C.P.R احیاء قلبی – ریوی - PowerPoint Presentation

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C.P.Rاحیاء قلبی – ریوی

دکترسعیدرضا پهلوانپور

سرپرست اورژانس 115 استان یزد

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تعریف

اقدامات و کوشش های سیستماتیک برای خارج کردن فرد از وضعیت بحرانی و ناگهانی تهدید کننده زندگی

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Synonymous Names

C.P.R

C.C.R

C.P.C.R

Hands only CPR

C.O.C.P.R

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History

1960 :CPR that was first use

(mouth-to-mouth)Ventilation+chest compression

(BLS+ACLS+PALS)

1986 :

American Heart Association (AHA)

(ACLS algorithms & CPR guideline)

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Cardiopulmonary arrest:

The abrupt cessation of spontaneous and effective cardiac out put and ventilation.

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The diagnosis of cardiac arrest



unconscionsness



pulselessness



Breathlessness

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Survival

Highest survival rates and quality of survival are attained when:

- BLS is initiated within 4 min

- ACLS is initiated within 8 min

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Management of CPR

It is a team effort.

Coordination of the team is the responsibility of the team leader (Ideally Anesthesiologist).

Responsibilities of the team leader:

1- Ensure the quality of BLS.

2- Facilitate early use of electrical defibrillation.

3- Direct and monitor the adequacy of drug therapy.

Ultimately, the team leader decide when CPR should cease.

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Indications

Unconscious (unresponsive)

Abnormal breathing, although there may be brief irregular, gasping breaths

Pulselessness or non effective circulation

Traumatic patient (electrical, drawing, crash, car accident, …)

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To handle a CPR

Avoid agitation

Have a good knowledge

Have a good physical ability

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Start CPR Immediately

Better chance of survival

Brain damage starts in 4-6 minutes

Brain damage is certain after 10 minutes without CPR

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Basic Life Support

CPR

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B L S

تكنيكهاي مقدماتي

CPR

كه افراد غير متخصّص هم با آموزشهاي اوليه ميتوانند انجام دهند

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BLS CONSIST OF

Circulation:

Circulation of blood by closed chest cardiac compression

Airway:

Provision of patent upper airway

Breathing:

Exhaled air ventilation

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زنجیره حیاتی در

BLS

تشخیص سریع و اطلاع به موقع اورژانس پیش بیمارستانی

احیاء سریع به وسیله فرد حاضر در صحنه

تجویز سریع شوک به وسیله دفیبریلاتور

اقدام به احیاء پیشرفته

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CAB

Circulation

Airway

Breathing

If victim is unconscious but does display vital signs, place on left side

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Unresponsive?

Shout for help

Open airway

Not breathing

normally?

Call EMS (115) or

CPR Team

30 chest

compression

2 rescue breaths

30 compression

Resuscitation council

(UK)

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CHEST COMPRESSION

1.CARDIAC PUMP

2 . THORACIC PUMP

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Put hand(s) in correct position for chest compressions

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ماساژ قلبی مناسب:

با سرعت حداقل 100باردردقیقه باشد.

بدون هیچگونه وقفه ای صورت گیرد.

درهربار ماساژقفسه سینه 5 سانتیمتر به داخل فرورود.

اجازه بازگشت به قفسه سینه داده شود.

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CPR

After 30 chest compressions give:

2 slow breaths

Continue until help arrives or victim recovers

If the victim starts moving: check breathing

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Checking Vital Signs

A – Airway

Open the airway

Head tilt chin lift

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Breathing

If the victim is not breathing,

give two breaths (1 second or longer)

Pinch the nose

Seal the mouth with yours

If the first two don’t go in,

re-tilt

and give two more breaths (if breaths still do not go in, suspect choking)

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When Can I Stop CPR?

Victim revives

Trained help arrives

Too exhausted to continue

Unsafe scene

Physician directed (do not resuscitate orders)

Cardiac arrest of longer than 30 minutes

(controversial)

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Checking for CPR Effectiveness

Does chest rise and fall with rescue breaths?

Have a second rescuer check pulse while you give compressions

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Why CPR May Fail

Delay in starting

Improper procedures (ex. Forget to pinch nose)

No ACLS follow-up and delay in defibrillation

Terminal disease or unmanageable disease (massive heart attack)

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Injuries Related to CPR

Rib fractures

Laceration related to the tip of the sternum

Liver, lung, spleen

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Complications of CPR

Vomiting

Aspiration

Place victim on left side

Wipe vomit from mouth with fingers wrapped in a cloth

Reposition and resume CPR

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Stomach Distension

Air in the stomach

Creates pressure against the lungs

Prevention of Stomach Distension

Don’t blow too hard

Slow rescue breathing

Re-tilt the head to make sure the airway is open

Use mouth to nose method

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A C L S

تكنيكهاي پيشرفتة

CPR

كه نياز به افراد متخصّص و تجهيزات ويژه دارد

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ACLS

Maintain the airway

External defibrillator

Drug therapy

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Airway Management

1) Face mask

a. simple

b. circumvents the concern about transmission of viral diseases and vomits

c. reservoir bag for manual ventilation and delivered O

2

for ventilation.

For example a flow O2

10 L/min

will provide inhaled oxygen concentration of about

50% by ambobag

Ambobag with Reserval bag inhaled oxygen concentration of about

100%

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Masks

Shields

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Mask ventilation

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One hand mask holding

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Endotracheal Intubation

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3)

The

best method

for maintenance of patent upper airway is placement of a

cuffed in the trachea

using direct

laryngoscope.

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AIMS

Control of the airway

Improve ventilation and oxygenation

Isolated the trachea from the GI tract

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Important:

Mechanical ventilators are not

reliably effective during CPR

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External defibrillation is definitive treatment of VF&VT

External defibrillator

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The most important determinant of success of DC shock and survival of victim is the length of interval from arrest to application of counter shock.

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Prompt tracheal intubations is important but DC shock should not be delayed to accomplish this goal if ventilation of the victims lungs can be accomplished without intubation

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Defibrillation

Strategies before defibrillation

Safe use of oxygen

Chest hair

Paddle force

Electrode position

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Safe use of oxygen

In an oxygen-enriched atmosphere, sparks from poorly-applied defibrillatorpaddles can cause a fire. Taking the following precautions can minimise this risk:

• Remove any oxygen mask or nasal cannulae and place them at least1 m away from the patient’s chest.

• Leave the ventilation bag connected to the tracheal tube or other

airway adjunct. Alternatively, disconnect the ventilation bag from thetracheal tube and move it at least 1 m from the patient’s chest duringdefibrillation.

• The use of self-adhesive defibrillation pads, rather than manualpaddles, may minimise the risk of sparks occurring.

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Chest hair

It may be necessary rapidly to shave the area intended for electrode placement,but do not delay defibrillation if a razor is not immediately available.

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Paddle force

If using paddles, apply them firmly to the chest wall. The optimal force is 8 kg inadults, and 5 kg in children 1-8 years using adult paddles. Place water-based gelpads between the paddles and the patient’s skin.

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Electrode position

Place the right (sternal) electrode to the right of the sternum, below the clavicle.

Place the apical paddle vertically in the mid-axillary line, approximately level withthe V6 ECG electrode position or the female breast. This position should beclear of any breast tissue. It is important that this electrode is placed sufficientlylaterally.

Antero-posterior electrode placement may be more effective than the traditionalantero-apical position in cardioversion of atrial fibrillation. Either position isacceptable.

An implantable medical device (e.g. permanent pacemaker or automaticimplantable cardioverter defibrillator (AICD)) may be damaged duringdefibrillation if current is discharged through electrodes placed directly over thedevice. Place the electrode away from the device or use an alternative electrodeposition. Remove any transdermal drug patches on the chest wall before defibrillation.

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Monitoring performance of CPR

1-

Palpation of the femoral or carotid pulse

2-

Pupillary size

3-

Systemic arterial pressure (Direct)

4-

Capnograph (PECO2)<

10

suggest a poor prognosis.

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Drug therapy

IV line for reliable delivery of drugs and fluids into circulation.

Correction of hypoxia and increasing coronary and cerebral blood flow.

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IV ACCESS FOR

MEDICATION

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Central line access

is not needed in most resuscitation attempts.

Drugs typically require

1

to

2 minutes

to reach the central circulation when given via a

peripheral vein

but require less time when given via central venous access.

IV Access for Medications:

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peripheral

venous route:

Follow with a 20 ml bolus of IV fluid

Elevate the extremity for 10 to 20 seconds to facilitate drug delivery to the central circulation.

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Intraosseous

(IO)

cannulation provides access to a noncollaps-ible venous plexus, enabling drug delivery

similar

to that achieved by

central venous

access

.

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If IV and IO access cannot be established, some resuscitation

drugs may be administered by the

endotracheal route

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Lidocaine

Epinephrine

Atropine

Naloxone

Vasopressin

E T route:

VALEN

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The optimal endotracheal dose of most drugs is unknown,

but typically the dose given by the endotracheal route is 2 to

2.5 times the recommended IV dose.

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Providers should

dilute

the recommended dose in

5

to

10

mL

of

water

or

normal saline

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Pulseless Arrest

4

rhythms

produce pulseless cardiac arrest:

Ventricular fibrillation (VF)

Rapid ventricular tachycardia (VT)

Pulseless electrical activity (PEA)

Asystole

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Survival

from these arrest rhythms requires both basic life support (BLS) and advanced cardiovascular life support (ACLS).

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For victims of

witnessed VF arrest

, prompt bystander

1.

CPR

2.

Early defibrillation

can significantly increase the chance for survival to hospital discharge.

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In comparison

, typical ACLS therapies, such as:

insertion of advanced airways and

pharmacologic support of the circulation,

have

not

been shown to increase rate of survival to hospital discharge.

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Pulseless

arrest and your reaction:

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ASYSTOLE / PEA

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complete cessation of myocardial electrical activity

End-stage rhythm

َ

Asystole should always be confirmed in at least two limb leads

It may be difficult to distinguish between extremely fine VF and asystole

Asystole

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PEA is defined as non-coordinated groups of electrical activity of the heart (other than VT/VF) without a palpable pulse.

Pulseless

Electrical

Activity

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Patients who have either asystole or PEA will not benefit

from defibrillation attempts

A vasopressor (epinephrine or vasopressin) may

be administered at this time.

Epinephrine can be administered

approximately every 3 to 5 minutes during cardiac arrest; one dose of vasopressin may be substituted for either the first or second epinephrine dose

For a patient in asystole or

slow PEA, consider atropine

ASYSTOLE/PEA MANAGEMENT

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Asystole & PEA

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Non-shockable rhythms (PEA and asystole)

Pulseless electrical activity (PEA) is defined as cardiac electrical activity in theabsence of any palpable pulse.

These patients often have some mechanicalmyocardial contractions but they are too weak to produce a detectable pulse orblood pressure.

PEA may be caused by reversible conditions that can be treated.

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Sequence of actions for PEA

Start CPR 30:2

• Give adrenaline 1 mg IV as soon as intravascular access is achieved

• Continue CPR 30:2 until the airway is secured, then continue chest

compressions without pausing during ventilation.

• Recheck the rhythm after 2 min.

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Sequence of actions for PEA

If there is no change in the ECG appearance

• Continue CPR

• Recheck the rhythm after 2 min and proceed accordingly

• Give further adrenaline 1 mg IV every 3-5 min

If the ECG

changes

and organised electrical activity is seen,check for a pulse.

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Sequence of actions for PEA

If a pulse is present, start post-resuscitation care.

• If

no

pulse is present:

Continue CPR.

Recheck the rhythm after 2 min

Give further adrenaline 1 mg IV every 3-5 min

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VT / VF

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VT / VF

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Shockable rhythms (VF/VT)

Sequence of actions

Attempt defibrillation (one shock - 150-200 J biphasic or 360J monophasic).

Immediately resume chest compressions (30:2) without reassessing

the rhythm or feeling for a pulse.

Continue CPR for 2 min, then pause briefly to check the monitor:

If VF/VT persists:

•

Give a further (2nd) shock (150-360 J biphasic or 360J monophasic).

Resume CPR immediately and continue for 2 min.

Pause briefly to check the monitor.

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Shockable rhythms (VF/VT)

Sequence of actions

• If VF/VT persists give adrenaline 1 mg IV followedimmediately by a (3rd) shock (150-360 J biphasic or 360 J monophasic).

• Resume CPR immediately and continue for 2 min.• Pause briefly to check the monitor.

• If VF/VT persists give amiodarone 300 mg IV followedimmediately by a (4th) shock (150-360 J biphasic or 360 Jmonophasic).

• Resume CPR immediately and continue for 2 min.

• Give adrenaline 1 mg IV immediately before alternateshocks (i.e. approximately every 3-5 min).

• Give a further shock after each 2 min period of CPR andafter confirming that VF/VT persists.

If organised electrical activity is seen during this brief pause incompressions, check for a pulse.

• If a pulse is present, start post-resuscitation care.

• If no pulse is present, continue CPR and switch to the nonshockablealgorithm.

If asystole is seen, continue CPR and switch to the nonshockable algorithm.

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Anti-arrhythmic drugs

On the basis of expertconsensus, if VF/VT persists after three shocks, give amiodarone 300 mg bybolus injection during the brief rhythm analysis before delivery of the fourthshock.

A further dose of 150 mg may be given for recurrent or refractory VF/VT,followed by an infusion of 900 mg over 24 h.

Lidocaine 1 mg/ kg may be usedas an alternative if amiodarone is not available, but do not give lidocaine ifamiodarone has been given already.

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During CPR

During the treatment of persistent VF/VT or PEA / asystole, there should be an emphasis on giving good quality chest compression between defibrillation attempts, recognizing and treating reversible causes (4 Hs and 4 Ts), and obtaining a secure airway and intravenous access.

Healthcare providers must practise efficient coordination between CPR and shock delivery. The shorter interval between cessation of chest compression and shock delivery, the morelikely it is that the shock will be successful. Reduction in the interval from compression to shock delivery by even a few seconds can increase the probability of shock success.

Providing CPR with a CV ratio of 30:2 is tiring;change the individual undertaking compressions every 2 min.

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Potentially reversible causes

Potential causes or aggravating factors for which specific treatment exists must be sought during any cardiac arrest.

For ease of memory, these are divided intotwo groups of four, based upon their initial letter, either H or T:

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Potentially reversible causes

H

ypoxia

•

H

ypovolaemia

•

H

yperkalaemia, hypokalaemia, hypocalcaemia, acidaemia, and othermetabolic disorders

•

H

ypothermia

•

T

ension pneumothorax

•

T

amponade

•

T

oxic substances

•

T

hromboembolism (pulmonary embolus/coronary thrombosis)

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1.Hypovolemia

2. Hypoxia

3. Hypothermia

4. Hypo/Hyper Kalemia. . Hypoglycemia

1. Toxins

2. Tamponad

3. Tension Pneumothorax

Thrombosis (coronary, pulmonary)

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Hypoxia

Minimise the risk of

hypoxia

by ensuring that the patient’s lungs are ventilated

adequately with 100% oxygen. Make sure there is adequate chest rise andbilateral breath sounds. check carefully

that the tracheal tube is not misplaced in a

.

bronchus or the oesophagus

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Hypovolaemia

Pulseless electrical activity caused by

hypovolaemia

is usually due to severehaemorrhage. This may be precipitated by trauma, gastrointestinal bleeding, orrupture of an aortic aneurysm.

Restore intravascular volume rapidly with fluid,coupled with urgent surgery to stop the haemorrhage.

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Hyperkalaemia, hypokalaemia, hypocalcaemia, acidaemia, and othermetabolic disorders

Hyperkalaemia,

hypokalaemia, hypocalcaemia, acidaemia, and other metabolicdisorders are detected by biochemical tests or suggested by the patient’s medicalhistory, e.g. renal failure.

A 12-lead ECG may be diagnostic.

Intravenouscalcium chloride is indicated in the presence of hyperkalaemia, hypocalcaemia,

and calcium-channel-blocking drug overdose

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• Hypothermia

Suspect

hypothermia

in any drowning incident; use a low-reading thermometer.

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Tension pneumothorax

A

tension pneumothorax

may be the primary cause of PEA and may followattempts at central venous catheter insertion.

The diagnosis is made clinically.

Decompress rapidly by needle thoracocentesis, and then insert a chest drain.

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Tamponade

Cardiac

tamponade

is difficult to diagnose because the typical signs of distendedneck veins and hypotension are usually obscured by the arrest itself.

Cardiacarrest after penetrating chest trauma is highly suggestive of tamponade and is anindication for needle pericardiocentesis or resuscitative thoracotomy

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Toxic substances

In the absence of a specific history, the accidental or deliberate ingestion oftherapeutic or

toxic

substances may be revealed only by laboratoryinvestigations.

Where available, the appropriate antidotes should be used, butmost often treatment is supportive.

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Slide102

Thromboembolism (pulmonary embolus/coronary thrombosis)

The commonest cause of

thromboembolic

or mechanical circulatory obstructionis massive pulmonary embolus.

If cardiac arrest is thought to be caused bypulmonary embolism, consider giving a thrombolytic drug immediately.

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During CPR

Correct reversible causes*

• Check electrode position

• Attempt / verify:IV access

airway and oxygen

• Give uninterruptedcompressions whenairway secure

• Give adrenalineevery 3-5 min

• Consider: amiodarone, magnesium

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104

Slide105

Emphasis on

effective

chest compression

One universal compression-to-ventilation

30/2

Recommendation for

1-second

breaths during all CPR

Do not delay defibrillation for in-hospital cardiac arrest

.

NOTICE

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Slide106

Although Guidelines 2010 recommended immediate defibrillation for allshockable rhythms, recent evidence indicates that a period of CPR beforedefibrillation may improve survival after prolonged collapse (> 5 min).

106

Slide107

Treat ventricular fibrillation/pulseless ventricular tachycardia (VF/VT)with a single shock, followed by immediate resumption of CPR (30compressions to 2 ventilations). Do not reassess the rhythm or feelfor a pulse. After 2 min of CPR, check the rhythm and give anothershock (if indicated).

The recommended initial energy for biphasic defibrillators is150-200 J

.

Defibrillation strategy

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Slide108

Rescuers should change compressors

every 2 min

Compression should ideally be

interrupted

only for rhythm check and shock delivery

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Slide109

Providers

do not attempt a pulse or check the rhythm

after

shock delivery

Drug

should be delivered during CPR,

as soon as

possible after rhythm check

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Slide110

Antiarrhythmics:

Amiodarone

is preferred to lidocaine , but either is acceptable

Deliver

1 shock

, then immediate CPR and

NO check pulse

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Slide111

1-Epinephrine

2-Amiodarone

3-Lidocaine

4-Magnesium

Medications for Arrest Rhythms

111

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Adrenaline (epinephrine)

VF/VT

Give adrenaline 1 mg IV if VF/VT persists after a second shock.

• Repeat the adrenaline every 3-5 min thereafter if VF/VT persists.

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Adrenaline (epinephrine)

VF/VT

The consensus recommendation is to giveadrenaline immediately after confirmation of the rhythm and just before shock delivery (

drug–shock–CPR–rhythm check

sequence).

Have the adrenalineready to give so that the delay between stopping chest compression and deliveryof the shock is minimised.

The adrenaline that is given immediately before theshock will be circulated by the CPR that follows the shock.

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Adrenaline (epinephrine)

VF/VT

When the rhythm is checked 2 min after giving a shock, if a non-shockable

rhythm is present and the rhythm is organised (complexes appear regular ornarrow), try to palpate a pulse. Rhythm checks must be brief, and pulse checksundertaken only if an organised rhythm is observed.

If an organised rhythm is seen during a 2-min period of CPR, do not interrupt chest compressions to palpate a pulse unless the patient shows signs of life suggesting return ofspontaneous circulation (ROSC).

If there is any doubt about the existence of a pulse in the presence of an organised rhythm, resume CPR.

If the patient hasROSC, begin post-resuscitation care

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Adrenaline (epinephrine)

VF/VT

In patients in asystole or PEA, give adrenaline 1 mg IV immediately intravenous access is achieved.

In both VF/VT and PEA / asystole, give adrenaline 1 mg IV every 3-5 min(approximately every other two-minute loop).

In patients with a spontaneous circulation, doses considerably smaller than 1 mgIV may be required to maintain an adequate blood pressure.

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Anti-arrhythmic drugs

On the basis of expertconsensus, if VF/VT persists after three shocks, give amiodarone 300 mg bybolus injection during the brief rhythm analysis before delivery of the fourthshock.

A further dose of 150 mg may be given for recurrent or refractory VF/VT,followed by an infusion of 900 mg over 24 h.

Lidocaine 1 mg/ kg may be usedas an alternative if amiodarone is not available, but do not give lidocaine ifamiodarone has been given already.

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Magnesium

Give magnesium sulphate 8 mmol (4 ml of a 50% solution) for refractory VF if there is any suspicion of hypomagnesaemia (e.g. patients on potassium-losingdiuretics).

• ventricular tachyarrhythmias in the presence of possible

hypomagnesaemia;

•torsade de pointes;

digoxin toxicity

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Bicarbonate

Giving sodium bicarbonate routinely during cardiac arrest and CPR (especially in

out-of-hospital cardiac arrest), or after ROSC, is not recommended.

Give sodiumbicarbonate (50 mmol) if cardiac arrest is associated with hyperkalaemia ortricyclic antidepressant overdose.

Repeat the dose according to the clinicalcondition of the patient and the results of repeated blood gas analysis

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Calcium

Calcium is indicated during resuscitation from PEA if this is thought to be caused

by:

• hyperkalaemia;

• hypocalcaemia;

• overdose of calcium-channel-blocking drugs;

• overdose of magnesium (e.g. during treatment of pre-eclampsia).

The initial dose of 10 ml 10% calcium chloride (6.8 mmol Ca2+) may be repeatedif necessary.

Remember that calcium can slow the heart rate and precipitatearrhythmias.

In cardiac arrest, calcium may be given by rapid intravenousinjection.

Do not give calcium solutions and sodium bicarbonate simultaneously by thesame venous access.

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Begins after establishment of a spontaneous cardiac out put

Post resuscitation life support (PRLS)

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supplemental 02

CXR

Drug therapy

Monitoring of pulmonary, cardiac

and renal

Slide122

The paitent who is awake and breathing spontaneously need only to monitored closely in an ICU

Slide123

Post-Resuscitation Management

Avoiding Fever

Cooling should begin within 1–2 hr after CPR.

Use cooling blanket to achieve a body temperature of 32°C–34°C

Use sedation and neuromuscular blockade to avoid shivering.

Watch for hyperkalemia and hyperglycemia during hypothermia.

Maintain hypothermia for 12- 24 hr, and then allow passive rewarming

Slide124

Post-Resuscitation Management

Glycemic Control

Hyperglycemia following cardiac arrest is associated with a poor neurologic outcome

Dextrose-containing intravenous solutions should be avoided

Hypoglycemia can also be injurious to the central nervous system,

Slide125

Do Not Attempt Resuscitation (DNAR) order

%

A

(DNAR) order is given by a licensed physician or

alternative authority as per local

regulation,and

it must be signed and dated to be valid.

%In

many settings, “Allow Natural Death” (AND) is becoming a preferred term to replace D

NAR

.

%

OralDNAR

order are not acceptable.

Slide126

Terminating Cardiac Arrest Resuscitative Efforts in Adult IHCA In the hospital the decision to terminate resuscitative efforts rests with the treating physician and is based on consideration of many factors, including witnessed versus

unwitnessed

arrest, time to CPR, initial arrest rhythm, time to defibrillation,

comorbid

disease,

prearrest

state, and whether there is ROSC at some point during the resuscitative efforts.

Slide127

1. Ask survivors if they want to view resuscitative efforts.

2. If they do, give them a quick briefing about what they will see, and have a knowledgeable staff member, usually a chaplain, social worker, or ED nurse who can answer their questions, accompany them.

3. Provide a chair for any elderly persons and allow survivors to leave and reenter as they wish.

4. Staff should attempt to cover as much of the patient as is compatible with effective resuscitative efforts.

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5. Team members should be advised that family is in the room.

6. The survivors should be encouraged to talk to and touch the patient.

7

. Decisions to pronounce the patient dead, although often discussed with the family, generally are communicated in the format of advising them that “we must stop now.” They should never be asked whether to stop the resuscitative effort; this is a medical decision.

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SAVE THE BRAIN