DR SUJATA

PROFESSOR

DEPT.OF ANAESTHESIOLOGY &CRITICAL CARE

UCMS & GTB HOSPITAL

CPBR/ CPCRCPBR/ CPCR

CPRCPR Cardiopulmonary brain resuscitation -Cardiopulmonary brain resuscitation -

CPBRCPBR Cardiopulmonary cerebral resuscitation-Cardiopulmonary cerebral resuscitation-

CPCRCPCR

GoalGoalSupport & restore effective oxygenation, Support & restore effective oxygenation, ventilation and circulation with return of intact ventilation and circulation with return of intact neurological function. neurological function.

Intermediate Goal:Intermediate Goal:Return of spontaneous circulation (ROSC)Return of spontaneous circulation (ROSC)

ApproachApproach

BLS ( Basic Life Support) Primary survey. BLS ( Basic Life Support) Primary survey.

ACLS (Advanced Cardiovascular Life ACLS (Advanced Cardiovascular Life Support) Secondary surveySupport) Secondary survey

CardiopulmonaryResuscitation

A - AirwayB - Breathing C - CirculationD- Defibrillation

Does BLS work? BLS- maximum attention of public .MMajority(70-80%) of cardiac arrests Out-of-Hospital.Pre-hospital care –key factor

ajority(70-80%) of cardiac arrests Out-of-Hospital.Pre-hospital care –key factor

Adult Chain of SurvivalAdult Chain of Survival

Early access Early CPR Early Defibrillation

1.Recognition of Early warning signs2.Activation of Emergency Medical Services3.Basic CPR4.Defibrillation

Early ACLS

Before BLS Primary Survey Before BLS Primary Survey

Scene Scene safetysafety Check responsivenessCheck responsiveness Activate EMS and get AEDActivate EMS and get AED

Assess & Perform appropriate action. Assess & Perform appropriate action.

Performance of the action improves chances of survival and Performance of the action improves chances of survival and better neurological outcome better neurological outcome

Before BLS Primary SurveyBefore BLS Primary Survey

Assess Assess ActionAction

Scene safetyScene safety For you and victimFor you and victim

Check responsivenessCheck responsiveness Tap/ shake and shoutTap/ shake and shout

““Are you all right?”Are you all right?”

Activate emergency Activate emergency response system and get response system and get AEDAED

Alone- shout for help.Alone- shout for help.

Activate emergency 102/ 1099Activate emergency 102/ 1099

Get AED…if availableGet AED…if available

Return to victim ……start CPRReturn to victim ……start CPR

BLS Primary surveyBLS Primary survey Support/ restore effective oxygenation, Support/ restore effective oxygenation,

ventilation and circulation until ROSC or ventilation and circulation until ROSC or ACLS team takes over.ACLS team takes over.

No advanced interventions- airway tech./ No advanced interventions- airway tech./ drugs (use universal precautions)drugs (use universal precautions)

Early CPR and early defibrillationEarly CPR and early defibrillation

BLS Primary Survey….componentsBLS Primary Survey….components

AssessAssess ActionAction

AAirwayirway

Open?Open?

Head tilt- chin lift or jaw thrustHead tilt- chin lift or jaw thrust

BBreathingreathing

Yes/ adequate?..... Look, Listen Yes/ adequate?..... Look, Listen and Feeland Feel

2 Breaths using a barrier device,2 Breaths using a barrier device,

Each over 1 sec, visible chest rise.Each over 1 sec, visible chest rise.

CCirculationirculation

Pulse present?...Carotid 5- 10 sec.Pulse present?...Carotid 5- 10 sec.

CPR until AED arrives.CPR until AED arrives.

C:V -30:2 5 cycles over 2 min.C:V -30:2 5 cycles over 2 min.

DefibrillationDefibrillation

AED/ Shockable rhythmAED/ Shockable rhythm

Shock as indicated.Shock as indicated.

Resume CPR with compressions.Resume CPR with compressions.

Basic airway skillsBasic airway skills

Head tilt- chin liftHead tilt- chin lift Jaw thrust without head extension (? Cx Jaw thrust without head extension (? Cx

spine trauma)spine trauma) Mouth- to- mouth ventilationMouth- to- mouth ventilation Mouth- to- nose ventilationMouth- to- nose ventilation Mouth- to- barrier device (pocket mask)Mouth- to- barrier device (pocket mask) Bag-mask ventilationBag-mask ventilation

Airway Head tilt, Chin lift, Jaw thrust AVOID HEAD TILT IF TRAUMAKeeping airway open- LOOK, LISTEN, FEEL

LOOK LISTEN FEEL

CHEST MOVEMENTS BREATH SOUNDS AIR FLOW RESP. RATE VOICE QUALITY CHEST

MOVEMENTSCYANOSIS ABNORMAL SOUNDS TRACHEAL POSITIONTRAUMAFLUID/BLOOD /VOMITING

NOT MORE THAN 10 SECONDS

BREATHING PRESENT

RECOVERY POSITION AND TRANSPORT

BREATHING ABSENT

2 EFFECTIVE RESCUE BREATHS•SLOW BREATHS•TIDAL VOL. 8-10 ml/kg•Deliver in one sec.•Rate- 10-12/min.•Chest rise/ expand

Assessing the victimAssessing the victim• 1-- Make sure the victim, any bystanders,

and you are safe.• 2-- Check the victim for a response.• Shake shoulders gently• Ask “Are you all right • If he responds• Leave as you find him.• Find out what is wrong.• Reassess regularly • If he does not respond:• Activate Code Blue and get AEDActivate Code Blue and get AED

• 4 --Keeping the airway open, look, listen, and feel for normal breathing.

• OPEN AIRWAY• Look, listen and feel for NORMAL

breathing• Do not confuse agonal breathing with

NORMAL breathing

Keeping the airway open, look, listen, and feel for normal breathing. ……OPEN AIRWAY

Look, listen and feel for NORMAL breathing

If he is breathing normallyIf he is breathing normally• Turn him into the recovery position

• Send or go for help, or call for an ambulance.• Check for continued breathing.

If he is not breathing normallyIf he is not breathing normally

Give 2 rescue breathsGive 2 rescue breaths• Pinch the nosePinch the nose• Take a normal breathTake a normal breath• Place lips over mouthPlace lips over mouth• Blow until the chest Blow until the chest

risesrises• Take about 1 secondTake about 1 second• Allow chest to fallAllow chest to fall• RepeatRepeat

Chest CompressionsChest Compressions

Patient positioning:Patient positioning:Firm and hard surface (ground, table/ hard bed) deflate Firm and hard surface (ground, table/ hard bed) deflate air/ water mattresses.air/ water mattresses.

Rescuer's position:Rescuer's position:Level with patient, elbows vertically straight and locked, Level with patient, elbows vertically straight and locked, shoulders directly above the hands, heel of one palm shoulders directly above the hands, heel of one palm over the other.over the other.

Site : sternum in inter-mammary line.Site : sternum in inter-mammary line. Depth: 1Depth: 11/21/2- 2 inches.- 2 inches. Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.).Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.). Allow complete chest recoil.Allow complete chest recoil.

CHEST COMPRESSIONSCHEST COMPRESSIONS30 CHEST COMPRESSIONS30 CHEST COMPRESSIONS

Hands off- timeHands off- time

Less than 10 sec.Less than 10 sec. Specific interventions: defibrillation, advanced airway, Specific interventions: defibrillation, advanced airway,

moving the patient.moving the patient.

Avoid :Avoid : Prolonged rhythm analysisProlonged rhythm analysis Frequent pulse checksFrequent pulse checks Too long breathsToo long breaths Unnecessary moving the pt.Unnecessary moving the pt.

CHEST COMPRESSIONS• Rate: 100/MIN., SITE- Sternal depression -1.5 in.-2 in.•Universal compression-ventilation ratio (30:2) - Recommended for all single rescuers of infant, child and adult victims (excluding newborns)• Two Rescuers = 30:2- ALL ADULTS, 15:2 – Infants and child

PURPOSE : PUSH HARD,PUSH FAST

PULSE PRESENT

CONTINUE VENTILATION TILL SPONTANEOUS RESPIRATION

PULSE ABSENT / NOT DETECTED

PULSE CHECK • NOT RECOMMENDED FOR LAY RESCUERS• POOR SENSITIVITY-55%• POOR SPECIFICITY-90%• ACCURACY RATE -65%

CHECK FOR SIGNS OF CIRCULATION

DefibrillationDefibrillation

AED: Follow the prompts.AED: Follow the prompts. Manual defibrillator: Analyse rhythm, Manual defibrillator: Analyse rhythm,

shockable- decide shock (Monophasic shockable- decide shock (Monophasic 360 J, Biphasic 120-200 J ), apply gel, 360 J, Biphasic 120-200 J ), apply gel, charge, clear the patient, no inflammables charge, clear the patient, no inflammables (incl. oxygen), deliver shock….. Resume (incl. oxygen), deliver shock….. Resume CPR immediately.CPR immediately.

AEDAED

Positioning of electrodes for automated external defibrillatorPositioning of electrodes for automated external defibrillator

DEFIBRILLATIONDEFIBRILLATION

ATTACH PADS TO VICTIM’S BARE CHEST

Ventricular FibrillationVentricular Fibrillation

Continuous electrocardiogram showing successful treatment of ventricular fibrillation by a countershock (given

at the arrow)

ANALYSING RHYTHM ANALYSING RHYTHM DO NOT TOUCH VICTIMDO NOT TOUCH VICTIM

SHOCK INDICATEDSHOCK INDICATEDStand clearStand clear

Speak Aloud- “I Clear......You Clear.......All Clear!”Speak Aloud- “I Clear......You Clear.......All Clear!”Deliver shockDeliver shock

IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN RECOVERY POSITIONRECOVERY POSITION

ACLS Secondary surveyACLS Secondary survey

Advanced, invasive assessment and management Advanced, invasive assessment and management techniques required.techniques required.

Basic airway adjunctsBasic airway adjuncts::

OPA, NPAOPA, NPA

Advanced Airway interventionsAdvanced Airway interventions::

Combitube, LMA, Endotracheal intubation.Combitube, LMA, Endotracheal intubation.

Advanced circulatory interventionsAdvanced circulatory interventions::

Drugs to control heart rhythm and blood pressure.Drugs to control heart rhythm and blood pressure.

ACLS Secondary Survey…… componentsACLS Secondary Survey…… components

AssessAssess ActionAction

AAirwayirway

Patent? Advanced needed?Patent? Advanced needed?

Head tilt-chin lift, OPA, NPA.Head tilt-chin lift, OPA, NPA.

Advanced airway if needed Advanced airway if needed (combitube, LMA, ETT)(combitube, LMA, ETT)

BBreathingreathing

Oxygenation, ventilation Oxygenation, ventilation adequate?adequate?

Advanced airway needed? Advanced airway needed? Placement, securement Placement, securement confirmed?confirmed?

EtCOEtCO22,SpO,SpO22 monitored? monitored?

Give supple OGive supple O2,2,

Clinical- chest rise,Clinical- chest rise,OO22 saturation, saturation,

Capnometry / capnographyCapnometry / capnography

Integrate Compressions & vent (1 Integrate Compressions & vent (1 breath 6-8 sec i.e. 8-10 bpm)breath 6-8 sec i.e. 8-10 bpm)

TECHNIQUES- Mouth-Mouth, Mouth-Nose

VENTILATORY DEVICES

Masks, Bag-Valve Devices

Airway Adjuncts

1.Oropharygeal Airway

2.Nasopharyngeal Airway

3.Esophageal –Tracheal Combitube

4.Laryngeal Mask Airway

5.Transtracheal catheter ventilation

6.Cuffed oropharyngeal airway

ADJUNCT of CHOICE: TRACHEAL TUBE

PURPOSEMAINTAIN AIRWAYAND OXYGENATE

ACLS Secondary Survey…….componentsACLS Secondary Survey…….components

AssessAssess ActionAction

CCirculationirculation

Initial/ current cardiac rhythm?Initial/ current cardiac rhythm?

Access for drugs/ fluids?Access for drugs/ fluids?

Needs volume/ drugsNeeds volume/ drugs

Obtain IV/ IO accessObtain IV/ IO access

Attach ECG leads, monitor for Attach ECG leads, monitor for rhythms (rhythms (Cardiac arrestCardiac arrest: VF, : VF, Pulseless VT, Asystole, PEA).Pulseless VT, Asystole, PEA).

Give IV/ IO fluidsGive IV/ IO fluids

Appropriate drugs (Appropriate drugs (RhythmRhythm: : Amiodarone, Lidocaine, Atropine, Amiodarone, Lidocaine, Atropine, Magnesium; Magnesium; BPBP: Adrenaline, : Adrenaline, Vasopressin, Dopamine)Vasopressin, Dopamine)

DDifferential ifferential DDiagnosisiagnosis

Reversible cause of arrest?Reversible cause of arrest?

Search for, find and treat the Search for, find and treat the cause (cause (H`sH`s and and T`sT`s))

Common Reversible CausesCommon Reversible Causes

H`sH`s T`sT`s

HypovolemiaHypovolemia ToxinsToxins

HypoxiaHypoxia Tamponade (cardiac)Tamponade (cardiac)

Hydrogen ion (Acidosis)Hydrogen ion (Acidosis) Tension pneumothoraxTension pneumothorax

Hyper-/ HypokalemiaHyper-/ Hypokalemia Thrombosis (coronary/ Thrombosis (coronary/ pulmonary)pulmonary)

HypoglycemiaHypoglycemia TraumaTrauma

HypothermiaHypothermia

PROBLEMS AND COMPLICATIONS OF CHEST COMPRESSIONS

1. RIB FRACTURES2. FRACTURE STERNUM3. RIB SEPARATION4. PNEUMOTHORAX5. HEMOTHORAX6. LUNG CONTUSIONS7. LIVER LACERATIONS8. FAT EMBOLI9. HIV, HEPATITIS10.INFECTIONS

MANAGE ACCORDINGLY BUT CONTINUE CPR

EFFECTIVE CHEST COMPRESSION WITH EFFECTIVE CHEST COMPRESSION WITH MINIMAL HANDS OFFMINIMAL HANDS OFF

ISIS

KEYKEY

FOR FOR

EFFECTIVE CPREFFECTIVE CPR

When to stop BLSWhen to stop BLS

ROSC, Conscious pt.ROSC, Conscious pt. ACLS team takes overACLS team takes over Rescuer tiredRescuer tired

Infant Infant (1-12 mo.) (1-12 mo.)

Child Child (>12 mo.)(>12 mo.)

AdultAdult

Resp. rateResp. rate 12-20/min.12-20/min. 20/min.20/min. 10-12/min.10-12/min.

Pulse CheckPulse Check Brachial/femoralBrachial/femoral CarotidCarotid CarotidCarotid

Comp. RateComp. Rate 100/min.100/min. 100/min.100/min. 100/min.100/min.

Comp. MethodComp. Method 2-3 fingers2-3 fingers

1/3-1/2 depth of 1/3-1/2 depth of chestchest

Heel of handHeel of hand

1/3-1/2 depth of 1/3-1/2 depth of chestchest

Hands interfacedHands interfaced

1.5-2 inches1.5-2 inches

Comp:Ventil.Comp:Ventil. 30:2 30:2 (single rescuer)(single rescuer)

HCP-15:2 HCP-15:2 (2 rescuers) (2 rescuers)

30:2 30:2 (single rescuer)(single rescuer)

HCP-15:2 HCP-15:2 (2 rescuers) (2 rescuers)

30:2 30:2 (1 or 2 (1 or 2 rescuers)rescuers)

Foreign body Foreign body

ObstructionsObstructions

Back blowsBack blows

Chest thrustsChest thrusts

Abdominal Abdominal

ThrustsThrusts

Abdominal Abdominal

ThrustsThrusts

SUMMARY

DRUGS

EPINEPHRINE

1. Peripheral vasoconstriction- -adrenergic

2. Increase in Central aortic perfusion pressure

3. Decrease Threshold for Defibrillation

4. Fine VF to Coarse VF

For Rhythm

• Amiodarone

• Lidocaine

• Atropine

• Magnesium

For Blood Pressure

• Epinephrine

• Vasopressin

• DOPAMINE-2-4 micro/kg/min.-DA rec

4-10 micro/kg/min- Beta-rec.

10-20 micro/kg/min- Alpha rec.

DRUGS

ll lll

l

LL

RA LA

+ +

+-

- -

WHITE-RIGHT SIDERED- RIBS-LEFT MID-AXILLARY

LEFT-OVER-LEFT SHOULDER

The dying heartThe dying heart

1.VENTRICULAR FIBRILLATION

2. RAPID VENTRICULAR TACHYCARDIA

3. PULSELESS ELECRICAL ACTIVITY

4. ASYSTOLE

2

OR