Download - Lecture 1 Cardio-pulmonary Resusictation
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CARDIO-PULMONARYRESUSCITATION
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2005 AHAGuidelines
for Cardiopulmonary Resuscitationand Emergency Cardiac Care
2005 International Consensus Conference on Cardio- Pulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommandations
andILCOR (International Liaison Committee on Resuscitation)2005 CPR Consensus.
These recommendations replace or complete the 2000 CPR guidelines.
published inCirculation - December 2005
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Gra de 1 Ra ndomized clinica l studies or metaa na lysises with significa ntthera peutic effects
Grade 2 Clinic
al studies with less signific
ant the
rapeutic effects
Gra de 3 Pr ospective contr olled nonra ndomized studies or ca se se r iesGra de 4 Retr ospective nonra ndomized studiesGra de 5 Uncontr olled ca se se r ies
Gra de 6 Exper imenta l a nima l or mecha nica l studiesGra de 7 Theor etica l a na lysisGra de 8 Ra tiona le a nd common pra ctice without evidence ba se
G rading of evidence
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H ierarchy of recommendations depends uponrisk/benefice ratio.
Cla ss Risk/beneficera tio.I benefice>>>r iskIIa benefice>>r isk
IIb benefice >/=r iskIII r isk >/= benefice
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CARDIO-PULMONARY RESUSCITATION
DEFINITIONSRespiratory arrest= the absence of breathing movements.Cardiac arrest= the clinical picture of overall cessation of circulation.Clinical death= coma, apnea and pulselessness in large arteries with cerebral failure still potentially reversible.Biological death= the irreversible absence of body functions due to irreversible structural cell damage.Cerebral death= the irreversible absence of brain and brainstem functions withtemporary presence of respiration and circulation.Persistent vegetative state= absence of motility and reaction to external stimulidue to persistent absence of cerebral activity with preservation of vegetative
functions (respiration, circulation, swallowing).
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CARDIO-PULMONARY ARREST Physiopa thology
respiratory arrest ? / cardiac arrest ?
There are semnificative differences, related to age, in the incidence of primary respiratory arrest (more frequent in newborns and children) and primary cardiac arrest (more frequent in adults and old persons)
There are semnificative differences of BLS in primary respiratory arrestand primary cardiac arrest.
understanding physiopathologyof cardio-pulmonary arrest correct CPR
efficient CPR ma neuver s
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RESPIRATORY ARREST Pathophysiology
Heart and lungs continue the tissue delivery of oxygenated blood until exhaution of alveolar O 2 reserves; pulse is present, altered consciousness;
Delay to cardio-circulatory arrest: variable (seconds-minutes); it depends on:Oxygen reserve in the moment of respiratory arrest (PAO2 i PaO2)Miocardial capacity to sustain hypoxemia
Uncorrected respiratory arrest results in cardiac arrest;
Causes Drowning,, foreign body aspiration, toxic inhalation, epiglotitis, strangulation, etc. Coma of any origin, stroke, etc. Electrocution, trauma, etc.Clinical signs Absence of breathing movements Progressive cyanosis Alterations of consciousness Muscle hypotonyTreatment Artificial ventilation in order to oxygenate the blood and to prevent
secondary cardiac arrest
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CARDIAC ARREST Pathophysiology
Cardiac arrest results in circulatory arrest with the immediate cessation of tissue O 2 delivery; Cessation of brain O 2 delivery:
Depletion of O 2 reserves in 10 seconds Depletion of phosphocreatine reserves in 2 minutes Depletion of glucose and ATP reserves in 5 minutes
For a short time delay ( a lways seconds): agonal respiration (Gasping) (unefficient respiratory efforts withrecruitment of accessory respiratory muscles);
Always cardiac arrest result in respiratory arrest;Causes Myocardial infarction Rhythm disturbances (myocardial infarction, myocardial ischemia electrolyte disturbances,etc.) Hypovolemia (exsanguination, politrauma) Pulmonary embolism Cardiac tamponade
Clinical signs Loss of conscience (10 seconds; izoelectric EEg in 15-30 seconds); Agonic respirations or apneea (10-15 seconds) Pulseless
Midriasis (30-60 secunde) General aspect of death ECG signs
Ventricular fibrillation Pulseless ventricular tachycardia pulseless electrical activitity Asystole
Treatment
Artificial support of ventilation and circulation
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CARDIO-PULMONARY RESUSCITATION
INDICATIONS of CPR:
Respiratory arrestCardiac arrestCardio-respiratory arrest
Primary/secondary - respiratory/cardiac arrest
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CARDIO-PULMONARY RESUSCITATION
DEFINITION= system of standard maneuvers, drugs and techniques indicated in case of cardio-respiratoryarrest in order to artificially deliver the oxygenated blood to systemic circulatory beds at rates that are
sufficient to preserve the vital organ function and at the same time providing the physiologic substrate for the return of spontaneous circulation.
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CARDIO-PULMONARY RESUSCITATION
FACTORS WHICH INFLUENCE THE RESULT OF RESUSCITATION:
Patient related factors:
The cause of cardio-respiratory arrest The functional status in the moment of cardio-respiratoryarrest Co-existing diseases
Resuscitator related factors: Precocity of CPRCorrectness of CPR
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CARDIO-PULMONARY RESUSCITATION
CHAIN OF SURVIVAL
B LS in
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The most important determinant of survival from suddencardiac arrest is the presence of a trained rescuer who isready, willing, able, and equipped to act.
(2005 AHA G uidelines for CPR a nd ECC, Circulation, 2005)
In the 1990s some predicted that cardio-pulmonaryresuscitation (CPR) could be rendered obsolete by thewidespread development of community automated external defibrillator (AED) programs. Cobb noted, however, as moreSeatle first responders were equipped with AEDs, survival rates from sudden cardiac arrest fell. He atributted thisdecline to reduces emphasis on CPR....
(2005 AHA G uidelines for CPR a nd ECC, Circulation, 2005)
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W hat means a successful cardio-pulmonary resuscitation?
Signs of successful CPR: return of spontaneous circulation hospital admission neurologic improvement hospital discharge
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CARDIO-PULMONARY RESUSCITATIONPhases of CPR:
Basic life support First phase of CPR; Goals:
Artificial delivery of oxygenated blood to systemic circulatory beds;Prevention of irreversible brain damage;
Preservation of chances for successful resuscitation;Return of spontaneous circulation; Provided without medical equipment (with bare hands);
Advanced life support The second/first phase of CPR; Goals:
Preservation of vital organ function;Return of spontaneous circulation;Postresuscitation stabilization;Cerebral protection;
Provided using equipment, drugs and medical devices.
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CARDIO-PULMONARY RESUSCITATION
THE ARMAMENTARIUM of CPR A (airway) airway maneuversB (breathing) evaluation and support of ventilation
C (circulation) evaluation and support of circulation D (drugs) - IV access and medication E (electrocardiography) - evaluation of electrical form of cardiac arre F (fibrillation treatment) - defibrillation
G (gauging) postresuscitation evaluation H (human mentation) cerebral protection I (intensive care) postresuscitation intensive care
THIS IS NOT THE PROPER ORDER TO APPLY
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P rimary steps of basic life support
Securing the inviroment Evaluation of consciousness Activation of emergency medical system (call 112)
Victim positioning Airway maneuvers Assessment of spontaneous breathing (10 seconds) Artificial ventilation (2 ventilation) Assessment of circulation (10 seconds) Chest compresion (100/minute) CPR sequence: 30 chest compressions /2 artificial breath Automatic external Defibrillation
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CPR r ecomenda tions200 6 2 esentia l a spects for the success of CPR:Av oid hiper v entilation for a pulmonary gas exchange (pulmonary blood flow decreased) encrease the intrathoracic pressure decrease the cardiac upload decrease the efficience of chest compresions stomach insuflation (encrease the risk of regurgitation/aspiration, push up t
diaphragm and encrease the intrathoracic pressure)
Av oid interupting the chest compresions CPR performed by trainned medical team total time of interupting chestcompresions 24-49% of the cardiac arrest duration.
Any interuption in chest compresions means the decrease of coronary perfusion pressure, which slowly rises when the chest compresions aredelivered once again, and so the chances of returning to spontaneouscirculation are decreased.
In the first minutes of cardiac arrest (VF) the artificial ventilation is not soimportant as the chest compresions because the hipoxy is primary caused bthe lack of tissulary perfussion, and there are sufficiently blood O2 rezervein the first minutes. That is why the rescue person should concentrate indelivering efficient chest compresions. The new recommendations regardinthe sequence chest compresions/ventilation 30:2 are made to minimalise thtime of chest compresion interuptions.
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The a ge
newborn immedia telya fter bir th a nd untilhospita l dischar ge.inf a nt untill thea ge of 1 year .child f r om 1 year until puber ty (12-14 year s).adult f r om puber ty a long
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CARDIO-PULMONARY RESUSCITATION
A AIRWAY MANEUVERS: Should be applyied in case of any unconscious victim; Should preceed assessment of spontaneous breathing; Should be maintained during assessment of spontaneous breathing; Should preceed artificial ventilation; Should be maintained during artificial ventilation;
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A AIRWAY MANEUVERS:DURING BASIC LIFE SUPPORT:
Safety position Head tilt Chin lift Head tilt and chin lift Subluxa ia anterioar a mandibulei Subluxa ia anterioar a mandibulei i deschiderea gurii Hiperextensia capului, subluxa ia anterioar a mandibulei i deschiderea gurii (tripla
manevr Safar); ndep rtarea corpilor str ini solizi (deget crlig) sau lichizi (pozi ie lateral a capului i
deget nf urat n pnz )DURING ADVANCED LIFE SUPPORT:
Airway devices Tracheal intubation
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A AIRWAY MANEUVERS:in pacient with posible cervical spine injury
When to suspect cervical spine injury?
Know the mechanism of injury Strangulation C dere de la n l ime Deceleration or acceleration s.o.
Traumaticsigns At the cephalic extremity In the cervical region In the region of thorax (the superior 1/3) So, superior to the intermamelonary line
Mentain the had in neutral position
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AIRWAY MANEUVERS:
Clinical signs of proper tracheal intubation visualising the endotrachel tube passing through vocalcords
simetrical thoracic expansions equal respiratory sounds on bouth lungs water vapors on the inside surface of the endotracheal tube the abscence of aeric sounds in epigastric region
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CARDIO-PULMONARY RESUSCITATIONB EVALUATION AND SUPPORT OF VENTILATION:
Assessment of spontaneous breathing maintaining MECA lisen, feel and see
Artificiale ventilation n SVB
Artificial ventilation mouth-to-mouth
Artificial ventilation mouth-to-noseArtificial ventilation mouth-to-tracheostomaeArtificial ventilation mouth-to-mouth and noseThe exhalated air containe 16-18% O2Evaluation of the efficience of artificial ventilation: chest movements
n SVAMask and Rueben baloon
Trachel tube and Rueben baloonTrachel tube and ventilatory deviceMechanical ventilation:
IPPV (intermitent positive pressure ventilation) Current volume 8ml/kg Frequence: 14-16/min FiO2 1 (O2 100%) PEEP (positive end expiratory pressure) 0
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Ar tificia l ventila tion
CHARACTERISTICS OF MOUTH-TO-MOUTH VENTILATION The rescue person take a normal inspiratory Insuflation - 1 second Current volume 500-600ml
Chest rise Frecquence 10-12/minute
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VENTILA IA ARTIFICIAL
CHARACTERISTICS OF MECHANICAL
VENTILATION IN SVA IN ADULT Current volume 6-8ml/kg Frecquence 8-10/minute Oxigen 100% No PEEP No interuptions of chest compressions for
ventilation
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CARDIO-PULMONARY RESUSCITATIONC CIRCULLATORY EVALUATION AND SUPPORT:ASSESSMENT of CIRCULATION
Always in the large arteries Adult: carotid or femoral artery; infant: brachial artery;
CHEST COMPRESSION It is performed during BLS and ALS Best achievable results: 25-30% of spontaneous cardiac output Chest compression technique:
Victim positionRescuer positionTechniqueParameters: depth, frequency/min, compression/decompression ratio
Mechanisms of cardiac output during chest compression:Cardiac pump theoryThoracic pump theory
Evaluation of chest compression efficency: pulse assessmente during CPR Options to increase the efficency of chest compression:Maximal values of recommended depth and frequency
Concomitantly performed chest compression and artificial ventilationInterposed abdominal compressionKower limb elevation at 60 (not in case of ongoing bleeding or trauma)Active compression/decompression deviceInternal cardiac massage (only during ALS)Extracorporeal circulation
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CHEST COMPRESSIONS
push hard, push fast, allow full chest recoil after each compression, and minimize
interruptions in chest compression
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CHEST COMPRESSIONS
T he indication for chest compresions is theabsence of pulse in large arteries .
T here are no contraindications for chest
compressions.
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CHEST COMPRESSIONS
ADULT
Depth of sternal compression 4-6 cmFrecquence of compressions 100/minuteDuration of compression/Duration of decompressionequal
Full chest recoil after each compressionRithmic compresionsAvoid interupting chest compressions
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CHEST COMPRESSIONS complica tions
Fra ctur es Ribs f ra ctur esSter na l f ra ctur es
Pa thology of these r osa s
Pneumothora x Hemothora xHemoper icar diumHemoper itoneum
Viscera l injur ies Pulmonar y r uptur eHepa tic r uptur eSplenic r uptur eGa str ic r uptur e
Other complica tions Aspira tion of ga str ic content
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ALTERNATIVE TECHNIQUES OF CARDIAC MASSAG E
High frecquence chest compressionsInterpose abdominal compressionInternal cardiac massageCPR through coughing
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MECHANICAL DEVICES FOR CARDIOCIRCULATORY SUPPORT
Active compression-decompresion deviceResistance-level valve deviceMechanical Piston deviceCPR vest
Fazic toraco-abdominal compression-decompressionmanual deviceExtracorporeale circulation
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CARDIO-PULMONARY RESUSCITATIONC MEDICATION:
Routes for drug administration Peripheral intravenous access standard route Central intravenous access Intratracheal administration Intraosseous administration Intracardiac administration
Drugs: Oxygen Epinephrine Atropine Lidocaine Vasopresine Sodium bicarbonate Amiodarone Procainamide Magnesium sulphate Dopamine Volume solutions
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ACCESUL INTRAOSOS
Este a doua op iune de acces venos n RCR.Ofer acces la un plex venos necolababil, deci, administrareadrogurilor este similar administr rii venos centrale.Exist truse dedicate cu toate materialele necesare.Doza medicamentelor n administrarea intraosoas este aceia ica n administrarea intravenoas .
La bolnavul hipovolemic cu acces venos periferic imposibilaccesul intraosos ofer o bun alternativ de refacere avolemiei.
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CENTRAL VENOUS ACCEESS
Adva nta ges Disa va nta ges
Shor t time of dr ug cir cula tionSa fe a nd longla stinga ccessHiper tonic solutions/ca thecola mines
Temporar y inter uption of car dia cma ss a geLong time for insta la tion
Vita l complica tions possible
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ENDOTRACHEAL DRUG ADMINISTRATION IN CPR
through trachel tube2-2,5x of intravenous dosediluted in NaCl 0,9% 5-10 ml
5 vigurous ventilations
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CARDIO-PULMONARY RESUSCITATION
E ELECTROCARDIOGRAPHY: E lectrical forms of cardiac arrest
Ventricular fibrillation
Pulseless ventricular tachycardia Pulseless electrical activity
E lectromechanical dissociation Pseudo E lectromechanical dissociation Idio-ventricular rhythm
E scape rhythm Bradiasystole Asystole
Identification of the eletrical form of cardiac arrest allowsthe choise of the proper CPR algorhythm
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RESUSCITAREA CARDIO-RESPIRATORIEF DEFIBRILAREA:
Defibr ilar ea este un ter men utiliza t pentr u a desemna livrar ea nesincr oniza t cu complexul QRS a unui ocelectr ic.
ocul elect r ic induce odepolar izar e sincr on ur ma t der epolar izar e sincr on a tutur or fibr elor miocar dice.Deci, dup ocul elect r ic toa te fibr ele miocar dicea jung la un numitor comun: z ero electric . Acest
fenomen per mite intrar ea n func iea centr ului car dia ccu func ie sponta n de p a cema ker , car e va pr elua contr olula ctivit ii electr ice i meca nice a inimii.
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CARDIO-PULMONARY RESUSCITATIONF DEFIBRILLATION:
Goal Defibrillation technique:
Patient positionRescuer position
Paddles preparation and positionClear order EnergyChecking for efficiency
Indications Differences cardioversion/defibrillation:Synchronic/asynchronic shock PreparationsEnergyIndications
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DEFIBRILAREA
TEHNICA DEFIBRIL RII: Pozi ia pacientului Pozi ia resuscitatorului Preg tirea i pozi ionarea padelelor Aten ionarea Energia utilizat Verificarea eficien ei
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ENERG IA UTILIZAT N DEFIBRILARE
curent monofazic ini ial 360 J i continu cuaceia i energie la urm toarele ocuri.
curent bifazic - ini ial o energie de 200 J, apoienergii crescnde de 300 J i 360 J.n fibrila ia ventricular /tahicardia ventricularf r puls recurent - energia utilizat pentruurm torul oc va fi energia care a convertitritmul.
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OCUL ELECTRIC EXTERN
Termenul decardioversie este utilizat pentrulivrarea sincronizat cu complexul QRS a unuioc electric. Sincronizarea evit livrareaocului n perioada refractar relativ a cicluluicardiac, perioad n care ocul electric poate
induce fibrila ie ventricular .Termenul dedefibrilare este utilizat pentrulivrarea nesincronizat cu complexul QRS aunui oc electric.
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CARDIOVERSIA
PREG TIRI PENTRU CARDIOVERSIEBolnavul trebuie s aib monitorizare ECG i monitorizarea
noninvaziv a TA.Se instituie oxigenoterapia.Se instituie un acces venos.Instrumentarul, materialele i drogurile de resuscitare trebuie
s fie preg tite.Se practic analgezie i sedare.
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CARACTERISTICI COMPARATIVE ALE CARDIOVERSIEI I DEFIBRIL RII
PARAMETRU CARDIOVERSIE DEFIBRILARE
Ener gia ini ia l 50 -100 J 200 JSincr onizar ea cu complexulQRS
DA NU
Indica ii TPSV Flutter a tr ia l par oxisticFibr ila ia a tr ia l p ar oxisticTa hicar dia ventr icular cu puls
Fibr ila ia ventr icular
Ta hicar dia ventr icular f r pulsTa hicar dia ventr icular polimor f cu puls
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STATUSUL POSTRESUSCITARE
dup reluarea circula iei spontane
perioad de mari dezechilibre homeostaticegenerate de: leziunile hipoxice
leziuni ischemice leziuni de reperfuzie.
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FIZIOPATOLOG IA STATUSULUI POSTRESUSCITARE
Hemodina mic Disfunc ie miocar dic(pr in ischemia miocar dic globa l i defib r ilar e)
Sindr om de debit car dic sc zutCr e te r e tra nzitor ie a enzimelor miocar diceInsta bilita te hemodina micTulbur r i de r itm
Neur ologic ComIni ia l hiper emie cer ebra l , a poi r educer ea fluxului sa nguin cer ebra le(chiar la va lor i nor ma le a le TAmedii)Hiper temie de or igine centra l
Convulsii
Respira tor Disfunc ie ventila tor ieTulbur r i de oxigenar e sa nguin
Meta bolic Acidoz meta bolicHiper glicemie
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STATUSUL POSTRESUSCITARE
Tulbur r ile pot fi:modeste i cu tendin p r ogr esiv sp r e r ezolu iesever e i pe r sistente
coma persistenthipertermia centralcon v ulsiilesindromul de disfunc ie multipl de organe
f r ecvente la 48-72 or e postr esuscitar epr ognostic nef a vora bil