Cpr guide lines
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CPR involves techniques to manually maintain circulation and respiration in a person whose heart and breathing have stopped. The main goals of CPR are to temporarily provide oxygen to the brain and heart until definitive medical treatment can restore normal heart function. Key aspects of CPR include chest compressions, artificial ventilation, use of an automated external defibrillator, and advanced life support with medications and procedures. Outcomes are best when bystander CPR is provided immediately and the cardiac arrest victim receives rapid defibrillation and advanced care. Post-cardiac arrest care focuses on optimizing the medical condition of cardiac arrest survivors.
Cpr guide lines
- 1. CPR Defination CPR is a technique through mechanical, physiologic and pharmacologic methods to resuscitate the individuals in sudden unexpected death resulting from reversible disease.
- 2. 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. Used alone, CPR will result in few complete recoveries, and those who do survive often develop serious complications.
- 3. 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 first International CPR Guidelines in 2000
- 4. History of CPR Inversion method Silvester’s method of artificial Ventilation
- 6. International Liaison Committee on Resuscitation (ILCOR) Formed in 1992 to provide a liaison between resuscitation organisations worldwide meets twice a year ILCOR comprises representatives of American Heart Association (AHA) European Resuscitation Council (ERC) Heart and Stroke Foundation of Canada (HSFC) Australian and New Zealand Committee on Resuscitation (ANZCOR) Resuscitation Councils of Southern Africa (RCSA) Inter American Heart Foundation (IAHF) Resuscitation Council of Asia (RCA)
- 7. A FEW HARD FACTS 330,000 die annually from coronary heart disease 60% from SCA @ home or en route 85-90% in VF/VT arrest Less than 1/3 get bystander CPR Even pros don’t do good CPR! 2-3 x greater survival if CPR is immediate, with defib <3 min. EMS relies on trained, willing, equipped public
- 8. Causes of cardiac arrest Cardiac Ischemic heart disease Arrhythmias Dysectrolytemia Valvular disease Cardiac tamponade Pulmonary thromboembolism Ruptured aneurysm of aorta Extracardiac Airway obstruction Acute respiratory failure Shock Embolisms of different origin Drug overdose Electrocution Poisoning
- 9. Start CPR Immediately Better chance of survival Brain damage starts in 4-6 minutes Brain damage is certain after 10 minutes without CPR Even With Successful CPR, Most Won’t Survive Without ACLS ACLS includes defibrillation, oxygen, drug therapy
- 10. following 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.
- 11. Diagnosis of cardiac arrest Absence of pulse on major arteries (carotid or femoral) – a pathognomonic symptom cessation of Respirations with or without pupillary dilatation. Blood pressure measurement Taking the pulse on peripheral arteries Auscultation of cardiac tones Loss of time !!!
- 12. Sudden cardiac death－ECG The arrest is usuallyassociated with the lethalarrhythmia 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
- 13. Ventricular fibrillation Asystole Electric –mechanical activity dissociation Pulseless Ventricular tachycardia
- 14. Post CARDIAC ARREST CARE
- 15. New AHA Adult Chain of Survival New 5th link –post-cardiac arrest care Links in the new adult Chain of Survival •Immediate recognition and activation of emergency response system •Early CPR, w/emphasis on chest compressions •Rapid defibrillation •Effective advanced life support •Integrated post-cardiac arrest care
- 16. Basic Life Support( BLS) BLS is the application of artificial ventilation and circulation with or without special equipment or drugs to prevent brain damage.
- 19. Primary Emphasis on Chest Compressions All rescuers should, at a minimum, provide chest compressions. If bystander not trained (adult arrest): Hands- Only CPR If bystander trained and able: perform compressions and ventilations at rate of 30:2 Healthcare provider: perform compressions and ventilations at rate of 30:2 For all pediatric arrest, compressions and ventilations still recommended
- 20. C. Circulation Restore the circulation, that is start chest compression
- 21. 2 mechanisms explaining the restoration of circulation by chest compression Cardiac pump Thoracic pump
- 22. Cardiac pump during the chest compression Blood pumping is assured by the compression of heart between sternum and spine Between compressions thoracic cage is expanding and heart is filled with blood
- 23. Thoracic pump at chest compression Blood circulation is restored because intrathoracic pressure exceeds extrathoracic vascular pressure and that flow is restricted to the venous-to-arterial direction because of jugular & subclavian venous valves that prevent retrograde flow
- 24. Compressions the victim to lie supine on a hard surface with the rescuer kneeling beside the victim’s thorax Place heel of one hand on center of chest between the nipples clasping both hands without flexion of elbow jt., give chest compressions For infants: Use the 2 thumb-encircling technique-sternum compressed with thumbs and use fingers to squeeze thorax just below nipple line
- 25. All rescuers should, at a minimum, provide chest compressions. If bystander not trained (adult arrest): Hands-Only CPR If bystander trained and able: perform compressions and ventilations at rate of 30:2 Healthcare provider: perform compressions and ventilations at rate of 30:2 For all pediatric arrest, compressions and ventilations still recommended Primary Emphasis on Chest Compressions
- 26. Adult Chest Compression Depth Change: Compress at least 2 inches 2005 recommendation was 1½ to 2 inches. Why? Compressions of at least 2 inches are more effective than those of 1½ inches. Rescuers often do not “push hard” enough. Confusion may result when range of depth is recommended.
- 27. Chest Compressions Critical Without effective chest compressions Oxygen flow to brain stops. Oxygen flow to heart stops. Drugs go no where.
- 28. Chest Compression Rate Change: Compression rate at least 100 per minute.2005 recommendation: Compression rate about 100/min Why? Absolute number of compressions delivered/minute has been linked with survival. Actual compression rate is often well below 100/min.
- 29. 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.
- 30. There are several simple airway maneuver to relieve this obstruction--opening the airway method:
- 31. if no concern cervical spine injury . Head-tilt/neck stretch
- 32. Head-tilt/chin-lift if no concern cervical spine injury. patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head- tilt chin lift
- 33. Jaw-thrust The jaw – thrust is the safest method for opening the airway if there is the possibility of cervical spine injury.
- 34. Change: This action removed from the CPR sequence After delivery of 30 compressions, lone rescuer opens airway and delivers 2 breaths. Why? Rescuer checks for response and “no breathing or no normal breathing” in adult before beginning CPR Starting CPR with compressions minimizes delay to action Elimination of “Look, Listen, and Feel” for Breathing
- 35. Pinch the nose- prevent air escape take a deep breath Seal the mouth 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
- 36. 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
- 37. After tracheotomy , the stoma becomes the patient’s airway. mouth-to-stoma
- 38. 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%。
- 39. 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.
- 40. 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.
- 41. Electrical Therapies Practice needed to minimize interruption in chest compressions to deliver shock. In-hospital use of AEDs may facilitate early defibrillation (goal: ≤ 3 minutes). AEDs can now be used in infants if a manual defibrillator is not available. Defibrillation doses unchanged, adult cardioversion doses provided
- 42. Monophasic vs Biphasic Defibrillators
- 43. Automated external defibrillators (AED) With a large pads are currently available. These machine can recognize VF and deliver direct current (DC) counter shock with better than 85% sensitivity and with 100% specificity.
- 44. Monophasic vs Biphasic Defibrillators Goal: delivery of current to depolarize myocardial cells and eliminate VF/VT 1st-shock efficacy of monophasic < 1st-shock efficacy of biphasic Monophasic: delivers current of one polarity dose of 360 J for all shocks Biphasic: <200J as safe and w/ higher efficacy than higher voltage in monophasic 150 J to 200 J with a biphasic truncated exponential waveform 120 J with a rectilinear biphasic waveform. subsequent shocks: same or higher energy CHILD: doses are 2 J/kg for the first attempt and 4 J/kg for subsequent attempts
- 45. Precordial Thump The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest. The precordial thump may be considered for patients with witnessed, monitored, unstable VT (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery.
- 47. Advanced Life Support-ALS ALS refers to used special equipment to manage airway, breathing and circulation and provide definitive care, including defibrillation , advanced airway management, mechanical ventilation and drug therapy of dysrhythimas and acid- base disturbance.
- 48. Advanced Cardiovascular Life Support (ACLS) Foundation of successful ACLS is good BLS. Traditional cardiac arrest algorithm simplified and alternative conceptual design (both emphasize importance of high-quality CPR.) Increased emphasis on continuous waveform capnography to verify endotracheal tube placement optimize CPR quality and detect ROSC.
- 49. ACLS: Waveform Capnography Change: Quantitative waveform capnography is most reliable method to confirm and monitor correct ET tube placement . Why: Unacceptably high incidence of unrecognized ET tube misplacement or displacement. Capnography has high sensitivity and specificity to identify correct endotracheal tube placement in cardiac arrest.
- 50. ACLS: Waveform Capnography After intubation, exhaled carbon dioxide is detected, confirming tracheal tube placement. Highest value at end-expiration.
- 51. ACLS: Physiologic Monitoring During CPR ACLS: Physiologic Monitoring During CPR
- 52. ACLS: De-emphasis of Devices, Drugs and other Distracters Focus on high-quality CPR and defibrillation Atropine no longer recommended for routine use in management of PEA/asystole. Chronotropic drug infusions now recommended as alternative to pacing in symptomatic and unstable bradycardia. Adenosine recommended as safe and potentially effective for treatment and diagnosis in initial management of undifferentiated regular monomorphic wide-complex tachycardia
- 53. ACLS: Medications for Pulseless Arrest Atropine: deleted from pulseless arrest algorithm Epinephrine: dose, interval unchanged Vasopressin: dose, use unchanged Amiodarone: dose, indications unchanged Lidocaine: dose, indications unchanged Sodium Bicarbonate: Routine use not recommended (Class III, LOE B). Calcium: Routine administration for treatment of cardiac arrest not recommended (Class III, LOE B).
- 54. EPINEPHRINE Alpha-adrenergic vasoconstrictor properties increases coronary and CPP during CPR Beta-adrenergic properties controversial - may increase myocardial workload and reduce subendocardial perfusion Converts finer fibrillary waves to coarser ones – more amenable to defibrillation Indication: All cardiac arrest ,VF /VT DOSE: 1mg bolus repeated every3-5 min. 0.0 to 0.03mg/kg, Endotracheal (0.05-0.1 mg)
- 55. VASOPRESSIN Non-adrenergic peripheral vasoconstrictor Retention of water by acting to increase water absorption in collecting ducts of nephrons. The results of coronary perfusion pressure and ROSC were also slightly better for vasopressin alone than for epinephrine alone. Dose: 40 Units iv to replace the 1st or 2nd dose of epinephrine.
- 56. Amiodarone Affects K, Na, Ca-channels, alpha and beta-adrenergic blocking properties Lowers the defibrillation threshold. INDICATION: Can be considered if multiple shock &Epinephrine have fail to revert VF/VT. Initial: 300mg slow iv, then 150mg, 5mg/kg.
- 57. ② Lidocaine Actions: Lidocaine is a class IB agent that depresses myocardial excitability by blocking sodium channels without extending action potential duration. Indication and dose: The drug is indicated in Ventricular ectopic, ventricular tachycardia and ventricular fibrillation that has recurred after a successful defibrillation or that has been refractory to defibrillation. Dose :In cardiac arrest the recommended dose is 1.5mg/kg bolus repeated in 5~10 min for total dose of 3mg/kg.
- 59. Post-Cardiac Arrest Care Change: New 5th link in the chain of survival Why: Emphasize importance of comprehensive multidisciplinary care through hospital discharge and beyond Includes: Optimizing vital organ perfusion Titration of FiO2 to maintain O2 sat ≥ 94% and < 100% Transport to comprehensive post-arrest system of care Emergent coronary reperfusion for STEMI or high suspicion of AMI Temperature control Anticipation, treatment, and prevention of multiple organ dysfunction
- 60. Terminating resuscitation in Adult out side Hospital (BLS) Arrest not witnessed by first responder . No ROSC after 3 complete to CPR and AED. No AED shocks delivered.
- 61. Terminating resuscitation in Adult in Hospital (ALS) Arrest not witnessed by anyone . No bystander CPR provider. No shock delivered. No ROSC after complete ALS care in field.
- 62. Pediatric Resuscitation Revised pediatric chain of survival New post-arrest care link
- 63. Paediatric Basic Life Support Similarities in paediatric BLS and adult BLSC-A-B rather than A-B-C sequence Continued emphasis on high-quality CPR Removal of “look, listen and feel” De-emphasis of pulse check for HCPs Use AEDs as soon as available AEDs may be used in infants, although manual defibrillation preferred
- 64. Pediatric Advanced Life Support (PALS) Optimal energy dose for defibrillation of children unknown. Initial dose 2-4 J/kg. Subsequent dose ≥ 4 J/kg Post-ROSC: titrate oxygen to limit hyperoxemia. Therapeutic hypothermia (to 32°C to 34°C) may be beneficial (studies in progress) Young victims of sudden, unexpected cardiac arrest should have a complete autopsy with genetic analysis of tissue to look for inherited channelopathy.
- 65. Neonatal Resuscitation For babies born at term, begin resuscitation with room air rather than 100% oxygen. Any oxygen administered should be blended with room air, titrated based on oxygen saturation measured from right upper extremity. Suctioning after birth reserved for infants with obvious airway obstruction, those requiring ventilation or non- vigorous babies with meconium Therapeutic hypothermia recommended for babies near term with evolving moderate to severe hypoxic- ischemic encephalopathy.
- 66. Education, Implementation, and Teams (EIT) New section focusing on methods to improve bystander willingness to act, education techniques, teamwork and leadership Key Issues: Current 2-year certification period for BLS, ACLS and PALS should include periodic refresher courses Hands-Only CPR should be taught Practice-while-watching is effective for BLS Training should not be required for lay rescuers but it does improve performance Debriefing is effective
- 67. Summary of 2010 Guidelines Many resuscitation systems and communities have documented improved survival from cardiac arrest. Too few victims of cardiac arrest receive bystander CPR. CPR quality must be high. Victims require excellent post–cardiac arrest care by organized, integrated teams. Education and frequent refresher training key to improving resuscitation performance. We must rededicate ourselves to improving the frequency of bystander CPR, the quality of all CPR and the quality of post–cardiac arrest care.
- 68. Type of Arrest ROSC Survival Witnessed In-Hospital Cardiac Arrest 48% 22%40% Unwitnessed In-Hospital Cardiac Arrest 21% 1% Bystander compression-only Resuscitation 6% Bystander Cardiopulmonary Resuscitation 40% 4% No Bystander CPR (Ambulance CPR) 15% 2% Defibrillation within 3–5 minutes 74% 30%