CARDIOPULM0NARY RESUSCITATION

by

Prof. E. S. ISAMADE

OUTLINE

• Introduction
• Background Physiology and Pathophysiology
•  General Causes
• Potentially reversible causes
• Signs of imminent cardiac arrest
•  Goal of care
•  Basic Life Support 
•  Advanced life support
• Postresuscitation care
•   Prognostication
• Summary

​

2

Introduction

• Several guidelines have been produced in an attempt to improve the quality of cardiopulmonary resuscitation (CPR).
• They are based on international consensus views and the most recent of them, relating to Advanced Life Support, was published in November 2019
• The aim of this lecture is to provide an overview of resuscitation based on these guidelines and will be confined to the detailed management of cardiac arrest .
• Cardiac arrest refers to sudden cessation of effective cardiac activity. 

​

3

Background physiology/pathophysiology

The maintenance of normal tissue metabolism relies principally on an adequate delivery of oxygen, in a functioning circulation. Failure of delivery rapidly results in the following changes:

4

Physiology/Pathophysiology cont.

• Hypoxia-following inadequate oxygen in blood(hypoxic,anaemic,stagnant,cytotoxic).
• Acidosis-anaerobic metabolism,with accumulation of CO₂ in tissues.
• Release of stress hormones-cathecolamines,ADH,Aldosterone(increase tendency for arrythmias).

5

General Causes

• Cardiac - IHD,Acute circulatory obstruction, cardiac

tamponade ff trauma,direct myocardial

stimulation,myocarditis

• Circulatory- Hypovolaemia,tension

pneumothorax, air or pulmonary

embolism.

• Respiratory- airway obstruction
• Metabolic-electrolytes imbalance,hypothermia
• Others- drugs,electrocution,drowning

6

Potentially reversible causes

• Hypoxia
• Hypovolaemia
• Hyperkalaemia, hypokalaemia, hypocalcaemia, acidaemia, and other metabolic disorders
• Hypothermia
• Tension pneumothorax
• Tamponade
• Toxic substances
• Thromboembolism (pulmonary embolus/coronary thrombosis)

7

Signs of imminent cardiac arrest?

• Hypotension
• Tachycardia
• Severe chest pain
• Dyspnoea/Tachypnoea
• High fever
• Restlessness
• Confusion
• Loss of consciousness
• Cardiac arrest-SUDDEN CIRCULATORY STANDSTILL .

8

Goal of care in CPR

To restore a beating heart and functioning circulation to maintain oxygen delivery to vital organs and therefore preserve vital function, including brain viability

The Heart, Lungs and Brain function interdependently

• Lungs oxygenates the blood → heart pumps to brain
• Loss of function – Brain → Respiratory system → Heart

​

9

Basic Life Support-Introduction

• BLS - essential link in “chain of survival”
• Purpose of BLS is to maintain an adequate circulation and ventilation until action can be taken to reverse the underlying cause of C-R arrest.
• Failure of circulation for 3-4 minutes (less if patient is hypoxaemic initially) leads to irreversible cerebral damage
• Any delay in starting BLS ↓ the chances of a successful outcome
• BLS
• Slows deterioration from VF to asystole
• May improve the probability of defibrillation and
• Leads to significantly increased survival

​

​

10

BLS-contd

• Conventional BLS implies that no equipment is used and is certainly applicable to the “lay rescuer”who is performing BLS outside a hospital or clinic.
• Immediate Life Support - course intended for healthcare personnel, who will have other people at hand as well as equipment (particularly airway adjuncts).
• Healthcare personnel must have knowledge of “lay person” BLS protocols since may have to perform BLS outside hospital and teach others.

​

​

11

Maintaining a patent airway

• Prevent or treat airway obstruction
• maintain the airway-airway tools

Common causes of airway obstruction are-

Upper Airway

• tongue - in the unconscious
• soft tissue oedema, foreign material
• blood, vomit

Larynx

• laryngospasm, foreign material

Lower Airway

• secretions, oedema, blood
• bronchospasm
• aspiration of gastric contents

12

13

​

Airway obstruction by the tongue in the unconscious patient

​

​

HEAD TILT, CHIN LIFT OPENS THE AIRWAY

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

​

Jaw thrust

14

Is the patient breathing?

• Look for chest movements
• Listen at the patient’s mouth for breath sounds
• Feel for air on your cheek

​

15

What is the circulation like?

• Assess circulation

- peripheral pulses may not be palpable(GO FOR THE CAROTID OR USE THE STETHOSCOPE).

• Take not more than 10 seconds to assess patient.

​

​

​

​

​

16

BLS-Sequence contd

• call for help-often more than two hands needed.
• Give immediate 30 chest compressions

17

Combined Rescue Breathing and Circulation

• After 30 compressions give two ventilations
• Return your hands without delay to the correct position on the sternum and given 30 further compressions, continuing compressions and breaths in a ratio of 30:2
• Stop to recheck for signs of a circulation only if the victim makes a movement or takes a spontaneous breath; otherwise resuscitation should not be interrupted.
• Sequence of resuscitation – C A B

18

How do I do EFFECTIVE cardiac massage?

• With the hand that is nearest to the victim’s feet, locate the lower half of the sternum
• Do not apply any pressure over the upper abdomen or bottom tip of the sternum
•  Position yourself vertically above the victim’s chest and, with your arms Straight, press down on the sternum to depress it between it between 4 and 5 cm.
• Release the pressure without losing contact between the hand and the sternum, and then repeat at a rate of about 100 times a minutes.
• Take equal time with compression and release and allow the chest to recoil to its normal position after each compression

19

Note on Techniques-1

• If your rescue breaths do not make the chest rise as in normal breathing, then

before your next attempt: Check the victim's mouth and remove any visible obstruction.

• Recheck that there is adequate head tilt and chin lift.
• Do not attempt more than two breaths each time before returning to chest compressions.
• Blowing too quickly - ↑risk of regurgitation
• If there is more than one rescuer present, another should take over CPR about every 2 mins to prevent fatigue. Ensure minimum delay during the changeover.

20

Continue BLS until…………�

• Qualified help arrives and takes over
• The victim shows signs of life
• You become exhausted

​

21

Variations In Cardiopulmonary Resuscitation Techniques

Compression-only CPR

• Reluctant rescuers - better than no CPR at all, combined with head tilt to provide a patent airway
• Untrained bystanders
• Appropriate during telephone-CPR.
• Appropriate in non-asphyxiated patients

​

22

Further variations

• Cervical spine Injury
• Keep the head, neck and chest in the neutral position
• Head tilt should be the least that allows unobstructed ventilation or intubation
• Use jaw thrust rather than chin lift.
• Assistance from others may be required to maintain head, neck and chest alignment if adequate cervical splinting is not available

​

23

Advanced Life Support

• Advanced Life Support refers to the use of specialised techniques, in an attempt to rapidly restore an effective rhythm to the heart. The most important components of the advanced life support techniques are
• direct current defibrillation, and
• efficient BLS.

Ideally ALS should take place in the Hospital.

24

In-hospital Basic Life Support

• First shout for help, then assess if the patient is responsive (shake and shout) If other members of staff are nearby it will possible to undertake actions simultaneously
• In witnessed arrest, a precordial thump is beneficial-can convert VT to sinus rhythm.
• Maintain airway
• Feel for a pulse and assessing for any signs of a circulation. If there is no pulse, call the medical personnel.
• If there is a pulse, urgent medical assessment is required. Depending on the local protocols, give the patient oxygen, attach ECG monitoring leads, and obtain venous access.

​

25

In-hospital Basic Life Support-contd

• As one person starts BLS others should call the medical team and collect the resuscitation equipment and a defibrillator. If only one member of staff is present, he/she should shout for help.
• Undertake airway management and ventilation with the most appropriate equipment immediately at hand
• Give two ventilations after every 30 chest compression, intubate, continue chest compressions uninterrupted (except for defibrillations or pulse checks when indicated), at a rate of 100, min^-1 and ventilate the lungs at approximately 12 breaths min^-1.

​

​

26

Further care

• Establish diagnosis with ECG
• Commence definitive treatment depending on the type of arrest.

27

ECG classification of Cardiac arrest

• Shockable

-Ventricular fibrillation

- Pulseless VT

• Non-shockable

-Asystole

- PEA

28

SINUS RHYTHM

29

VENTRICULAR TACHYCARDIA

30

VENTRICULAR FIBRILLATION

31

Shockable-Sequence of actions�

• Attempt defibrillation (one shock - 200 J biphasic,360J monophasic).
• Immediately resume chest compressions (30:2) without reassessing the rhythm or feeling for a pulse.
• Continue CPR for 2 min, then pause briefly to check the monitor:If VF/VT persists:

Give a further (2nd) shock (200 J biphasic, 360 monophasic).

• Resume CPR immediately and continue for 2 min.

32

contd

• Pause briefly to check the monitor
• If VF/VT persists give adrenaline 1 mg IV followed immediately by a (3rd) shock (360J).
• Resume CPR immediately and continue for 2 min.

​

​

33

contd

• Pause briefly to check the monitor.
• If VF/VT persists give amiodarone 300 mg IV followed immediately by a (4th) shock (360J).
• Resume CPR immediately and continue for 2 min.
• Give adrenaline 1 mg IV immediately before alternate shocks (i.e. approximately every 3-5 min).
• Give a further shock after each 2 min period of CPR and after confirming that VF/VT persists

34

contd

• If organised electrical activity is seen during this brief pause in compressions, check for a pulse.
• If a pulse is present, start post-resuscitation care.
• If no pulse is present, continue CPR and switch to the nonshockable algorithm.
• If asystole is seen, continue CPR and switch to the nonshockable algorithm.

35

Non-Shockable

• Start CPR 30:2.
• Give adrenaline 1 mg IV as soon as intravascular access is achieved.
• Continue CPR 30:2 until the airway is secured, then continue chest compressions without pausing during ventilation.
• Recheck the rhythm after 2 min.
• If there is no change in the ECG appearance: Continue CPR.
• Give further adrenaline 1 mg IV every 3-5 min (alternate loops).
• If a pulse is present, start post-resuscitation care.
• If no pulse is present: Continue CPR.

​

36

Strategies before defribillation

• Safe use of oxygen
• Chest hair
• Paddle force
• Electrode position
• Pads versus paddle
• Automated External Defribillation

37

Airway manouvres

• Oropharyngeal airway-simple or cuffed
• Laryngeal mask airway
• Combitube
• Tracheal tube
• Cricothyroidotomy

​

38

Assisting the circulation

• Peripheral IV access
• Intraosseous route
• Tracheal route

39

Post-resuscitation care

• Starts with return of spontaneous circulation
• Often times patient might need to be transferred to an ICU or HDU
• Interventions at this stage influence final outcome significantly

40

PRC-contd

• Airway and breathing

- sedate and ventilate obtunded patient

- Decompress stomach with NG tube

- X-ray to check TT position and rule out

pneumothorax ff rib fracture.

​

​

41

contd

• Circulation

-Venous or arterial line may be needed.

- Infusion of fluids

- Use of diuretics and ionotropic dgs

42

Contd

• Optimising neurological recovery

- Sedation

- Control of seizures

- Temperature control

- Blood glucose control

43

Prognostication

• There are no neurological signs that can predict outcome in the comatose patient in the first hours after ROSC.
• By three days after the onset of coma related to cardiac arrest, 50% of patients with no chance of ultimate recovery have died.
• In the remaining patients, the absence of pupil light reflexes on day three, and an absent motor response to pain on day three, are both independently predictive of a poor outcome (death or vegetative state) with very high specificity

44

Summary

• Knowledge of Anatomy and physiology is the foundation for understanding life threatening conditions.
• All acutely ill patients that suddenly stops breathing with loss of consciousness should benefit from immediate life support.
• Finally,note that, at all time resuscitation sequentially follows the first three letters of the alphabet C(irculation). A(irway): B(reathing):

​

45

Therefore resuscitation is as simple as � � ABC�� Thank you

46