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Who ?

Who ?. Out-of-Hospital Cardiac Arrest (OHCA). Keuper W. Resuscitation 2007;73:189-201. Josephson M and Wellens HJJ Circulation 2004,109:2685-2691. What to do ?. The bellows Method. The „barrel method” and the „strolling horse”. History of modern resuscitation. Peter Safar:

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Who ?

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  1. Who ?

  2. Out-of-Hospital Cardiac Arrest (OHCA) Keuper W. Resuscitation 2007;73:189-201

  3. Josephson M and Wellens HJJ Circulation 2004,109:2685-2691.

  4. What to do ?

  5. The bellows Method

  6. The „barrel method” and the „strolling horse”

  7. History of modern resuscitation

  8. Peter Safar: • Founding father of intensive therapy • - Pioneer of airway management. • - Pioneer of therapeutic hypothermia. • - Physician, teacher,and philosopher.

  9. History of modern resuscitation

  10. Knickerbocker; the „lucky” Jude; The „witness” Kouwenhoven; the „engineer”

  11. Safar & McMahon 1958 Kouwenhoven et al 1960 The „kiss of life” ABC

  12. Chances of survival are declining by 10% / minute following the onset of ventricular fibrillation Cummins RO et al Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Care

  13. The „time-dependent, 3-phase model” of cardiac death 0-4 min: „Electric phase” Priority: - Early defibrilation Evidence: - EP-laboratory, ICU, - ICD data - AED in special areas (airports, casinos) Weisfeldt ML, Becker LB JAMA 2002

  14. The „time-dependent, 3-phase model” of cardiac death 4-10 min: „circulatory phase” Patients: - the wast majority of OHCA victims Characteristics: - Tissue oxygen depletion - Accumulation of toxic metabolits - Cardiac distension Priority: ? Weisfeldt ML, Becker LB JAMA 2002

  15. Pathological hemodynamical responses during the circulatory phase of sudden death

  16. Steen S et al. Resuscitation 2003;58:249-258. systole aorta középnyomás diastole CPP CPP = minimum aorta nyomás (diastole, illetve compresszió-szünet) – jobb pitvari nyomás

  17. Cardiac arrest: MRI series Chamberlain D et al. Resuscitation 2008;77:10-15

  18. Ventricular interdependency Jobb kamra volumen (ml) 50 20 0 Left ventricular pressure (Hgmm) 0 10 20 30 40 Left ventricular volume (ml) Taylor RR Am J Physiol 1967,213:711-718

  19. Preserved contractility Stroke work Poor contractility End-diastolic volume

  20. Chamberlain D et al. Resuscitation 2008;77:10-15

  21. The „time-dependent, 3-phase model” of cardiac death 4-10 min: „circulatory phase” Priority: - immediate chest compressions Evidence: ….. Weisfeldt ML, Becker LB JAMA 2002

  22. The Ontario Prehospital Advanced Life Support (OPALS) study Modifiable Factors Associated With Improved Cardiac Arrest Survival in a Multicenter Basic Life Support/Defibrillation System: OPALS Study Phase I Results (Helyzetfelmérés 1991-1995) Stiell IG, Ann Emerg Med 1999;33:44-50

  23. Seattle (JAMA 1999) Oslo (JAMA 2003) Protokol-váltás: -Shock 1st -CPR 1st Fej-fej melletti összehasonlítás

  24. Seattle (JAMA 1999) Oslo (JAMA 2003)

  25. The „time-dependent, 3-phase model” of cardiac death > 10min: „Metabolic phase” characteristics: - Circulating cytokines, interleukin alfa - Cytokin induced myocardial suppression - Gram negatíve translocation from the gut (secondary endotoxin exposition) -Reperfusion injury Therapeutic options: ? ? ? ? Weisfeldt ML, Becker LB JAMA 2002

  26. Myocardial perfusion Aortic root Epicardial coronaries Capillary arterioles Capilláry veins Large cardiac veins Sinus coronarius Right atrium Coronary perfusion pressure (CPP)

  27. Coronary Perfusion Pressure and Resuscitation (100 beteg adatai !) Paradis NA et al JAMA 1990;263:1106-1113

  28. Coronary Perfusion Pressure and Resuscitation küszöb Paradis NA et al JAMA 1990;263:1106-1113

  29. Determinants of coronary perfusion pressure: - Frequency and quality of chest compressions - Vascular resistance - Intravascular volume - Intrathoracic pressure

  30. A CPR megszakítása

  31. 4 s aorta jobb pitvar Berg RA. Circulation 2001;104:2465-2470.

  32. Coronary perfusion pressures The last 2 cycles of 15 The first 2 cycles of 15 Berg RA. Circulation 2001;104:2465-2470.

  33. „Rescue breathing”, in real life 16 sec Ewy GA Circulation 2005;111:2134-2142.

  34. „Two quick breaths” – an oxymoron Ewy GA Circulation 2005;111:2134-2142.

  35. (advanced life support) Exceptional resuer (BR:16/min) IT nyomás Tipical rescuer (BR: 47/min) IT nyomás Crit Care Med 2004;32:S345-S351

  36. At baseline (BR: 46/min) IT nyomás Following Re-education (BR 11/min with length of inflations >4sec) IT nyomás Crit Care Med 2004;32:S345-S351

  37. At baseline (BR: 46/min) IT nyomás Kampec Dolóresz Following Re-education (BR 11/min with length of inflations >4sec) IT nyomás Crit Care Med 2004;32:S345-S351

  38. Resuscitation 2005;67:S39-S86 Eszméletlen ? Légút ellenőrzés, életjelek CRR 30:2 Ritmus? Sokkolható (VF/VT) Nem-sokkolható (PEA/asystolia) CPR során - reverzibilis okok korrekciója* - elektród pozíció, kontaktus ? - létesíts / ellenőrizd - i-v-kapu, légút, oxigén - légút biztosíiás (intubálás) után megszakítás nélküli kompressziók ! - Tonogen 3-5 percenként 1-1 mg - Mérlegelendő.: Amiodaron atropin, magnesium 1 sokk 150-360 J bifázisos 360 J monofázisos Azonnal visszatérni a CPR 30:2 rzsimhez 2 percre Azonnal visszatérni a CPR 30:2 rzsimhez 2 percre Reverzibilis okok: Hypoxia Tensios pneumothorax Hypovbolaemia Tamponad Hypo/hyperkalemia/metabolikus Toxikus eredet Hypothermia Thrombosis (coronaria vagy pulmonalis)

  39. Ewy GA Circulation 2005;111:2134-2142.

  40. 60 kompresszió Compression Only CPR Cardiocerebral Resuscitation Ewy GA Circulation 2005;111:2134-2142.

  41. Lélegeztetés resuscitáció során: Lehet átmenetileg nélkülözni ?

  42. O2 hiány

  43. O2 hiány CO2 túltermelés

  44. Sus scrofa domestica Homo Sapiens Sapiens = ?

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