Cardio-pulmonary Cerebral Resuscitation

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CARDIOPULMONARY RESUSCITATION
DR SUJATA PROFESSOR DEPT.OF ANAESTHESIOLOGY
CRITICAL CARE UCMS GTB HOSPITAL
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CPBR/ CPCR

• CPR
• Cardiopulmonary brain resuscitation -CPBR
• Cardiopulmonary cerebral resuscitation-CPCR

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Goal

• Support restore effective oxygenation,
  
• ventilation and circulation with return of
  intact
• neurological function.
• Intermediate Goal
• Return of spontaneous circulation (ROSC)

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Approach

• BLS ( Basic Life Support) Primary survey.
• ACLS (Advanced Cardiovascular Life Support)
  Secondary survey

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Cardiopulmonary Resuscitation
ACLS
PROLONGED LIFE SUPPORT
BLS
A - Airway B - Breathing C - Circulation D-
Defibrillation
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• Does BLS work?
• BLS- maximum attention of public
  
• .MMajority(70-80) of cardiac arrests
• Out-of-Hospital
• .Pre-hospital care key factor
• ajority(70-80) of cardiac arrests
• Out-of-Hospital
• .Pre-hospital care key factor

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Adult Chain of Survival
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CHAIN OF SURVIVAL
Early Defibrillation
Early ACLS
Early access
Early CPR
1.Recognition of Early warning signs 2.Activation
of Emergency Medical Services 3.Basic
CPR 4.Defibrillation
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Before BLS Primary Survey

• Scene safety
• Check responsiveness
• Activate EMS and get AED
• Assess Perform appropriate action.
• Performance of the action improves chances of
  survival and better neurological outcome

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Before BLS Primary Survey
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BLS Primary survey

• Support/ restore effective oxygenation,
  ventilation and circulation until ROSC or ACLS
  team takes over.
• No advanced interventions- airway tech./ drugs
  (use universal precautions)
• Early CPR and early defibrillation

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BLS Primary Survey.components
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Basic airway skills

• Head tilt- chin lift
• Jaw thrust without head extension (? Cx spine
  trauma)
• Mouth- to- mouth ventilation
• Mouth- to- nose ventilation
• Mouth- to- barrier device (pocket mask)
• Bag-mask ventilation

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A
C
B
AIRWAY
BREATHING
CIRCULATION
DEFIBRILLATION
D
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• Airway
• Head tilt, Chin lift, Jaw thrust
• AVOID HEAD TILT IF TRAUMA
• Keeping airway open- LOOK, LISTEN, FEEL
• LOOK LISTEN FEEL
• CHEST MOVEMENTS BREATH SOUNDS
  AIR FLOW
• RESP. RATE VOICE QUALITY
  CHEST MOVEMENTS
• CYANOSIS ABNORMAL SOUNDS
  TRACHEAL POSITION
• TRAUMA
• FLUID/BLOOD /VOMITING
• NOT MORE THAN 10 SECONDS

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BREATHING ABSENT
BREATHING PRESENT

• 2 EFFECTIVE RESCUE BREATHS
• SLOW BREATHS
• TIDAL VOL. 8-10 ml/kg
• Deliver in one sec.
• Rate- 10-12/min.
• Chest rise/ expand

RECOVERY POSITION AND TRANSPORT
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Assessing the victim

• 1-- Make sure the victim, any bystanders, and you
  are safe.
• 2-- Check the victim for a response.
• Shake shoulders gently
• Ask Are you all right
• If he responds
• Leave as you find him.
• Find out what is wrong.
• Reassess regularly
• If he does not respond
• Activate Code Blue and get AED
• 4 --Keeping the airway open, look, listen, and
  feel for normal breathing.
• OPEN AIRWAY
• Look, listen and feel for NORMAL breathing
• Do not confuse agonal breathing with NORMAL
  breathing

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Keeping the airway open, look, listen, and feel
for normal breathing. OPEN AIRWAY
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Look, listen and feel for NORMAL breathing
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If he is breathing normally Turn him into the
recovery position Send or go for help, or call
for an ambulance. Check for continued breathing.
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If he is not breathing normally

• Give 2 rescue breaths
• Pinch the nose
• Take a normal breath
• Place lips over mouth
• Blow until the chest rises
• Take about 1 second
• Allow chest to fall
• Repeat

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Chest Compressions

• Patient positioning
• Firm and hard surface (ground, table/ hard bed)
  deflate air/ water mattresses.
• Rescuer's position
• Level with patient, elbows vertically straight
  and locked, shoulders directly above the hands,
  heel of one palm over the other.
• Site sternum in inter-mammary line.
• Depth 11/2- 2 inches.
• Rate100 per minute (5 cycles of 302-CV over 2
  min.).
• Allow complete chest recoil.

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CHEST COMPRESSIONS30 CHEST COMPRESSIONS
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Hands off- time

• Less than 10 sec.
• Specific interventions defibrillation, advanced
  airway, moving the patient.
• Avoid
• Prolonged rhythm analysis
• Frequent pulse checks
• Too long breaths
• Unnecessary moving the pt.

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CHECK FOR SIGNS OF CIRCULATION
PULSE PRESENT
PULSE ABSENT / NOT DETECTED
CONTINUE VENTILATION TILL SPONTANEOUS RESPIRATION

• PULSE CHECK
• NOT RECOMMENDED FOR LAY RESCUERS
• POOR SENSITIVITY-55
• POOR SPECIFICITY-90
• ACCURACY RATE -65

• CHEST COMPRESSIONS
• Rate 100/MIN., SITE- Sternal depression -1.5
  in.-2 in.
• Universal compression-ventilation ratio (302) -
  Recommended for all
• single rescuers of infant, child and adult
  victims (excluding newborns)
• Two Rescuers 302- ALL ADULTS,
• 152 Infants and
  child
• PURPOSE PUSH HARD,PUSH FAST

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Defibrillation

• AED Follow the prompts.
• Manual defibrillator Analyse rhythm, shockable-
  decide shock (Monophasic 360 J, Biphasic 120-200
  J ), apply gel, charge, clear the patient, no
  inflammables (incl. oxygen), deliver shock..
  Resume CPR immediately.

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AED

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Positioning of electrodes for automated external
defibrillator

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DEFIBRILLATION
ATTACH PADS TO VICTIMS BARE CHEST
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Ventricular Fibrillation
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Continuous electrocardiogram showing successful
treatment of ventricular fibrillation by a
countershock (given at the arrow)
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ANALYSING RHYTHM DO NOT TOUCH VICTIMSHOCK
INDICATEDStand clearSpeak Aloud- I
Clear......You Clear.......All Clear!Deliver
shockIF VICTIM STARTS TO BREATHE NORMALLY PLACE
IN RECOVERY POSITION
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ACLS Secondary survey

• Advanced, invasive assessment and management
  techniques required.
• Basic airway adjuncts
• OPA, NPA
• Advanced Airway interventions
• Combitube, LMA, Endotracheal intubation.
• Advanced circulatory interventions
• Drugs to control heart rhythm and blood pressure.

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ACLS Secondary Survey components
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AIRWAY EQUIPMENTS
TECHNIQUES- Mouth-Mouth, Mouth-Nose VENTILATORY
DEVICES Masks, Bag-Valve Devices Airway
Adjuncts 1.Oropharygeal Airway 2.Nasopharyngeal
Airway 3.Esophageal Tracheal Combitube 4.Laryngea
l Mask Airway 5.Transtracheal catheter
ventilation 6.Cuffed oropharyngeal airway
ADJUNCT of CHOICE TRACHEAL TUBE
PURPOSE MAINTAIN AIRWAYAND OXYGENATE
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ACLS Secondary Survey.components
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Common Reversible Causes
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• PROBLEMS AND COMPLICATIONS OF CHEST COMPRESSIONS
• RIB FRACTURES
• FRACTURE STERNUM
• RIB SEPARATION
• PNEUMOTHORAX
• HEMOTHORAX
• LUNG CONTUSIONS
• LIVER LACERATIONS
• FAT EMBOLI
• HIV, HEPATITIS
• INFECTIONS

MANAGE ACCORDINGLY BUT CONTINUE CPR
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• EFFECTIVE CHEST COMPRESSION WITH MINIMAL HANDS
  OFF
• IS
• KEY
• FOR
• EFFECTIVE CPR

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When to stop BLS

• ROSC, Conscious pt.
• ACLS team takes over
• Rescuer tired

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SUMMARY
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DRUGS

• EPINEPHRINE

• Peripheral vasoconstriction- ?
  -adrenergic
• Increase in Central aortic perfusion pressure
• Decrease Threshold for Defibrillation
• Fine VF to Coarse VF

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DRUGS

• For Rhythm
• Amiodarone
• Lidocaine
• Atropine
• Magnesium
• For Blood Pressure
• Epinephrine
• Vasopressin
• DOPAMINE-2-4 micro/kg/min.-DA rec
• 4-10 micro/kg/min-
  Beta-rec.
• 10-20 micro/kg/min-
  Alpha rec.

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DEFIBRILLATOR
ECG
WHITE-RIGHT SIDE RED- RIBS-LEFT
MID-AXILLARY LEFT-OVER-LEFT SHOULDER
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The dying heart
IDENTIFY THE RHYTHM
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RHYTHMS
1.VENTRICULAR FIBRILLATION 2.
RAPID VENTRICULAR TACHYCARDIA 3.
PULSELESS ELECRICAL ACTIVITY 4. ASYSTOLE

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2
Asystole
OR
Pulseless Electrical Activity
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UCMS GTBH,DELHI