DR SUJATA PROFESSOR DEPT.OF ANAESTHESIOLOGY &CRITICAL CARE UCMS & GTB HOSPITAL

1. CARDIOPULMONARY RESUSCITATION DR SUJATA PROFESSOR DEPT.OF ANAESTHESIOLOGY &CRITICAL CARE UCMS & GTB HOSPITAL

2. CPBR/ CPCR • CPR • Cardiopulmonary brain resuscitation -CPBR • Cardiopulmonary cerebral resuscitation-CPCR

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

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

5. Cardiopulmonary Resuscitation ACLS PROLONGED LIFE SUPPORT BLS A - Airway B - Breathing C - Circulation D- Defibrillation

6. 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

7. Adult Chain of Survival

8. 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

9. 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

10. Before BLS Primary Survey

11. 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

12. BLS Primary Survey….components

13. 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

14. A C B AIRWAY BREATHING CIRCULATION DEFIBRILLATION D

15. 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

16. 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

17. 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

18. Keeping the airway open, look, listen, and feel for normal breathing. ……OPEN AIRWAY

19. Look, listen and feel for NORMAL breathing

20. 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.

21. 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

22. 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. • Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.). • Allow complete chest recoil.

23. CHEST COMPRESSIONS30 CHEST COMPRESSIONS

24. 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.

25. 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 (30:2) - Recommended for all • single rescuers of infant, child and adult victims (excluding newborns) • Two Rescuers = 30:2- ALL ADULTS, • 15:2 – Infants and child • PURPOSE : PUSH HARD,PUSH FAST

26. 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.

27. AED

29. Positioning of electrodes for automated external defibrillator

30. DEFIBRILLATION ATTACH PADS TO VICTIM’S BARE CHEST

31. Ventricular Fibrillation

32. Continuous electrocardiogram showing successful treatment of ventricular fibrillation by a countershock (given at the arrow)

33. 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

34. 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.

35. ACLS Secondary Survey…… components

36. 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.Laryngeal Mask Airway 5.Transtracheal catheter ventilation 6.Cuffed oropharyngeal airway ADJUNCT of CHOICE: TRACHEAL TUBE PURPOSE MAINTAIN AIRWAYAND OXYGENATE

37. ACLS Secondary Survey…….components

38. Common Reversible Causes

39. 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

40. EFFECTIVE CHEST COMPRESSION WITH MINIMAL HANDS OFF IS KEY FOR EFFECTIVE CPR

41. When to stop BLS • ROSC, Conscious pt. • ACLS team takes over • Rescuer tired

42. SUMMARY

43. DRUGS • EPINEPHRINE • Peripheral vasoconstriction-  -adrenergic • Increase in Central aortic perfusion pressure • Decrease Threshold for Defibrillation • Fine VF to Coarse VF

44. 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.

45. DEFIBRILLATOR l - + RA LA - - lll ll + + LL ECG WHITE-RIGHT SIDE RED- RIBS-LEFT MID-AXILLARY LEFT-OVER-LEFT SHOULDER

46. The dying heart IDENTIFY THE RHYTHM

47. RHYTHMS • 1.VENTRICULAR FIBRILLATION • 2. RAPID VENTRICULAR TACHYCARDIA • 3. PULSELESS ELECRICAL ACTIVITY • 4. ASYSTOLE

48. 2 Asystole OR Pulseless Electrical Activity