Advances in Basic CPR

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Advances in Basic CPR

• Rajesh Sehdev

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Cardiac Resuscitation

• Survival from cardiac resuscitation NOT changed
  in the last 3 decades
• DOGMA followed more than evidence
• Uptake of new GUIDELINES is slow
• THRUST of latest guidelines- more compressions,
  with less interruptions prevent hyperventilation

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Cardiac Arrest
Cessation of circulation due to ineffective
cardiac function
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Clinical Dx
Patient unconscious No major pulse (carotid or
femoral)
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Clinical features

• Not moving. Not breathing adequately.
  Pallor/cyanosis.
• Occasionally arrest may present as grand mal
  seizure
• Some respiratory effort (eg gasping) may persist
  for several minutes
• If pulse not identified within 10 seconds, or
  uncertainty, commence CPR immediately

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Survival

• Cardiac arrest witnessed 50.
• Bystander CPR in 20 gtsignificant incr
  survival
• Pre-hosp arrest 14 overall survival from VF
  arrest. 2 from asystole
• MAJOR survival determinant time VF-onset to
  defib
• From 70 immediate, to 1 at gt 12 mins

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Survival

• OTHER factors- witnessed collapse, bystander
  CPR, VF/VT as cause
• High survival rate depends on a public trained in
  CPR, and well-organised public access AED
  programmes
• AED sites- airports, airlines, casinos,
  hospitals
• Also, good survival from police/fire responder
  CPR and AED rescuer programmes

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AED
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Public access AED
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Public access defibrillation
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Historical

• Modern era of CPR began in 50s with rediscovery
  of closed-chest cardiac massage and mouth to
  mouth ventilation.
• 1st successful VF cardioversion by external
  paddles in 56
• 76 ARC established voluntary co-ordinating body
  for standardisation of resuscitation techniques
• 92 ILCOR formed. Guidelines 2000, 05, 10, .

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Resuscitation end-points

• ROSC Restoration of adequate cardiac function
• Successful resuscitation Restoration of
  normal brain function.
• Likelihood of achieving both these goals
  decreases with every minute in cardiac arrest.
• Cardiac output by standard chest compression is
  at best lt30 baseline decreases precipitously
  with time to initiation and duration of chest
  compression.

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Recent changes (ILCOR 05)

• Emphasis on early defibrillation
• Single shock. Can give 3 at initial attempt by
  Health Care Professional (HCP)
• Minimise interruptions to chest compression
• After each defibrillation, give 2 mins (5 cycles)
  CPR
• Emphasis on correctable causes (see later)
• CV 302, except for paeds/HCP scenario, where
  152
• Circulation 2005 IV-12-IV-18 (http//www.circulat
  ionaha.org)

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Shockable rhythms

• 1/5 deaths from sudden death syndromes
• 2/3 of these start off as VF
• VF and pulseless VT treated identically. If
  either occur whilst on a monitor, may be seen to
  remain conscious for 15-30 s.
• Encouraged to cough vigorously till defibrillator
  available.

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ATP

• In VF, ATP depletes over time. Defib 1st in early
  minutes of arrest. 1 ½ -3 mins CPR 1st if arrest
  prolonged (gt 4-5 minutes) increases likelihood of
  ROSC and survival to discharge.
• CPR important both BEFORE and AFTER shock
  delivery

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Asystole

• Unlikely to survive (as are arrests gt 1hr)
• 1mg adrenaline every 3 mins in CPR cycle
• Exceptions (ie benefit from prolonged CPR)
• Children
• Hypothermia
• Near drowning
• Drug OD

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Asphyxia

• Unknown of adult deaths have asphyxial
  mechanisms e.g. drowning or drug o/d
• Is the mechanism of cardiac arrest in most
  children, although about 5-15 have VF
• Rescue breathing/ early CPR more important in
  these cases

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Cardiac Arrest Mx

• 1o ABCD Survey
• Focus Basic CPR and defib
• Check responsiveness
• Activate emergency response
• Call for defibrillator
• A open Airway /- 2 rescue breaths
• B Breathing PPV (O2, bag-valve mask)
• C Circulation chest compression
• D Defib. Assess for shock VF or pulseless VT

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Cardiac Arrest Mx

• Team leader co-ordinate organise team
• Remove clothing from upper body
• Allows defibrillation
• ECG monitoring
• Chest compressions
• IV access
• BLS defib is key. Chain of survival
• CPR early and continuous 100/min, 302
• Praecordial thump?
• Adults witnessed or monitored
• When defib not avail, within 1st 15 seconds
  ideally
• Delivers 4J can be hazardous

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Cardiac Arrest Mx

• Defibrillation
• The only specific early intervention shown to
  improve outcome
• Know the machine in your practice
• ALS algorithm
• Shockable (VF and pulseless VT)
• Non-shockable
• Remove O2 flux, and transdermal GTN
• 200J biphasic. 360J monophasic.
• Not necessary to check for pulse after
  defibrillation unless rhythm obtained compatible
  with output
• With good CPR acidosis unlikely in 1st 15mins

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Compression technique

• Infants (lt1 y.o.)
• Lower ½ sternum (just below nipples)
• Use 2-3 fingers
• Compression depth third to ½ chest depth
• Children (1 to 8-14)
• Visualise centre of chest
• Heel of 1 hand
• Depth 1/3 to ½ chest
• Adults
• Chest centre
• Heel of 2 hands, 1 on top of other
• 1 ½ - 2 inch depth
• Push hard and fast. Allow complete chest recoil
  after compressn. Minimise interruptions

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Defib. in children

• No AED guidelines for neonates
• Monophasic or biphasic defibrillators 1st shock
  2 J/Kg, subsequent 4 J/Kg
• Differentiate-
• Found collapsed, or layperson provider 2 mins
  CPR, then AED
• Witnessed collapse by HCP AED a.s.a.p.
• In-hosp CPR immediately, defib when available
• Paeds dose attenuators for children lt8 y.o., /or
  lt25Kg

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Neonatal CPR

• Rescue breath rate 40-60/min
• Compression depth 1/3 chest depth
• Without airway aim for 90 compressions and 30
  ventilations per minute, i.e. 31

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Algorithm non-shockable

• The following directs AHA accepted actions as
  part of the Secondary ABCDs for pulselessness
  with an organized cardiac rhythm. Provide 2
  minute cycles of CPR-rhythm/pulse checks and
  think P E A
• P Problem search (see Differential Diagnosis
  Table). Treat accordingly. Continue this
  algorithm if indicated. E Epi 1 mg IV/IO q3-5
  min. Or vasopressin 40 U IV/IO, once, in place of
  the 1st or 2nd dose of epi.
• A Atropine, with a slow heart rate, 1 mg IV/IO
  q3-5 min. (3mg max.)

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Differential Diagnosis Table

• The acronym "PATCH(4) MDs" provides a guide to
  problem search.
• Problem Assess (Possible Interventions)
• Pulmonary Embolism No pulse w/ CPR, JVD
  (Thrombolytics, surgery)
• Acidosis (pre-existing) Diabetic/renal patient,
  ABGs (Sodium bicarbonate, hyperventilation)
• Tension pneumothorax No pulse w/ CPR, JVD,
  tracheal deviation (Needle thoracostomy)
• Cardiac Tamponade No pulse w/ CPR, JVD, narrow
  pulse pressure prior to arrest (Pericardiocentesis
  )
• Hyperkalemia (pre-existing) Renal patient, EKG,
  serum K level, (Sodium bicarbonate, calcium
  chloride, albuterol nebulizer, insulin/glucose,
  dialysis, diuresis, Kayexalate)
• Hypokalemia EKG, serum K level (Treat with great
  prudence after careful assessment of the cause. K
  can kill.)
• Hypovolemia Collapsed vasculature (Fluids)
• Hypoxia Airway, cyanosis, ABGs (Oxygen,
  ventilation)
• Myocardial infarct History, EKG (Acute Coronary
  Syndrome algorithm)
• Drugs Medications, illicit drug use, toxins
  (Treat accordingly)
• Shivering Core temperature (Hypothermia
  Algorithm)
• If trauma is present then proceed with ATLS
  protocol.

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6 Hs, 5 Ts

• Toxins
• Tamponade
• Tension Ptx
• Thrombosis
• Coronary or Pulmonary
• Trauma

• Hypovolaemia
• Hypoxia
• Hyperkalaemia
• Hypokalaemia
• Hypoglycaemia
• Hypothermia

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Compression/ventilation

• Continuous sequential compression cumulatively
  increases coronary perfusion.
• Hands-off periods appear detrimental, reducing
  rate of ROSC.
• Delays in recommencing CPR-
• during rhythm check
• decision-making
• etc.

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Adequacy of respiration in CPR

• Aim Ventilation should match perfusion
• In absence of PEEP need 10 ml/kg tidal volume for
  adequate respiration
• Components-
• oxygenation (saturation of rbcs)
• ventilation (clearing CO2)

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Oxygenation and ventilation

• In cardiac arrest -
• reduced O2 consumption and delivery
• reduced CO2 production
• reduced venous return
• Therefore
• reduced need for ventilation, though need
  occasional lung inflation for oxygenation

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Sources of ventilation in CPR

• Active positive pressure
• Chest compression
• Gasping (agonal breaths) more effective breaths
  than standard breaths-
• Oxygenation (more lung inflation)
• Ventilation (more efficient breath)
• Circulation (more venous return)

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Compression-only CPR

• Easier to perform
• More acceptable to bystanders (because no mouth
  to mouth)
• Increased coronary perfusion
• Increased perfusion to brain and respiratory
  systemmay prolong gasping ( good)

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PEA and Asystole

• Ascendant rhythms over the last decade
• Less VF than previously
• More B-blockers and CCBs than ever before
• Glucagon important for adrenaline response
• Survivorship may improve
• Future work on possible synergy of vasopressin
  and adrenaline in asystole
• Stratton, Ann Em Med 32448, Oct.98

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Discontinuing CPR

• USS ? no cardiac motion ? stop
• Save resources
• If PEA with no cardiac motion ? ALL dead
• PEA with motion ? 8/11 ROSC ? 1 lived
• No ROSC ? no survivors ? NOT worthwhile
• Am J EM 23459-62, July 05

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USS early in Resuscitation

• Detect correctable causes causes of PEA
• near PEA low BP with detectable pulses
• Cardiac motion RV collapse
• Drain it with a needle
• 7/8 with drainage survived to discharge
• Tayal VS, Resusc 59315, Dec 03

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Post-arrest Mx Hypothermia

• Recommended in unconscious adults with ROSC in
  OHCA where initial rhythm was ventricular
  fibrillation
• Start ASAP with external and internal cooling
  techniques
• May also benefit in-hosp arrests and non-VF
• Current study RICH trial, of Ice Cold Hartmanns

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Hypothermia

• Largevol ice-cold i.v.fluids, to total of 40
  ml/kg
• Reduce temp by 2 deg C over 30 mins
• No pulm oedema caused
• Maintain BP with adren infusion to sys BP gt100
• Then cath. Lab.
• Maintain 33 deg C for 24 hrs
• Then slowly rewarm over 12 hrs
• Bernard et al., NEJM 346(8), 2002

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Other on-going trials

• The Adrenaline trial
• Adrenaline vs placebo (NHMRC-funded)
• The CPR 1st trial
• Adelaide, commenced July 05
• Future trials on no ventilation (hi flow O2)

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For now

• Concentrate on rapid delivery of good quality
  standard CPR
• rather than too much change