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Current trends in CPBR: Techniques and underlying mechanism. Dr. Gaurav Dhakate. University College of Medical Sciences & GTB Hospital, Delhi. Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands. JAMA 1960. History :.

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current trends in cpbr techniques and underlying mechanism

Current trends in CPBR:Techniques and underlying mechanism

Dr. GauravDhakate

University College of Medical Sciences & GTB Hospital, Delhi

slide2

Anyone, anywhere, can now initiate cardiac resuscitative procedures. All that is needed are two hands.

JAMA 1960

history
History :
  • 1960 : Kouwenhoven et al reported survival of 14 patients of cardiac arrest following closed cardiac massage.
  • 1960 : combination of chest compression and rescue breath introduced.
  • 1962 : direct-current , monophasic waveform defibrillation was described.
  • 1947 : Beck successfully defibrillated his first patient, a 14-year-old boy whose heart went into fibrillation after an operation.
slide4

1978 : The first AED was originally designed and created by American biomedical engineer Joshua L. Koelker and Italian emergency medical professional Jordan M. Blondino.

2010 AHA ECC guidelines mark the 50th anniversary of CPR.

what is cpr
What is CPR ?
  • Cardio pulmonary resuscitation is an emergency medical procedure performed on a victim of cardiac or respiratory arrest and it consists of rapid chest compressions to maintain blood circulation, along with artificial respiration.
purpose
Purpose :

To maintain circulation to brain and heart thereby prevent the tissue death and brain damage until cardiac activity is restarted.

Goal :

  • Support & restore effective oxygenation,

ventilation and circulation with return of intact neurological function.

Intermediate Goal:

  • Return of spontaneous circulation (ROSC)
3 phases of cardiac arrest
3 phases of cardiac arrest :

Following a cardiac arrests, 3 distinct phases are characterized in the body:

  • Electrical phase : first 4 – 5 mins, defibrillation has most dramatic effect and it is highly successful.
  • Haemodynamic phase : next 4 – 5 mins. Fibrillating heart losses all ATPs.
  • Metabolic phase : CPR is only effective if commenced within 6 minutes after the blood flow stops. Hypothermia helps in prolonging this phase.
recommendations for cpr
Recommendations for CPR:
  • AHA guidelines every 5 yrs.
  • The guidelines are based on strength of available evidence.
  • These are based on most current and comprehensive review published by the 2010 ILCOR International consensus on CPR and ECC science with treatment recommendations.
  • ILCOR is a body of 7 international resuscitation organizations (AHA, ERC, IAHF, HSFC, ANZCOR, RCSA, RCA).
slide9
Cont.
  • Included 356 resuscitation experts from 29 countries.
  • Took 36 months before the consensus.
  • These experts produced 411 scientific evidence reviews on 277 topics in resuscitation and emergency cardiovascular care.
slide11
SCA
  • LEADING CAUSE OF DEATH
  • Etiologies:

Cardiac vs non cardiac

  • Circumstances

out of hospital and in the hospital SCA.

  • Settings :

witnessed or unwitnessed .

Single approach for maximum benefit…..

Chain of survival

early access
Early access

Early access to the victim

  • Scene safety: Rescuer, victim.
  • Call help: outside the hospital102, inside the hospital, activate the code.
  • Get AED
early cpr components of bls
Early CPRComponents of BLS:

C A B Defibrillation

A B C Defibrillation

WHY THE CHANGE?

  • C : circulation
  • A : airway
  • B : breathing
the change from a b c to c a b
The change from “A-B-C” to “C-A-B”
  • Most common cause of witnessed fall: cardiac arrest.
  • Most common cause of cardiac arrests: VF, pulseless Ventricular tachycardia.
  • key to survival: chest compression and early defibrillator.
  • Securing airway is most difficult part.
  • Hesitancy on part of rescuer to provide breaths.
  • This new sequence leads to early starting of most important part of therapy with minimal delay in ventilation.
  • Healthcare providers could tailor the sequence of rescue action to its cause.
bls primary survey
BLS Primary survey
  • Support/ restore effective oxygenation, circulation and ventilation until ROSC or ACLS team takes over.
  • No advanced interventions- airway tech./ drugs (use safety measures).
  • Early CPR and early defibrillation
chest compressions
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: at least 2 inches
  • Rate: at least 100 per minute (5 cycles of 30:2-C:V over 2 min.).
  • Allow complete chest recoil.
cpr techniques and devices
CPR techniques and devices :
  • High frequency chest compression.
  • Open chest CPR.
  • Interposed abdominal compression CPR.
  • Cough CPR.
  • Prone CPR.
  • Precordial thump.
  • Percussion pacing.
mechanism of action of chest compressions
Mechanism of action of chest compressions:
  • Thoracic pump theory
  • Cardiac pump theory
hands off time
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.
basic airway skills
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
breathing
Breathing

Assessed at beginning while assessing responsiveness.

Look, Listen & feel ……has been removed

Each breath:

  • 1 Sec
  • Visible chest rise (ventilate not hyperventilate….)
  • Allow similar time for exhalation.
  • C:V 30:2
  • No chest rise after 1st breath- reposition airway/ mask seal .
  • No chest rise after 2nd breath- resume chest compression.

Compression only CPR for bystander rescuer

early defibrillation
Early defibrillation

How does a shock act?

  • High energy current- stuns the myocardium
  • Pacemaker: SA node restarts the rhythm

Why early? Will help only if myocardium is still viable.

  • Chance of survival : decline more gradually
  • 7%-10% /min…..if no CPR
  • 3%-4%/ min from collapse to defib if CPR is provided.
  • Like wise the decline is more gradual when early defib is done.
d defibrillators
D:Defibrillators:

Unresponsive victim

No pulse

No breathing

Rhythm shockable: VF

Pulseless VT

defibrillators
Defibrillators

Types : Manual defibrillators,

Automated external defibrillators (AED).

  • Monophasic / biphasic.

Adult and child (1-8 yrs).

Infants: Manual defib is preferred.

>4 J/kg- 9J/kg have effectively defibrillated children and animal models.

slide30

One shock f/b CPR has better results .

Less time consuming.

Optimal energy level: undecided.

Monophasic manual defibrillators: 360 J f/b 360 J subsequently.

Biphasic defibrillators: Better and safe. No studies on exact initial energy levels. Use manufacturers guidelines (120 J – 200 J).

Subsequent shocks: use same or higher energy levels.

AED: as programmed.

defib
Defib
  • Pad sizes:
  • Adult
  • Paediatric
  • Adult pads may be used in paediatric victims..not vice- versa

Special situations:

  • Hairy chest,
  • Pacemakers,
  • Medication patches,
  • Drowning.
after d
After D:
  • IMMEDIATE CHEST COMPRESSIONS……

WHY?

RETURN OF ELECTRICAL ACTIVITY ……. CONTRACTILITY IS LIKELY TO BE LIMITED ..NOT SUFFICIENT ENOUGH TO PUMP BLOOD FORWARD.

respiratory arrest
Respiratory arrest
  • Unresponsive victim who is not breathing normally but has a pulse.
  • Provide ventilations @ 10-12 breaths /min (1 breath every 5-6 secs).
  • Definitive airway device in place ventilate @ 8-10 breaths/min (1 breath every 6-8 secs).
  • Assess circulation every 2 minutes and maintain airway with a chin lift and call for help.
when not to start cpr
WHEN NOT TO START CPR
  • Unsafe scene
  • Valid DNAR order (?).
  • Signs of death (rigor mortis, decapitation or dependent lividity).
when to stop cpr
WHEN TO STOP CPR
  • ROSC
  • Trained help arrives
  • Too exhausted to continue
  • Unsafe scene
  • DNAR orders received (?).
  • Provide longer help if hypothermic or suspected toxins.
acls secondary survey
ACLS secondary survey

Components

  • C : CIRCULATION.
  • A: ADVANCED AIRWAYS- ETT, LMA, Combi-tube, Laryngeal tube
  • B : BREATHING.
  • D: DRUGS. DIFF DIAGNOSIS.
c circulation
C: Circulation

Advanced circulatory interventions:

Access for drug administration: IV/ IO/ ET.

IV: Preferred route, follow drug admin by 20 ml

fluid bolus, elevate limb for 10-20 secs.

IO: If iv route not available.

All drugs given iv can be given IO.

ET: Ideal dose not known, 2-2.5 X IV dose.

Dilute in 5-10 ml NS.

(Epi., vasopressin, atropine, lidocaine

naloxone).

circulation
Circulation

Drugs to control heart rhythm and blood pressure.

BP: Adrenaline, Vasopressin, Dopamine.

  • Adrenaline: α adrenergic vasoconstriction 1mg iv/ io every 3-5 mins.
  • Vasopressin: nonadrenergic peripheral vasoconstriction, 40 units iv/ io single dose,

Replaces 1st or 2nd dose of adrenaline.

  • Dopamine: 2-10 µg/kg/min.
drugs for rhythm
Drugs for rhythm

Rhythm: Atropine, Lidocaine, Amiodarone, Magnesium,

Adenosine.

  • Atropine:

Bradycardia: 0.5 mg upto a total of 3mg.

  • Amiodarone: VF/ pulseless VT unresponsive to

CPR, shock and vasopressor. 300 mg iv/ io first

dose, 150 mg iv/ io 2nd dose if reqd.

drugs for rhythm1
Drugs for rhythm
  • Lidocaine: alternative to amiodarone.

1-1.5 mg/kg iv/ io 1st dose, rpt 0.5-0.75

mg/kg upto total 3 doses or 3mg/kg.

  • Magnesium: terminate/ prevent torsades- de pointes, known/ suspected low magnesium (alcoholism, malnutrition).

load 1-2 g iv/ io in 10 ml 5% Dex 5-20 mins.

  • Adenosine: Narrow complex tachy (SVT), undiff. Regular, monomorphic wide- complex tachy.

6 mg rapid flush large vein, if reqd 12 mg

twice after 1-2 min.

IV injections f/b 20 ml fluid bolus and raising the arm.

a airway
A= Airway

Head tilt- chin lift/ jaw thrust

Basic airway adjuncts:

  • OPA: Use only in unconscious pts.
  • NPA: When OPA is difficult/ impossible.
airway
Airway

Advanced Airway interventions:

Endotracheal tube.

Laryngeal mask airway,

Laryngeal tube,

Combitube (esophageal-tracheal combitube)

breathing1
Breathing
  • 1 Breath every 5 -6 sec (10-12 breaths/ min).
  • Ventilation adequate?
  • Advanced airway ……required?
  • Advanced airway in place: 1 Breath every 6-8 sec (8-10 breaths / min).
  • Confirm placement of device, secure, confirm again- clinical (visible chest rise, 5 pt auscultation), Et CO2.
  • Compressions and ventilations are independent

( no more C:V 30:2 cycles).

pulseless arrest
PULSELESS ARREST
  • VF shockable rhythm
  • Pulseless VT
  • Asystole non shockable rhythm
  • PEA
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