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Cardiopulmanary and cerebral resuscitation. BLS. ALS. Basic Life Support Advanced Life Support Prolonged Life Support. AED. Survival Rate in Cardiopulmonary Arrest. 0 – 50 % (64%, 80%?). AED. Safety use Permissive legislation to use A ED (“Good Samaritan Law”)

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slide2

BLS

ALS

Basic Life Support

Advanced Life Support

Prolonged Life Support

AED

slide5
AED

Safety use

Permissive legislation to use AED(“Good Samaritan Law”)

1 DEA – 10.000 inhabitants

(population crowds,airports, police cars, fire fighters, casinos, etc.)

An AED uses voice prompts to guide the rescuer. It analyses the ECG rhythm and informs the rescuer if a shock is needed. AEDs are extremely accurate and will deliver a shock only when VF (or its precursor,

rapid ventricular tachycardia) is present .

early bls
Early BLS

Done by lays (from bystanders)

Until an emergency staff is available

Double the surviving

defibrilare precoce
DEFIBRILARE PRECOCE

Fiecare 1 minut scade şansa de supravieţuire cu 7 - 10 %

După 4 - 6 minute - leziuni neurologice

După 10 minute - tentative de resuscitare nereuşite

DEA ÎN 8-10 MINUTE!

suportul vital de baza svb
SUPORTUL VITAL DE BAZASVB

Scopul SVB: cardiac and cerebral oxygenation

Increase the defibrillation efficiency

DEFINITION:

Basic life support (BLS) refers to maintaining airway patency and supporting breathing and the circulation,

without the use of equipment other than a protective device

slide9

Consequences: - 3-5 min. => irreversible nerve cells lesions.

Optmal time (until) to start CPR = 4 min.

Longer time: - hypothermia (temp rectală 19-24 grade C)

- barbiturics influence

- child < 1 year old

Shorter time, 2-3 min.:

- respiratory arrest before heart stops

٠ barbiturics overdose

٠strangle

slide10

all cases accompanied with hypoxia

extracardiac

Causes of cardiac arrest

cardiac

Primary lesion of cardiac muscle leading to the progressive decline of contractility, conductivity disorders, mechanical factors

causes of circulation arrest
Cardiac

ischemic heart disease (myocardial infarction, stenocardia)

arrhythmias of different origin and character

valvular disease

cardiac tamponade

pulmonary artery thromboembolism

ruptured aneurysm of aorta

reflector cardiac arrest

Extracardiac

airway obstruction

acute respiratory failure

shock

electrolytic disorders

embolisms of different origin

drug overdose

electrocution

poisoning

metabolic acidosis

Causes of circulation arrest
slide12

FIOZIOPATOLOGIE

Încetarea (ceasing) activit de pompă a cordului

- lipsa debitului cardiac P.pf. miocardică şi coronariană

=> hipoxia cel, metabolism anaerob, acumularea de toxice

lez tisulare ireversibile

  • vasodilataţie sitemică
  • vasoconstricţie pulm
  • rasp la catecolamine

Acidoza

P.pf. cerebrală = PAM – PIC (P sist)

P.pf. miocard = PAM – P miocard (P diast)

slide13

DIAGNOSTIC of SCR

  • Rapid
  • unconscious + no respiration
  • + no pulse
  • ECG: asistole, FV, TV (activit electrică fără puls), PEA
  • Late clinical picture: - cyanosis and pale teguments
  • - areactive midriasis
bls sequence of operations
BLS - sequence of operations
  • Check responsiveness
  • Call for help
  • Correctly place the victim and ensure the open airway
  • Check the presence of spontaneous respiration
  • Check pulse
  • Start external cardiac massage and artificial ventilation
slide15

In case of unconsciousness it is necessary to estimate quickly

  • the open airway
  • respiration
  • hemodynamics
slide16

Main stages of resuscitation

A (Airway) – ensure open airway by preventing the falling back of tongue, tracheal intubation if possible

B (Breathing) – start artificial ventilation of lungs

C (Circulation) – restore the circulation by external cardiac massage

D (Differentiation, Drugs, Defibrilation) – quickly perform differential diagnosis of cardiac arrest, use different medication and electric defibrillation in case of ventricular fibrillation

slide17

Probleme teoretice

Ventilaţia artificială cu aer inspirat (16-18% O2)

Teoria pompei cardiace

- 30 % din perfuzia cerebrală optimă – limita critică a viabil. cel. corticale

- fluxul miocardic – 20-30% din valoarea normală

- fluxul visceral abdominal – 5%

slide18

1 Make sure you, the victim and any bystanders are safe.

2 Check the victim for a response

Adult basic life support algorithm.

• gently shake his shoulders and ask loudly: ‘‘Are you all right?’’

If he responds

• leave him in the position in which you find him provided there is no further danger

• try to find out what is wrong with him and get help if needed

• reassess him regularly

slide19

If he does not respond

• shout for help

• turn the victim onto his back and then open the airway using head tilt and chin lift

- place your hand on his forehead and gently tilt his head back keeping your thumb and index finger free to close his nose if rescue breathing is required. with your fingertips under the point of the victim’s chin, lift the chin to open the airway

slide20

Keeping the airway open, look, listen and feel for normal breathing

• Look for chest movement.

• Listen at the victim’s mouth for breath

sounds.

• Feel for air on your cheek.

In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, noisy gasps. Do not confuse this with normal breathing. Look, listen, and feel for no more than 10 s to determine whether the victim is breathing normally.

If you have any doubt whether breathing is normal, act as if it is not normal.

slide21

If he is breathing normally

• turn him into the recovery position

• send or go for help/call for an ambulance

• check for continued breathing

slide23

If he is not breathing normally

• send someone for help or, if you are on your own, leave the victim and alert the ambulance service; return and start chest compression as follows:

. kneel by the side of the victim

. place the heel of one hand in the centre of the victim’s chest. place the heel of your other hand on top of the first hand

. interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs.

. position yourself vertically above the victim’s chest and, with your arms straight,

.after each compression, release all the pressure on the chest without losing contact between your hands and the sternum; repeat at a rate of about 100/min. . . compression and release should take equal amounts of time

slide24

Combine chest compression with rescue breaths.

• After 30 compressions open the airway again using head tilt and chin lift.

• Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead.

• Allow the mouth to open, but maintain chin lift.

• Take a normal breath and place your lips around his mouth, making sure that you have a good seal.

• Blow steadily into the mouth while watching for the chest to rise, taking about 1 s as in normal breathing; this is an effective rescue breath.

• Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air passes out.

slide25

• Take another normal breath and blow into the victim’s mouth once more, to achieve a total of two effective rescue breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressi.

• Continue with chest compressions and rescue breaths in a ratio of 30:2.

• Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

If your initial rescue breath does not make the chest rise as in normal breathing, then before your next attempt:

• check the victim’s mouth and remove any obstruction

• recheck that there is adequate head tilt and chin lift

• do not attempt more than two breaths each time before returning to chest compr.

If there is more than one rescuer present, another should take over CPR every 1—2 min to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers

slide26

• Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

Continue resuscitation until

• qualifed help arrives and takes over

• the victim starts breathing normally

• you become exhausted

slide27

Ventilation

  • During CPR the purpose of ventilation is to maintain adequate oxygenation. The optimal tidal volume, respiratory rate and inspired oxygen concentration
  • to achieve this, however, are not fully known. The current recommendations are based on the following evidence:
  • During CPR, blood flow to the lungs is substantially reduced, so an adequate ventilation perfusion ratio can be maintained with lower tidal volumes and respiratory rates than normal.
  • 2. Not only is hyperventilation (too many breaths or too large a volume) unnecessary, but it is harmful because it increases intrathoracic pressure, thus decreasing venous return to the heart and diminishing cardiac output. Survival is consequently reduced.
  • 3. When the airway is unprotected, a tidal volume of 1 l produces significantly more gastric distention than a tidal volume of 500 ml.
slide28

4. Low minute-ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation during CPR. During adult CPR, tidal volumes of approximately 500—600 ml (6—7 ml kg-1) should be adequate.

5. Interruptions in chest compression (for example to give rescue breaths) have a detrimental effect on survival. Giving rescue breaths over a shorter time will help to reduce the duration of essential interruptions.

6. The current recommendation is, therefore, for rescuers to give each rescue breath over about 1 s, with enough volume to make the victim’s chest

rise, but to avoid rapid or forceful breaths. This recommendation applies to all forms of ventilation during CPR, including mouth-to-mouth and bagvalve-mask (BVM) with and without supplementary oxygen.

7. Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth ventilation. It may be considered if the victim’s mouth is seriously injured or cannot be opened, the rescuer is assisting a victim in the water, or a mouth-to-mouth seal is difcult to achieve.

slide29

RESUSCITAREA

EFECTUATĂ DE UN SINGUR SALVATOR

RATA CTE : RESPIRAŢII 15:2

EFECTUATĂ DE DOI SALVATORI

RATA CTE : RESPIRAŢII 5:1

RECOMANDAREA ANULUI 2002

RATA CTE : RESPIRAŢII 15:2

INDIFERENT DE NUMĂRUL DE SALVATORI

RECOMANDAREA ANULUI 2006

RATA CTE : RESPIRAŢII 30:2

INDIFERENT DE NUMĂRUL DE SALVATORI

slide30

OBSTRUCŢIA CRS PRIN CORP STRĂIN

RECUNOAŞTERE

- TUSE

- FLUX AERIAN BUN

- PARŢIALĂ

- EFORT RESPIRATOR

  • TUSE INEFICIENTĂ

- FLUX AERIAN PROST

  • INSPIR ZGOMOTOS

Noisy inspiration

  • CIANOZĂ

- COMPLETĂ

slide31

EVALUAREA SEVERITĂŢII

OBSTRUCŢIE SEVERĂ

(tuse ineficientă)

OBSTRUCŢIE UŞOARĂ

(tuse eficientă)

INCONŞTIENT

CONŞTIENT

RCP

5 LOVITURI INTERSCAPULARE

5 COMPRIMĂRI ABDOMINALE

ÎNCURAJAREA TUSEI

OBSTRUCŢIA CU CORP STRĂIN

A CĂILOR AERIENE

slide33

ÎNDEPĂRTAREA OBSTRUCŢIEI

5 LOVITURI CU PODUL PALMEI LA

NIVELUL SPAŢIULUI INTERSCAPULOVERTEBRAL

5 COMPRESIUNI ABDOMINALE

MANEVRA HEIMLICH

slide34

MANEVRA HEIMLICH

VICTIMĂ CONŞTIENTĂ

VICTIMĂ INCONŞTIENTĂ

slide36

CPR

Advanced Life Support

slide37

SUPORTUL VITAL AVANSAT

  • Scop:restore heart pomp activity by medication and defibrillation
  • - 8 min. since the heart stoped
  • maintaining BLS!!
  • IOT
  • venous acces
  • medication
  • DEFIBRILLATION !! – as soon as possible
slide39

FIBRILATIA VENTRICULARA

= activitateaanarhica a maimultorcentriectopiciraspanditidifuz in micoardul ventricular; acesticentrigenereaza automatism producanddescarcarielectricezonaleceduc la contractiiparcelare, facandincapabilafunctia de pompa

FV primara– aparepe un cord indemnhipoxic ( frecvent la copii)

FV secundara– un mecanism de alteraremorfofunctionala a miocardului

slide40

TAHICARDIA VENTRICULARA

= expresiaunordepolarizarisuccesive de origineventriculara (sub bifurcatiahisiana), de obiceicauzata de boalacornoranianaischemica

TV nesustinuta< 30 sec.

TV sustinuta> 30 sec. + colapshemodinamic

In functie de morfologiacomplexului ORS clasificarea TV se va face in TV monomorfasi TV polimorfa

O forma particulara de TV este torsada varfurilor generata de posdepolarizarea precoce in anumite conditii: QT lung (efect toxic a fenotiazidelor, antidepresive triciclice, haloperidol, antiaritmice), bradicardie severa, AVC-uri, dezechilibre hidroelectrolitice, hipotermie, boli cardiace

slide43

ASISTOLA

  • = lipsa totala a activitatii electrice a cordului, cu un prognostic rezervat, rata de supravietuire 1-2%
  • reprezentata de o linie sinusoidala (nu izoelectrica) compusa de mici unde date de depolarizarile de mica intensitate a musculaturii scheletice
  • trebuie diferentiata de FV cu unde mici
slide45

DISOCIATIA ELECTROMECANICA

= entitatepatologicaparticulara a SCR, caracterizataprinasociereadintr-e o activitateelectricaprezenta (altadecat FV/TV) silipsaactivitatiimecanice a miocardului ventricular.

DEM cu complexe QRS largi cu frecventascazutaapar in: IM masiv, hipopotasemiesevera, hipotermie, hipoxieacidoza, supradoajul de antidepresivetriciclice, beta-blocante, blocante ale canalelor de calciu, digitalice.

DEM cu complexeingustecu frecventacrescuta (d.p.d.v. electric cordulraspunderelativ normal): hipovolemie, tampodanacardiaca, pneumotoracecompresiv, TEP masiv.

shockable rhythms ventricular fibrillation pulseless ventricular tachycardia
Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia)

* VF may be preceded by a period of VT or even supraventriculr tachycardia (SVT)

VF/VT confirmed

one shock (150 – 200 J biphasic)

without reassessing the rhythm

resume CPR (CV ration 30:2) 2 min.

check monitor if there is still VF/VT

second shock (200 J biphasic)

resume CPR (CV ration 30:2) 2 min.

slide48

check monitor if there is still VF/VT

Adrenaline 1 mg**

3rd shock (200 J biphasic)

resumption of CPR for 2 min.

analyze the rhythm if is still present VF/VT

i.v. bolus of Amiodarone 300 mg

4th shock

** - adrenaline 1 mg every 3-5 min., once every two loops of the algorithm

slide49

Non-shockable rhythms (PEA and asystole)

Asystole

  • PEA = pulseless electrical activity is defined as cardiac activity in the absence of any palpable pulses
  • mechanical myocardial contractions, but these are too weak to produce pulse
  • caused by reversible conditions

CPR 30:2

Asystole/PEA

i.v. + Adrenaline 1mg

Atropine 3 mg

secure airway, IOT

Recheck the rhythm every 2 min

airway and ventilation
Airway and ventilation

- without a good oxygenation it may be impossible to restore a spontaneous cardiac output.

- consider reversible causes (4 H’s and 4 T’s) and, if identified, correct them.

Tracheal intubation provides the most reliable healthcare provider but only for trained staff.

- do not hyperventilate, ventilate the lungs at 10 breaths/min.

Alternatives: - combitube

- laryngeal mask airway (LMA)

- laryngeal tube

Deliver chest compressions, uninterrupted during ventilation.

slide51

Suportul Vital Avansat

Intubatia oro-traheala

slide61

PRESIUNEA CRICOIDIANĂ

PENTRU EVITAREA REGURGITĂRII

CONŢINUTULUI GASTRIC

slide70

DEFIBRILAREA

  • trebuie aplicata cat mai rapid pt o recuperare neurologica cat m completa;
  • este tratamentul propriu-zis al FV

= aplicarea unui soc electric miocardului pt a realiza depolarizarea fibrelor miocardice simultan si pt a permite preluarea controlului de catre struct naturale generatoare de impulsuri.

slide71

Mecanismuldefibrilarii

  • depolarizarea unei mase de miocard prin traversarea curentului electric
  • marimea electrozilor 10-30 cm
  • plasarea corecta a padelelor, gel transconductor

150 - 200 J bifazic

360J monofazic

Energia socului electric

slide72

CARDIOVERSIA SINCRONA

  • tratamentul: - TV, TA (pacientul constient trebuie sedat)
  • socul sincronizat cu unda R a complexului QRS
  • 50 J, 100J, 200J, 300J, 360J

Securitatea manoperei

slide73

LOVITURA CU PUMNUL

poate :

-stimula activitatea electrica in asistola

- “converti” o TV (11-40%)

- “converti” o FiV (2,5%),

slide74

LOVITURA CU PUMNUL

Leziuni fizice directe:

-fracturi sternale,

-fracturi costale,

-contuzii miocardice

-rupturi(?)de cord

*Accelerarea frecventei unei TV

*Precipitarea FiV(risc mai mare la bolnavii digitalizati).

slide76

ADRENALINA

= amina simpaticomimetica

  • primul medicament utilizat în algoritmul SCR
  • acţiune betaexcitatoare – efect B, D, C, I (+)
  • alfa adrenergic – creşte R.art.perif. – ameliorarea PAM

Doze în SCR: - 1 mg i.v – repetabil la 3 min.

- 3 mg IOT – diluat in 10-20 ml SF.

Ef. sec. – artimogenă când miocardul este ischemic sau hipoxic

slide77

ATROPINA

Ind: - asistolă

- DEM cu fc<60/min.

- bradicardii sinusale, atriale sau nodale + hTA

  • antagonizează ef. parasimpatic al acetilcolinei la niv. rec. muscarinici;
  • determină bloc ef vagale la niv nodului sinoatrial sau AV - creşeterea automatismului sinusal + facilitarea conducerii

Doze: - 0,5 – 1 mg i.v., repetabilă la 5 min. – in bradicardii

- max 3 mg i.v. o singura data in SCR - asistolie

- IOT 9 mg/20 ml soluţie de diluţie

slide78

AMIODARONA

  • scade automatismul nodului sinusal, alungeste timpul de conducere si perioada refractara a nodului AV si a miocardului V.
  • creste durata potentialului de actiune in miocardul atrial si ventricular.
  • eficace inotrop negativ si cronotrop negativ – proprietati antianginoase
  • poate deveni paradoxal proartimogena.
  • INDICATII
  • FV/TV fara puls refractara la defibrilare (dupa 3 socuri)
  • doza este de 300 mg diluata in 20 ml G 5% bolus
  • a doua doza este ½ din prima, poate fi urmata de perf continua 1 mg/min timp de 6 ore in anumite situatii (doza totala este 2 g)
slide79

LIDOCAINA

Ind: - TV instabile hemodinamic

- FV refractară la defibrilare

Efecte: - scade automatismul V.

- ef anestezic local suprimă activitatea ectopică V

- creşte pragul FV

!!! Nu are efect pe artimiile atriale

- eficienţa scade în hipo-K, hipo-Mg

Doza: - iniţial 100 mg i.v sau 1 mg/kg (efect 10 min), repetabil

- pfz 2-4 mg/min

slide80

CALCIU

Ind: - disociaţia electromecanică dat hiper-K, hipo-Ca, supradozarea Ca-blocan

Doze: - CaCl 10% - 2 ml/70kg

- gluconat de Ca 10% - 3-8ml/70 kg

- repeabile la interval de 10 min.

BICARBONATUL DE Na

Ind: - acidoză metabolică severă, pH < 7,1

- hiper-K (exces de baze – 10mmol/l)

Doze mici de bicarbonat de Na 8,4%, repetabile

!! Monitorizarea gazelor sanguine

slide81

SUPORTUL VITAL PRELUNGIT

Scop: mentinerea activitatii cordului si a respiratiei si refacerea integrala a functiilor neuronale

  • recuperarea pacientului intr-o sectie ATI
  • supraveghere si monitorizare permanenta
  • Rx toracica !!

Protectie cerebrala - ameliorarea fluxului sanguin cerebral

- reducerea metabolismului cerebral

- prevenirea autolizei postischemice

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