thump should be used. A sharp blow using the fleshy outside of a closed fist is delivered to the sternum from a height of 8 ～ 12in (25 ～ 30cm). If this successfully results in sinus rhythm, a bolus of lidocaine should be given.

If VF persists, proceed to BLS and to defibrillation as soon as the defibrillator is available.

While awaiting arrival a defibrillator, effective BLS must be maintained.

The method of defibrillation 2.Electrical defibrillation :passing an electrical current through a fibrillating heart, and causing synchronous depolarization the disorganized contracting myofibrils at once, and allowing for uniform repolarization and subsequent organized cardiac electromechanical activity.

traditional handheld defibrillator

Automated external defibrillators (AED) With a large pads are currently available. These machine can recognize VF and deliver direct current (DC) countershock with better than 85% sensivity and with 100%specificity.

Defibrillation success rate appears equal traditional handheld defibrillator. The potential impact of using this technology widely in office building, stadiums, factories and rural areas served by volunteer rescue personnel 。

Procedure of Electrical defibrillation ⑴ Adiminister BLS until the equipment and personnel arrive. ⑵ Assess the patient’s pulse and ECG. ⑶ Proper asynchronous mode ⑷ Selection energy level—360J

⑸ Adequate contact Apply electrode gel or saline-soaked4×4 gauze pads between paddles and skin ⑹ Proper position of the paddles :one paddle placed to the right of the upper half of the sternum, below the clavicle. the other is placed to the left of the cardiac apex

⑺ Clear the area ,no contact with anyone other than the victim. ⑻ Recheck the ECG ⑼ Activate the firing button.

⑽ If no skeletal muscle twitch or spasm has occurred ， you should check the equipment ， contacts ， and synchronizer switch ⑾ The rhythm should be assessed after each countershock and the patient should be checked for a pulse at appropriate time. ⑿ If unsuccessful, continue BLS.

Checking for CPR Effectiveness ★ With each compression, an arterial pulse should appear.The carotid artery pulse is more meaningful than either the radial artery or femoral artery pulse. Does chest rise and fall with rescue breaths? Have a second rescuer check pulse while you give compressions

★ The ECG also responds to the ECC, Various types of electrocardiographic artifacts may appear with each compression. Occasionally, each ECC cause a recognizable QRS complex and T wave to appear. ★ The reaction of the pupils -if present, is a good indicator of cerebral circulation

BLS Success Advanced Life Support

Advanced Life Support-ALS ALS refers to used special equipment to manage airway, breathing and circulation and provide definitive care, including defibrillation , advanced airway managment,, mechanical ventilation and drug therapy of dysrhythimas and acid- base disturbance.

ALS may be applied by trained individuals operating within an emergency medical services system in the community, in transport, and in the hospital setting.

1.Artificial airway 1. Oropharyngeal airway 2. Nasopharyngeal airway 3. Endotracheal intubation Note : The resuscitative efforts should not be interrupted by than more 30s with each attempt.

2. Artificial ventilation ⑴ Bag-valve-mask manual ventilation ⑵ Mechanical ventilation

3.Support of circulation Chest compression during ALS are performed in the same manner as in BLS. Newer techniques include the use of compression-decompression devices and abdominal counterpulsation compression-decompression device. These mechanical devices were used, have result in improved rates of return of spontaneous circulation but not in improved ultimate survival.

Automated extral chest compression-decompresion devices

Venous access The establishment of a reliable intravenous route is an essential part of ALS ， this allow administration of necessary drugs and fluids in the course of the CPR . Peripheral veins Central venous

● Peripherial veins : may be used because of convenience ， usually recommed median cubital vein ， particularly during the arrest situation when access to the neck and chest is restricted by BLS procedure.when these route are being used, IV medication should be administered rapidly by bolus injection and following by a 20ml fluid bolus injection and elevation of the extremity . ● Central venous : offers more secure route for drug administration ， internal jugular or subclavian are preferable because of proximity to the heart ， but their placement should not be allowed delay defibrillation attempts or interfere with BLS. femoral vein cannulation is difficult to achieve during CPR.

Other access If intravenous lines cannot be established quickly ， some drugs （ such as epinephrine ， lidocaine ， atropine ） can be administered by endotracheal ， and intracardiac routes.

Note: ★ Endotracheal route requires a higher dose to achieving an equivalent blood level .It is suggested that 2.5 times the IV dose be administered.Delivery of the drug to the circulation is facilitated by diluting the drug to a 10ml volume and delivering it though a catheter positioned to the tip of the endotracheal tube. ★ Intracardiac injection should be avoided and is indicated only if intravenous and endotracheal toutes are not available.

The roles of fluid and drug therapy Increase central volume ， rising the perfusion pressure of myocardium and brain. Treatment of arrhythmias and prevent recurrent cardiac arrest. Correction of acidosis and hypoxia Correction the causes of cardiac arrest.

IV fluid To maintain the IV access and increased central volume are often required during CPR. The standard fluid infusion for ALS should be normal saline or lactated Ringer’s solution, rather than dextrose in water, since hyperglucose may exacerbate anoxic injury to the brain.

Drug therapy During CPR ,only a few drugs have proved useful. I introduce epinephrine , lidocaine , amiodarone, atropine , magneium,and sodium bicarbonate .

① Epinephrine Actions: Epinephrine can stimulate peripheral α-adrenergic receptor and cardial β adrenergic receptor ， increases resistance in non-cerebral and non-coronary arteries,result in decreased blood flow to non-cerebral and non coronary vessels.in creased aortic blood pressure and increased perfusion of heart and brain vessel.

It possible β-receptor effect on the coronary arteries and brain vessels ， resulting in increased blood flow to both of these organs during CPR. And also help to restore spontaneous norm tension in cardiac arrest of more than about 1 to 2minute’s duration. It can help convert fine VF into coarse VF ， which is more susceptible to termination by electrical countershock.

Indication: include all forms cardiac arrest. It is recommeded in VF/VT cardiac arrest if there is no ROSC after first three defibrillation.It is recommended in EMD and asystole after initiation of CPR. The standard adult dose: is 1mgIV bolus and repeated every 3~5min until return of spontaneous circulation.

② Lidocaine Actions: Lidocaine is a classIB agent that depresses myocardial excitability by blocking sodium channels without extending action potential dduration. Indication and dose: The drug is indicated in Ventricular ectopy, ventricular tachycardia and ventricular fibrillation that has recurred after a successful defibrillation or that has been refractory to defibrillation. Prophylactic lidocaine therapeutic dose is deemphasized.

Its onset of action is rapid.its duration of action is brief but may be prolonged by use of a continuous infusion of drug . dose : In cardiac arrest the recommened dose is 1.5mg/kg bolus repeated in 5~10 min for total dose of 3mg/kg.

③ Amiodarone Actions: Amiodarone is classIII agent that has some classI activity weak non-competitive β-blocking effects.It lowers the defibrillation threshold and has potent antifibrillatory effect.its broad spectrum of antidysthythmic effects make it a potentially useful agent. Indication and dose: can be considered if multiple DC shocks and epinephrine have failed to revert VF/VT.The initial dose is 5mg/kg given as a slow intravenous infusion over 5-15min.This may be repeated if indicated

④ Atropine Actions: Atropine antagonizes parasympathetic nervous effects on the heart by blocking cholinergic receptors,leading to increased sinoatrial and atrioventricular automaticity and rate on conduction. Indication and dose:It is retained as pharmacotherapy for symptomatic bradycardia. It is given in dosages of 0.5~1.0mg every 3~5min, The total dose of atropine is 0.04mg/kg(3mg)

Class I recommendation (definitely helpful) : symptomatic sinus bradycardia Class II recommendation (acceptable, or possibly helpful) : atrioventricular block （ AVB ） at the nodal level, or in asystole. Class III recommendation (not indicated, maybe harmful) : In Mobitz AVB or CHB.

⑤ Magnesium Actions: Magnesiun is an essential electrolyte that may be depleted by duretics,severe diarrhoca and alcohol abuse.Hypomagnesaemia may cause cardiac dysrhythmias. Indication and dose: Magnesium may be considered in refractory VF/VT,particularly hypokalaemia is present,and is an agent of choice in torsaded de pointes. The initial dose is 5mmol given over1 minute, which may be repeated if indicated and followed by an infusion of 20 mmol over 4 hours.

⑥ Sodium bicarbonate Acidosis is often present in victims of cardiorespiratory arrest, particularly if the arrest condition has persisted for more a few minutes.

There two components contributing to he acid load. Respiratory acidosis result from failure carbon dioxide elimination, carbon dioxide(CO 2 ) production continues , but it can not be remove because pulmonary and heart failure during CPR, the PaCO 2 rise. Metabolic acidosis develops concomitantly with tissue hypoperfusion and conversion to anaerobic forms of metabolism.

Actions: Sodium bicarbonate (NaHCO 3 )is an alkalinizing agent,that theoretically reverse the metabolic acidosis associated with profound ischemia.However,provided CPR is effective, acidosis does not develop rapidly or severely in otherwise healthy individuals during during cardiac arrest. Indication and dose: It is unneccessary in brief resuscitation when the patient have been previously well.It can be considered if cardiac arrest exceeds 10-15mintures duration.It should be considered when cardiac arrest occurs in a patient with a prexisting profound acidosis or in special conditions,such as hyperkalaemia and tricyclie antidepressant overdose.

Note: If alveolar ventilation is not adequate, the CO 2 released from the NaHCO 3, ,and correction of the acidosis will not be attained, and may result in increased central venous and tissue PaCO 2 level .Tissue acidosis may worsen following NaHCO 3, administration.

NaHCO 3 administration is not indicated for hypoxic lactic acidosis. The initial dose should be 1mmol/kg

4. Different diagnosis （ 5H 、 5T ） 5“H” ： hypoxemia ( cerebral anoxia 、 central nervous system disease ) hypopotassaemia ／ hyperpotassaemia (or other electrolyte disturbance ) hypothermia ／ hyperthermia hypoglycemia ／ hyperglykemia hypovolemia ( drug overdose or anaphylactic response 、 blood loss or pregnant )

5“T” ： Trauma Tamponade Thromboembolism of pulmonary Thromboembolism of coronary artery （ or ACS ） Toxication (acidosis) ; tension pneumothorax and etc.

1.General Consideration 2. CPR Steps 3.Complication of CPR 4.Monitoring during CPR 5.Terminating Resuscitation

Complications of CPR The complication of CPR are legion( 很多 ), but unavoidable complications are acceptable compared with an otherwise certain death .

Complication of ECC : fractures of ribs, sternum or spine; Laceration related to the tip of the sternum ： lung 、 liver spleen or other abdominal organs; pulmonary or cerebral fat embolism; laceration or rupture of heart; herniation of the heart through the pericardium; cardiac tamponade; hemothorax or pneumothorax .

These complications can be minimized by careful attention to the details of ECC.

Complication of artificial ventilation: Gastric distension and regurgitation and aspiration are common without endotracheal.

1.Vomiting Aspiration Place victim on left side Wipe vomit from mouth with fingers wrapped in a cloth Reposition and resume CPR

2.Stomach Distension Air in the stomach Creates pressure against the lungs This complication is more likely to occur when ventilation pressure exceeded the opening pressure of the lower esophageal sphincter . Prevention of Stomach Distension Don’t blow too hard Slow rescue breathing Re-tilt the head to make sure the airway is open Use mouth to nose method

In mouth-to-mouth ventilation, 1.5~2.0 seconds should be allowed for air delivery to the lungs to prevent airway pressure from exceeding 20~25cmH 2 O.Breathing rapidly without allowing full exhalation should be avoided for same reason.

Late complication pulmonary edema, gastrointestinal hemorrhage, pneumonia and recurrent cardiopulmonary arrest. Anoxic brain injury can occur in a resuscitated individual who suffered prolonged hypoxia. It is the most common cause of death in resuscitated patients.

Monitoring during CPR 1.ECG monitoring It is essential during resuscitation, both as a diagnostic tool and as a guide to the most effective therapy. Initially, the “quick look” paddles should be used. If available, the standard ECG machine or monitoring unit with a display screen should be attached as soon as possible.

1.Blood pressure Intra- arterial pressure monitoring provides an accurate and continuous measure of SBP, DBP and MAP. Continuous intra-arterial monitoring during CPR allows for rational titration of vasoconstrictor therapy and accurate assessment of the hemodynamic effectiveness of spontaneous rhythms 。

3.Endotracheal CO2 monitoring Provide a noninvasive measure of pulmonary perfusion (CO). Which also has been shown to correlate with coronary perfusion pressure. Patients who have undergoing 10~15 min of ECC with accompanying ALS ,and have an endotracheal CO2 above 10-15mmHg are unlikely to survive.

4.Laboratory investigation Will guide ongoing therapy. The most useful initial measurements include arterial blood gas, the hematocrit, serum glucose, sodium, potassium, calcium. If abnormalities are noted, they may be treated, and the success of such treatment maybe monitored by repeated measurement.

When Can I Stop CPR? 1.Victim revives 2.Trained help arrives （ or Replaced by another rescuer ） 3.Too exhausted to continue 4.Unsafe scene 5.Physician directed (do not resuscitate orders) 6.Cardiac arrest of longer than 30 minutes ( controversial)

The decision to terminate unsuccessful resuscitative efforts is always difficult, particulary if the patient is a child or a young adult.

Why CPR May Fail Delay in starting Improper procedures (ex. Forget to pinch nose) No ACLS follow-up and delay in defibrillation Only 15% who receive CPR live to go home Improper techniques Terminal disease or unmanageable disease (massive heart attack,diffusely metastatic cancer)

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