CARDIOPULMONARY RESUSCITATION DR SUBHASH THAKUR(JR ANAESTHESIA)

1. CARDIOPULMONARY RESUSCITATION DR SUBHASH THAKUR(JR ANAESTHESIA)

2. CARDIOPULMONARY RESUSCITATION CLINICAL DEATH period during which loss of vital signs may be reversed BIOLOGICAL DEATH there is irreversible damage to vital organs EFFICACY OF CPR data from pre hospital care system in Seattle showed that 43% of patients found in VF were discharged from hospital if CPR was applied within 4 min and defibrillation within 8 min if onset of CPR is delayed or if time to defibrillation is longer than 10min the probability is > the patient will be in asystole or I fine VF and will convert to asystole During conventional CPR CO is measured about 25%of normal. Cerebral blood flow 3-15% of normal if CPR is started immediately but it decreases progressively as CPR continues and ICT rises

3. Mechanisms of blood flow during resuscitation • During CPR several mechanism are operating but important theories are • Cardiac pump theory 2. Thoracic pump theory

4. INFECTIOUS DISEASES AND CPR • Public fear can be counter acted by continuous education and explaining facts • Concerns of health care workers should be adequately addressed. • Saliva has not been implicated in transmission of HIV even after bites percutaneous inoculation contamination of open wounds with saliva • HBV + saliva is not infectious if applied to oral mucosa but mouth to mouth respiration may result in exchange of blood between pt. and rescuer if there are open lesions or trauma to oral mucosa or lips

5. STANDARD PROCEDURES AND TEAM EFFORT • Skills necessary to perform adequately during cardiac or resp arrest and to interface smoothly with ACLS techniques cannot be learned from reading texts and manuals. • Be trained as these skills deteriorate with disuse • They need to be updated.

6. BASIC LIFESUPPORT FOR ADULTS WITH AN UNOBSTRUCTED AIRWAY • BLS is meant to support the circulation and respiration of those who has experienced cardiac or resp arrest • Heart usually cont to circulate blood for several minutes and residual oxygen in lungs and blood may keep the brain viable • Cardiac arrest results in rapid depletion of O2 in vital organs. after 6 min brain damage is expected

7. SEQUENCE OF STEPS IN CPR • Include A B C of CPR • Airway- before opening the airway rescuer determines the unresponsiveness. • Breathing- before breathing rescuer determines breathlessness. • Circulation- before circulation rescuer determines pulselessness • Assessment and determination of unresponiveness-can be done by tapping or gently shaking or shouting. Then pulse is assessed .

8. No defibrillator available Strike lower 1/3 rd of sternum with fist No pulse Establish airway Defibrillator available Use it immediately No carotid pulse palpitated in 5-10 sec

9. Opening the airway and determining the breathlessness • Maneuvers that can be applied for opening the airway are • Head tilt and chin lift • Jaw thrust • Once airway is opened look for spont gas exchange which can be accomplished by • Look • Listen • Feel • If no spont breathing, rescue breathing should be initiated with airway mask bag unit • If rescuer trained and equipments are available then intubate and ventilatory adjuncts to be used. • Rescue breathing should be delivered at @10-12/min, Vt of 700 ml • If pt. wears dentures don’t remove it • If rescue breathing fails give another jaw thrust –if no ventilation it is obstructed airway • DETERMINE PULSELESSNESS-in adults central pulses is best determined by palpating carotid artery. • If pulse not felt for 10 sec initiate chest compression unless electrical counter shock is available • CHEST COMPRESSION –the recent recommendations of CPR are –push hard @100 compressions /min,allow full chest recoil,minimise interruptions in chest compression

10. TWO RESCUER CPR • One rescuer positioned at pts.side,gives chest compressions • Other positioned at pts head ,maintains open airway and performs ventilation.in this tech compression rate is 100/min but newer recommendation of compression:ventilation is 30:2 • For infants and children 15:2 • COMPLICATIONS of BLS • Gastric distension and regurgitation • Rib and sternal # • Flail chest • CC separation • Pneumothorax ,haemo thorax • Haemopericardium • Pulmonary contusions • SC emphysema • Fat embolism • Laceration of intra abd organs

11. MONITORING THE EFFECTIVENESS OF BLS • CAN BE MONITORED BY • Chest movements • Escape of expired air • Adequate carotid pulse with chest compression 4. Pupillary response

12. PEDIATRIC RESUSCIATION • In infants and children who require resuscitation have had a primary resp arrest. Cardiac arrest results from hypoxia and acidosis • The outcome of CPR in children with cardiac arrest are poor because cessation of cardiac activity is usually is manifestation of prolonged hypoxia • For purpose of CPR • Infant tech-age<1 Yr • Children tech-age 1-8 Yr • Adult tech –age>8 Yrs If child is found apenic ,put the child in supine position ,use head lift chin lift maneuver, if no adequate airway achieved or neck injury suspected use jaw thrust man. Gastric decompression is dangerous and should be avoided until pt has been intubated.if gastric distension is so severe that ventilation is compromised, turn child to one side ,use gastric tube and suction. • Ventilatory rates for • Infants-20 b/min • Child 12-20b/min • Adolescents 10-12b/min If child does not have pulse ,institute artificial circulation Pulse to be looked for –carotid in older children, brachial artery b/w elbow and shoulder, and femoral art in infants Techniques for chest compression in infants are • Two finger tech • Two thumbs tech

13. OBSTRUCTED AIRWAY • If attempted rescue breathing in an arrested pt fails to move air into the lungs ,obstructed airway must be presumed to be present • The Persons who experience partial obst with reasonable gas exchange should be encouraged to cont breathing efforts with attempts at coughing • the person whose obst is so severe that air exchange is markedly impaired i.e. cyanosis with lapsing consciousness should be treated as having complete obst • If airway remains closed after repositioning of head other mane to open airway should be used which include Jaw thrust and tongue jaw lift If airway remains obst use HEIMLICK Maneuver In cases of advanced pregnancy, severe ascitis ,marked obesity chest thrust can be used If these attempts fail we can adopt direct visualisation,intubation,tracheostomy.

14. ACLS IN ADULTS • The use of adjunctive equipment ,more specialized tech,pharmacological and electrical therapy in treatment of pts who has experienced cardiac or resp arrest is generally referred to as ACLS • Airway and ventilatory support-the pre-requisites for successful resuscitation are oxygenation and optimal ventilation.supplemental O2 should be given as soon as it is available • Emergency ventilation commonly begins with combined use of mask and oral airway. The Vt should be about 700ml • Endotracheal intubation is required if pt cannot be rapidly resusciatated or adequate spont ventilation does not resume quickly • Once trachea is secured hyper ventilation is avoided • LMA can be used for airway control and ventilation during CPR • If attempts at releaving an obst airway have failed ,advanced tech like transtracheal catheter ventilation or cricothyroidotomy may be used for ventilation but tracheostomy is still necessary. • Circulatory support-donot unduely interrupt chest compressions • ECG monitoring is useful but never relied upon ECG without frequent ref to pts. Pulse and clinical condition • Defibrillation-it is definitve tt for post cardiac arrest.it should be delievered as soon as possible Proper use of defibrillator requires special attention to • Selection of proper energy level • Proper asyn mode • Proper pos of paddels • Adequate contact b/w paddle & skin • No contact with anyone except pt. • If not skeletal ms twitch check for equipment,contacts,synchroniser switch • Pacemakers which can be –transvenous and trans thoracic electrodes

15. EXTERNAL PACING EQUIPMENT • Venous access-peripheral venous access through antecubital vein is often more convenient • Central venous access is more secure route for drug admn. • IO route is easy to achieve in infants and children • Drugs like ADR,Atropine & lidocaine can be given thru tracheal tube • Lower extremity peripheral veins should be avoided • Correction of hypoxia-to be done earliest • Correction of acidosis –AHA guidelines suggest that soda bicarb be avoided until a perfusing rhythm is established • Volume replacement with crystalloids,colloids or blood • Drug therapy-include sympathomimetic drugs and vasopressors ,anti arrhythmic agents or other agents like NTG ,SNP.atropine

16. Shockable VF/VT Give 1 shock Cont CPR (5 cycles) Check rhythm Shockable Cont CPR,give 1 shock Give vasopressors Give 5 cycles of CPR Check rhythm Shockable Cont CPR Give 1 shock Give anti arrhythmic Consider Mg After 5 cycles of CPR Check rhythm Asystole/PEA Resume CPR for 5 cycles Give vasopressors Consider atropine Give 5 cycles of CPR Check rhythm Shockable/or not If shockable proceed for as in VF/VT If not shockable-resume CPR as for asystole/PEA. Pulseless arrestCPRO2MONITOR/defibrillatorcheck rhythm

17. thanks