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RESUSCITATIONGUIDE LINES 2005
Aries Perdana
Department of AnesthesiologyFaculty of Medicine, University of Indonesia/
Cipto Mangunkusumo Hospital
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GUIDE LINES 2005
Prevention
Cardiac
Arrest /
MET
BASIC
LIFE
SUPPORT
Advanced
Life
Support
Pediatric
Life
Support
NEONATAL
RESUS.
SPECIAL
RESUS.
SITUATIONS
POST
RESUS.
CARE
CONTROVERSIAL
TOPICS
BRADY &
TACHYCARDIA
Acute
Coronary
Syndrome
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Jerry P Nolan,Mary F H, et allResuscitation,2005;67:175-179
Compression first vs shock first
Compression ventilation ratio 1 vs 3- shock sequence for
defibrillation Shock dose Role of Vasopressor in treatment of
cardiac arrest Post resuscitation care
CONTROVERSIAL TOPICS FROM THE 2005INTERNATIONAL CONFERENCE ON CoSTR
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Compression first vs shock first
Delaying Defibrillation to Give Basic CPR toPatients With Out-of-Hospital VF,Randomized
Trial Lars Wik, MD, PhD,Trond Boye Hansen, MD et all
Conclusions : Compared with standard care forventricular fibrillation, CPR first prior to defibrillationoffered no advantage in improving outcomes forpatients with ambulance response times shorterthan 5 minutes. However, the patients withventricular fibrillation and ambulanceresponse intervals longer than 5 minutes hadbetter outcomes with CPR first beforedefibrillation was at tempted.
JAMA.2003;289:1389-1395
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The Cobb Study : influence of CPR prior todefib. in patients with out-of-hospital VF
Result: All patients:
* Survival shock first 24%* Survival CPR first 30%
Patients with response interval 4 minutes:* Survival shock first 17%* Survival CPR first 27%
After adjusting patient & factor differences:* CPR first- improved survival
JAMA. 1999;281: 1182-1188
Compression first vs shock first
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Compression first vs shock first
Other Research Robinson et al. (European journal of
anesthesiology. 1998; 15:702-709) :
CPR first 2 minutes unwitnessed VFarrests ROSC = 16 %, survival = 4% Defibrillation first questioned
Yakaitis rw, Ewy GA ( Critical Care Medicine.1980;8:157-163) : CPR first increases defibrillation successrates if limited to 3 7.5 minutes
?
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Compression first vs shock first
Conclusions
Absolute delay before Shock is critical Survival better with shorter response
times Survival improve with CPR first if
response times > 5 minutes CPR may provide critical cardiac
perfusion & metabolic state ofmyocytes more favorable responseto defibrillation
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Compression first vs shock first
Recommendation: CPR is performed 1,5-3 minutes
before defibrillation on ventricularfibrillation or pulseless ventriculartachiccardi which occurred out ofhospital orif emergency responsetime is more than 4 minutes
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Compression ventilation ratio
Survival and Neurologic Outcome After
Cardiopulmonary Resuscitation With FourDifferent Chest Compression-VentilationRatios
Arthur B. Sanders, Karl B Kern et all
Conclusion: In this experimental model of
bystander CPR, the group receiving compressionsonly for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved betterneurologic outcome than the group receivingstandard CPR and CC-CPR. Consideration ofalternative chest compression-ventilation ratiosmight be appropriate.
(Ann Emerg Med. 2002;40:553-562.)
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Compression ventilation ratio
Quality of Cardiopulmonary Resuscitation
During in-hospital Cardiac Arrest Benjamin S. Abella, MD, PhilJason P. Alvarado, BA,et all
ResultResult Analysis of the first 5 minutes of eachAnalysis of the first 5 minutes of eachresuscitation by 30resuscitation by 30--second segments revealed thatsecond segments revealed thatchest compression rates were less than 90/min inchest compression rates were less than 90/min in
28.1% of segments. Compression depth was too28.1% of segments. Compression depth was tooshallow for 37.4% of compression. Ventilationshallow for 37.4% of compression. Ventilationrates were high, with 60.9% of segmentsrates were high, with 60.9% of segmentscontaining a rate of more than 20/min.containing a rate of more than 20/min.
(JAMA. 2005;293:305-310)
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Compression ventilation ratio .
Conclusions : In this study of in-hospital cardiac arrest, the quality ofmultiple parameters of CPR wasinconsistent and often did not meetpublished guideline recommendationseven when performed by well-trained
hospital staff.
(JAMA. 2005;293:305-310)
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Compression ventilation ratio
Adverse Hemodynamic Effects of Interrupting ChestCompressions for Rescue Breathing During
Cardiopulmonary Resuscitation for VentricularFibrillation Cardiac Arrest
Robert A. Berg, MD; Arthur B. Sanders, MD; et all
Conclusion :
Interrupting chest compressions for rescue
breathing can adversely affect hemodynamicsduring CPR for VF.
(Circulation.2001;104:2465-2470.)
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Compression ventilation ratio
Importance of Continuous Chest Compressions During
Cardiopulmonary Resuscitation Improved OutcomeDuring A Simulated Single Lay-Rescuer ScenarioKarl B. Kern, MD Ronald W. Hilwig, DVM, PhD et all
ConclusionsMouth-to-mouth ventilation performed by
single layperson rescuers produces substantialinterruptions in chests compressionsupportedcirculation. Continuous chest compression CPRproduces greater neurologically normal 24-hoursurvival than standard ABC CPR when performed in aclinically realistic fashion. Any technique that minimizes
lengthy interruptions of chest compressions during the first10 to 15 minutes of basic life support should be givenserious consideration in future efforts to improve outcomeresults from cardiac arrest.
(Circulation. 2002;105:645-649.)
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Compression ventilation ratio
Recommendation: Universal ratio of 30:2 for lone
rescuers of victims from infancy(excluding newly born) through
adulthood. Ratio 15:2 for 2 rescuers CPR in
infants & children.
Make rotation every 5 cycles/2minutes
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1 vs 3- shock sequence for defibrillation
Interruption of Cardiopulmonary Resuscitation
With the Use of the Automated ExternalDefibrillator in Out-Of-Hospital Cardiac Arrest
Anouk P. van Alem, MD, Rudolph W. Koster, MD, PhD et all
Conclusion : First responders using automatedexternal defibrillator voice prompts provide CPR lessthan half the time that the automated externaldefibrillator is connected to the patient. Technicalimprovements in automated external defibrillatorrhythm analysis, more efficient resuscitation
algorithms, and first-responder education couldincrease CPR delivery and, perhaps, improveoutcome.
(Ann Emerg Med. 2003;42:449-457)
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1 vs 3- shock sequence for defibrillation.
Outcome of Interrupted Precordial Compression DuringAutomated Defibrillation
Ting Yu, MD; Max Harry Weil, MD, PhD; et all
Conclusion :
Interruptions of precordial compression for rhythm analyses thatexceed 15 second before each shock compromise the outcome of CPRand increase the severity of post-resuscitation myocardialdysfunction.
(Circulation 2002;106:368-372.)
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1 vs 3- shock sequence for defibrillation.
Automated eksternal defibrillator; to what
extend does the algorithm delay CPR Rea TD, Shah S,et all
Rhythm analysis for a 3-shock sequence
performed by commercially Available AEDresulted in delays of 29 to 37 secondsbetween delivery of 1st shock and thebeginning of 1st post shock compression.
Ann Emerg Med. 2005;46:132-141
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1 vs 3- shock sequence for defibrillation.
Recommendation :
One initial shock immediately followed
by CPR, beginning with chest
compression without initial evaluation
of cardiac rhythm orcheck circulation
based on pulse examination, until one
period of CPR (5 cycles or 2 minutes)
is completed.
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Shock dose
Recommendation: One shock
optimum shock dose needed
efficiency of first shock monophasic
< biphasic
Monophasic : 360 J for initial and
subsequent shocks
Biphasic : initially 150-200 J or 120 J
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Role of Vasopressor in teatment of cardiac arrest
Vasopresin for cardiac arrest A systematicreview & meta analysis
Aung K, Htay T
No statistically significant difference between vasopresinand epinephrine on ROSC , death within 24 hours or deathbefore discharge from Hospital.Arch Intern Med 2005:165;17-24
Recommendation:Individual resuscitationcouncils will need to determine the Roleof vasopresin in their guide lines.
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Post resuscitation careILCOR Recommendations
The Advanced Life Support Task Force of theInternational Liaison Committee on Resuscitation(ILCOR) made the following recommendations :
Unconscious adult patients with spontaneouscirculation after out-of-hospital cardiac arrestshould be cooled to 32o C to 34o C for 12 to24 hours when the initial rhythm wasventricular fibrillation (VF).
Such cooling may also be beneficial for otherrhythms or in-hospital arrest.
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GUIDE LINES FOR PREVENTION OF IN- HOSPITALCARDIAC ARREST
Provide care for patients who are critically ill or at risk ofclinical deterioration in appropriate areas, with the level of careprovided matched to the level of patient sickness
Regular observations for critically ill patients; match thefrequency & type of observations to the severity of illness or
the likelihood of clinical deterioration and cardiopulmonaryarrest. Often simple vital sign observations (pulse, BP, RR) areneeded.
Early Warning Score (EWS) to identify patients who arecritically ill and or at risk of clinical deterioration &cardiopulmonary arrest.
Charting system that enables the regular measurement &
recording of EWS Rules about clinical responses to EWS system, including rules
about medical treatment & detail responsible of the medicalstaff & nurse
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GUIDE LINES FOR PREVENTION OF IN- HOSPITALCARDIAC ARREST
Clear identified response to critical illnes
resuscitation team ready for 24 hours
Training for all staffs in nursing ward to recognice,
monitor & take care of patients with severe diseasewhile waiting for more experienced team arrived
Identification of patients on terminal state of cardiacarrest
certain rules in hospitals about DNAR
Adequate audit of every cardiac arrest incidences,unexpected death, patients with unexpected ICU care,& response time of emergency (code blue)
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ILCOR Universal
Cardiac Arrest Algorithm
Circulation 2005; III 1-4
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IN HOSPITAL RESUSCITATIONEUROPEAN RESUSCITATION COUNCIL
Collapsed/sick patient
Shout forHELP & assess patient
Signs of life?No Yes
Call Resuscitation Team Assess ABCDE
Recognize & treat
Oxygen, monitoring, iv accessCPR 30:2
With oxygen & airway adjuncts
Call Resuscitation TeamIf appropriate
Apply pads/monitor
Attempt defibrillation if appropriateHandover to Resuscitation
Team
Advanced Life Support
When Resuscitation Team arrives
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Circulation 2005;112: IV 18-34
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5
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ADULT ALS ALGORITHM, EUROPEAN RESUSCITATION COUNCIL
Unresponsive?
Open Airway
Look for signs of lifeCall
Resuscitation Team
CPR 30 : 2Until defibrillator/monitor attached
Assess rhythm
Shockable
(VF/Pulseless VT)
1 Shock150-360 J biphasic or
360 J monophasic
Immediately resume:
CPR 30:2For 2 min
Non-shockable
(PEA/Asystole)
Immediately resume:
CPR 30:2For 2 min
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LANJUTAN
During CPR :
Correct reversible causes *
Check electrode position & contact
Attempt/verify :
IV access
Airway & oxygen
Give uninterrupted compressions when airway secure
Give adrenaline every 3-5 mins
Consider : amiodarone, atropine, magnesium
*Reversible Causes
Hypoxia Tension Pneumothorax
Hypovolemia Tamponade cardiac
Hypo/hyperkalaemia/Metabolic Toxins
Hypothermia Thrombosis (coronary or pulmonary)
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Circulation 2005;112: IV 57-66
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4
10
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Adult Child InfantLay rescuer: ? 8 year Lay rescuers: 1 to 8 years Under 1 year of age
Maneuver HCP: Adolescent and older HCP: 1 year to adolescent
Airway
Breathing Initial 2 breaths at 1 second/breathHCP: Rescue breathing without chest
compressions
10 to 12 breaths/min
(approximate)
HCP: Rescue breaths for CPR with
advanced airway
Foreign-body airway obstruction Back slaps and chest thrusts
Circulation HCP : Pulse check (?10 sec) Brachial or femoral
Compression landmarks Just below nipple line (lower half of sternum)
Compression method Heel of one hand, other hand Heel of one hand or as for adults 2 or 3 fingers
Push hard and fast on top HCP (2 rescuers):
Allow complete recoll 2 thumb-encircling hands
Compression depth 1 to 2 inches
Compression rate
Compression-ventilation ratio 30:2 (one or two rescuers)
Defibrillation AED Use adult pads Use AED after 5 cycles of CPR (out of No recommendation for
Do not use child pads hodpital). infants
Use pediatric system for child 1 to 2 years
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