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SANIL VARGHESE
CARDIOPULMONARY
RESUSCITATION
HISTORICAL REVIEW
• In the 19th century, Doctor H. R. Silvesterdescribed a method “The Silvester Method”.
• Holger Neilson technique was in the United States in 1911.
• In the 20th century at Johns Hopkins University where the technique of CPR was originally developed. The first effort at testing the technique was performed on a dog by Redding, Safar and JW Perason. Soon afterward, the technique was used to save the life of a child.
• Peter Safar wrote the book ABC of resuscitation in 1957.
CPR For Health Care Providers
• Adult
• Child
• Infant
Terminology
• BLS / BCLS
• ALS / ACLS
• Respiratory Arrest
• Arrest, Cardiac Arrest, Code, Code Blue
• Ventilations
5
Diagnosis of cardiac arrest
Symptoms of cardiac arrest3 absence of pulse on carotid arteries – a
pathognomonic symptom
3 respiration arrest – may be in 30 seconds after
cardiac arrest
3 enlargement of pupils – may be in 90 seconds after
cardiac arrest
Blood pressure measurement
Taking the pulse on peripheral arteries
Auscultation of cardiac tones
Loss of time !!!
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
Health Care Provider*
“PUSH HARD AND PUSH FAST”
At least 100 COMPRESSIONS / MINUTE*
Allow the chest to recoil -- equal compression and relaxation times
<10 seconds for pulse checks or rescue breaths
Compression Depth*
Adults 2”
Child/Infant 1/3 depth of chest 1.5" infant 2" child
Avoid excessive ventilations
A-B-C changed to C-A-B*
Critical element is chest compressions
Delay in A-B
Avoidance of A & B
Early defib
If alone--call and retrieve AED
Exception asphyxial arrest
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
• Cricoid pressure not recommended
• Advanced airway = 1 every 6-8 seconds
• Adult: 1 every 5-6 Peds: 1 every 3
• With advanced airway- no pause
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
AHA ECC Adult Chain of Survival - New
Simplified Universal
BLS algorithm
AMERICAN HEART ASSOCIATION:2010 GUIDELINES
Electrical Therapies
• Shock first vs CPR first
• No precordial thump
• CPR devices – no data for
• AED in hospital (goal to shock =< 3 mins)
• Use in infants (with or without attenuator)
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
ACLS• Simplified algorithm
• Optimized CPR quality with monitoring
• Waveform capnography (>12 mmHg)
• Atropine deleted (PEA/Asystole)
• Chronotropic drugs for brady, then pacing
• Adenosine safe for monomorphic wide tachs
• Post-cardiac arrest
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
AMERICAN HEART ASSOCIATIONCAPNOGRAPHY
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
Post-Cardiac Arrest – ROSC
• Therapeutic Hypothermia
– Remain comatose
– 32-34 degree C (all ages) (89.6-93.2 F)
– 12-24 hours
• PCI
• O2 sat ≥94% & PETCO 35-40
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
• Asthma
• Anaphylaxis
• Pregnancy
• Morbid obesity
• PE
• Electrolyte imbalance
• Toxins
Special Resuscitation Situations
• Hypothermia
• Avalanche
• Drowning
• Electric shock/lightening
• PCI
• Cardiac tamponade
• Cardiac surgery
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
Acute Coronary Syndromes
• Out of hospital 12-lead
• Triage to PCI
• Oxygen – > 94 % is the goal (capno)
• Morphine – use with caution in UA/non-STEMI
AMERICAN HEART ASSOCIATION:
2010 GUIDELINES
Stroke
• Stroke-prepared hospitals
• Triage to stroke centers
• TPA up to 4.5 hours
18
C. CirculationRestore the circulation, that is
start external cardiac massage
Hand Position
• At the nipple line
• Off the zyphoid process
2 fingers = infant
1 hand = child
2 hands = adult
20
A (Airway)
ensure open
airway
21
Open the airway using a head
tilt lifting of chin. Do not tilt the
head too far back
Check the pulse on
carotid artery using
fingers of the other hand
22
B (Breathing)
Tilt the head back
and listen for. If
not breathing
normally, pinch
nose and cover
the mouth with
yours and blow
until you see the
chest rise.
VENTRICULAR FIBRILLATION OR PULSELESS TACHYCARDIA
23
Witnessed Unwitnessed
Precordial thump
Check pulse, if none:
Begin CPR
Defibrillate with 200 joules
Defibrillate with 200-300 joules
Establish IV access, intubate
Adrenaline 1 mg push
Defibrillate with 360 joules
Lidocaine 1 mg/kg IV, ET
Defibrillate with 360 joules
24
Operations in case of asystole
Asystole
• Start CPR
• IV line
• Adrenaline:IV 1 mg, each 3-5 min.
-or
- intratracheal 2 - 2.5 mg
- in the absence of effect increase
the dose
-Atropine 1 mg push (repeated once
in 5 min)
•Na Bicarbonate 1 Eq/kg IV
•Consider pacing
25
Drugs used in CPR
• Atropine – can be injected bolus, max 3 mg to
block vagal tone, which plays significant role in
some cases of cardiac arrest
• Adrenaline – large doses have been
withdrawn from the algorithm. The
recommended dose is 1 mg in each 3-5 min.
• Vasopresine – in some cases 40 U can
replace adrenaline
• Amiodarone - should be included in algorithm
• Lidocaine – should be used only in ventricular
fibrillation
Public Access Defibrillation -PAD
• Casinos
• Airports
• City buildings
• Senior centers
• Gated communities
Complications of Compressions
• fractured ribs
• fractured sternum
• lacerated lungs
• lacerated liver, blood vessels, etc,.
2010 AHA GUIDELINESRecommendations
Component Adults Children Infants
Recognition Unresponsive (for all ages)
No breathing or no normalbreathing (ie, only gasping)
No breathing or only gasping
No pulse palpated within 10 seconds for all ages (HCP only)
CPR sequence C-A-B
Compression rate At least 100/min
Compression depth
At least 2 inches (5 cm)
At least 2 inches (5 cm)
About 1. inches (4 cm)
Recommendations
Component Adults Children Infants
Chest wall recoil Allow complete recoil between compressionsHCPs rotate compressors every 2 minutes
Compression interruptions
Minimize interruptions in chest compressionsAttempt to limit interrruptions to <10 seconds
Airway Head tilt–chin lift (HCP suspected trauma: jaw thrust)
Compression-to-ventilationratio (until advancedairway placed)
30:21 or 2 rescuers
30:2Single rescuer
15:22 HCP rescuers
Ventilations: when rescueruntrained or trained andnot proficient
Compressions only
Ventilations with advancedairway (HCP)
1 breath every 6-8 seconds (8-10 breaths/min)
Asynchronous with chest compressionsAbout 1 second per breath
Visible chest rise
Defibrillation Attach and use AED as soon as available. Minimize interruptions in chest compressions before and after shock;resume CPR beginning with compressions immediately after each shock.
Thank you