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Clinical Anaesthesiology

Clinical Anaesthesiology. Qiu Wei Fan Associate professor Department of Anaesthesiology Rui Jin Hospital Shanghai Second Medical University. 1. Cardiopulmonary Resuscitation. Consider most frequent causes Signs of cardiac arrest Management of cardiac arrest Management of brain damage. 2.

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Clinical Anaesthesiology

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  1. Clinical Anaesthesiology Qiu Wei Fan Associate professorDepartment of AnaesthesiologyRui Jin HospitalShanghai Second Medical University 1

  2. Cardiopulmonary Resuscitation Consider most frequent causes Signs of cardiac arrest Management of cardiac arrest Management of brain damage 2

  3. Consider most frequent causes 1)Hypovolemia 2)Hypoxia 3)Hydrogen ion-acidosis 4)Hyper-/Hypokalemia, other metabolic 5)Hypothemia 3

  4. Consider most frequent causes 6)‘Tables’(Drug OD, accidents) 7)Tamponnade, cardiac 8)Tension pneumothorax 9)Thrombosis,coronary(ACS) 10)Thrombosis,pulmonary(embolism) 4

  5. Signs of cardiac arrest Sudden deep unconsciousness Absent carotid and femoral pulse Dilated pupils Ashen cyanosis Apnoea or gasping 5

  6. Management of cardiac arrest Basic Life Support, BLS Advanced Life Support, ALS 6

  7. Cardiopulmonary Resuscitation The ABCs of cardiopulmonary resuscitation Airway, Breathing, and Circulation 7

  8. Cardiopulmonary Resuscitation Basic Life Support: life support without the use of special equipment 8

  9. Cardiopulmonary Resuscitation Advanced Cardiac Life Support: life support with the use of special equipment and drugs 9

  10. A: AIRWAY Head-tilt and Chin-lift, easy to perform Jaw-trust without Head-tilt, preferred whenever a cervical spine injury is suspected Heimlich Maneuver 10

  11. A: AIRWAY A. Tracheal intubation B. Cricothyroid puncture Cricothyrotomy Tracheostomy 11

  12. B: BREATHING Mouth –to-mouth: mouth-to-mouth-and-nose supplemental oxygen Mouth-to-mask: bag-valve-mask bag-valve-endotracheal tube 12

  13. C: CIRCULATION External Chest Compression Intravenous Access Dysrhythmia Recognition Drug Administration Defibrillaion and Cardioversion 13

  14. Basic Life Support, BLS External cardiac massage Airway and artificial ventilation Operator expired-air resuscitation Bag and mask ventilation Tracheal intubation If upper respiratory tract obstruction: Cricothyrotomy,Cricothyroid puncture,Tracheostomy 14

  15. External cardiac massage Lie on a hard surface (patient) Use weight of the upper body Arm straight to reduce fatigue heels of hands crossed Fingers clear of chest Apply pressure over the low half of the sternum The sternum is depressed 4-5cm in adult,2-4cm in children, and then allow to return to its normal position 15

  16. Advanced Life Support, ALS Intravenous infusion Administer drugs: Adrenaline Massive transfusion:Crystalloid or colloid solutions Correction of metabolic acidosis ECG monitoring: Management of important arrhythmias during CPR 16

  17. Advanced Life Support, ALS Cardiovascular system Respiratory system Central nerve system 17

  18. Dysrhythmia RecognitionDrug Administration 18

  19. Cardiac arrest (Patterns of ECG) Ventricular fibrillation (VF) Ventricular tachycardia with no cardiac output Asystole Electromechanical dissociation (EMD) 19

  20. VENTRICULAR ECTOPY 20

  21. PREMATURE VENTRICULARCONTRACTIONS Recognition Irregular rhythm Usually no P wave Compensatory pause follows (dose not reset sinus node) Bizarre QRS, often with right bundle branch block form 21

  22. PREMATURE VENTRICULARCONTRACTIONS Clinical Considerations More likely to cause ventricular fibrillation if PVS are multiple, multifocal, or occur during ventricular repolarization (vulnerable R-on-T period) 22

  23. PREMATURE VENTRICULARCONTRACTIONS Management Lidocaine (1.5 mg/kg I.V. repeated once, followed by lidocaine infusion of 1-4 mg/min) Procainamide (20 mg/min to a maximum of 1000 mg)Bretylium (5-10 mg/kg I.V.) 23

  24. VENTRICULAR TACHYCARDIARecognition Rate 100-220/min Rhythm regular of irregular P waves usually not present (if present, not temporally associated with QRS complexes) QRS complexes appear like premature ventricular contractions (ventricular tachycardia is three or more premature ventricular contractions in succession) 24

  25. VENTRICULAR TACHYCARDIAClinical Considerations Usually associated with dramatic decline in blood pressure and cardiac output 25

  26. VENTRICULAR TACHYCARDIAManagement If blood pressure is stable, deliver a precordial thump or give lidocaine (1.5 mg/kg I.V. repeated once) If pulse is present but blood pressure is unstable, begin immediate cardioversion If pulseless, treat as ventricular fibrillation 26

  27. VENTRUCULAR FIBRILLATIONRecognition Disorganized ventricular electrical activity Rate too rapid and disorganized to count Rhythm irregular No discernible P waves of QRS complexes Irregular undulations in electrocardiograph baseline 27

  28. VENTRUCULAR FIBRILLATIONClinical Considerations Always results on no effective cardiac output, and resuscitation must be started immediately 28

  29. VENTRUCULAR FIBRILLATIONManagement Defibrillation as soon as possible and repeated a necessary Epinephrine (0.5-1 mg I.V.) every 5 minutes Lidocaine (1 mg/kg I.V.) Bretylium (10 mg/kg I.V.) 29

  30. VENTRICULAR ASYSTOLERecognition Total absence of ventricular activity Absolutely flat baseline (except possible P waves) 30

  31. VENTRICULAR ASYSTOLEClinical Considerations Consider possibility of fine ventricular fibrillation and need for defibrillation Poor prognosis 31

  32. VENTRICULAR ASYSTOLEManagement Epinephrine (0.5-1 mg I.V.) every 5 minutes Atropine (1 mg I.V.) every 5 minutes Pacemaker (external or transvenous) 32

  33. Algorithm for treating Cardiac arrest Primary ABCD Survery Focus: basic CPR and defibrillation Check responsiveness Activate emergency response system Call for defibrilator 33

  34. Algorithm for treating Cardiac arrest A Airway: Open the airway B Breathing: provide positive-pressure ventilations C Circulation: give chest compressions D Defibrillation: assess for and shock VF/ pulseless VT, up to 3 times (200J,200J to 300J, 360J or equivalent biphasic) if necessary 34

  35. Algorithm for treating Cardiac arrest Rhythm after first 3 shocks? Persistent or recurrent VF/VT Secondary ABCD Survery Focus: more advanced assessments and treatments 35

  36. Algorithm for treating Cardiac arrest More advanced assessments and treatments A Airway: place airway device as soon as possible B Breathing: confirm airway device placement by exam plus confirmation device; secure airway device ; purpose-made tube holders preferred; confirmeffective oxygenation and ventilation C Circulation: establish IV access; identify rhythm; administer drugs appropriate for rhythm and condition D Differential Diagnosis: search for and treat identified reversible causes 36

  37. Management of brain damage General measures Prevention of hypoxaemia and hypercapnia Depression of cough and swallowing Specialised treatment Hyperventilation Osmotherapy Steroids Barbiturates and CNS depressants Calcium antagonists 37

  38. Questions What are the most frequent causes of cardiac arrest? What are the signs of cardiac arrest to justify diagnosis? How to manage cardiac arrest? 38

  39. Any Questions? Thank You! 39

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