CARDIOPULMONARY RESUSCITATION

Prof S S Danbauchi

Objectives

• Define CPR- cardiopulmonary resuscitation

​

• Indications

​

• Procedure

​

• Importance to life

Introduction

• Basic Life Support is needed for patient whose breathing or heart has stopped
• Ventilations are given to oxygenate blood when breathing is inadequate or has stopped
•     If heart has stopped, chest compressions are given to circulate blood to vital organs
• Ventilation combined with chest compressions is called cardiopulmonary resuscitation (CPR)
• CPR is commonly given to patients in cardiac arrest as a result of heart attack

​

CPR Saves Lives

• CPR and defibrillation within 3-5 minutes can save over 50% of cardiac arrest victims

​

• CPR followed by AED saves thousands of lives each year

​

• In most cases CPR helps keep victim alive until EMS or AED arrives
•  

Circulatory System

• Circulatory system consists of heart, blood, and blood vessels.
• Transports blood to lungs
• Delivers carbon dioxide and picks up oxygen
• Transports oxygen and nutrients to all parts of body
• Helps regulate body temperature
• Helps maintain body’s fluid balance

​

Anatomy of the Heart

Coronary Arteries

Major Arteries

Circulatory System Emergencies

• Any condition that affects heart/blood volume reduces ability to deliver oxygen

‣Severe bleeding

‣Shock

‣Stroke

‣Heart conditions

​

Cardiac Arrest

• Heart may stop (cardiac arrest) as a result of heart attack and arrhythmias
• Brain damage begins 4 - 6 minutes after cardiac arrest
• Brain damage becomes irreversible in 8 - 10 minutes
• Dysrhythmia or arrhyythmias, an abnormal rhythm of heart beat, may also reduce heart’s pumping effectiveness�

​

Causes of Cardiac Arrest

• Heart attack
• Drowning
• Suffocation
• Stroke
• Allergic reaction (angioedema)
• Diabetic emergency
• Prolonged seizures
• Drug overdose
• Electric shock
• Certain injuries

​

CPR

Cardiopulmonary Resuscitation

​

Chain of Survival

• Early Access
• Early CPR
• Early Defibrillation
• Early Advanced Care

​

​

Cardiopulmonary Resuscitation (CPR)

• CPR helps keep patient alive by circulating some oxygenated blood to vital organs

​

• Ventilations move oxygen into lungs where it is picked up by blood

​

• Compressions on sternum increase pressure inside chest, moving some blood to brain/other tissues

​

• Blood circulation resulting from chest compressions are not as strong as circulation from heartbeat

​

• Can help keep brain/other tissues alive until normal heart rhythm restored

​

• Often electric shock from AED is needed to restore a heartbeat—and CPR can keep patient viable until then

​

• CPR is effective only for a short time

​

• CPR should be started as soon as possible

​

• In some instances, the heart may start again spontaneously with CPR

​

Overview of Initial BLS Steps

1. Assess the victim for response and look for normal or abnormal breathing. If there is no response and no breathing, or no normal breathing (i.e. only gasping), shout for help.
2. If you are alone, activate the emergency response system and get an AED (or defibrillator) if available and return to the victim.

Overview of Initial BLS Steps

3. Check the victim’s pulse (take at least 5 seconds but no more than 10 seconds).

4. If you do not definitely feel a pulse within 10 seconds, perform 5 cycles of compressions and breaths (30:2 ratio), starting with compressions (C-A-B sequence)

CPR Sequence

• Check the scene
• Check for response
• Call for help
• Open the airway using the head tilt/chin lift
• Give two breaths
• Check for pulse (carotid) 5-10 seconds
• Give 30 chest compressions
• Open the airway using the head tilt/chin lift
• Give two breaths
• Continue cycle 30 chest

compressions/ 2 breaths at a rate of 100 per minute

INSPECTION OF THE CHEST

You must check adequate breathing before giving breaths to an unresponsive adult victim.  You do this by looking for chest rise and feeling for airflow through the victim's nose or mouth.  What other sign should you assess?��

Listen for airflow from the victim’s nose or mouth

INSPECTING/LISTENING FOR BREATHING

CPR

After you open the airway and pinch the nose of an unresponsive adult or child, what is the best way to give mouth-to-mouth breaths?

​

Seal your mouth over the victims mouth and give 2 breaths, watching for the chest to rise

MOUTH TO MOUTH RESPIRATION

Chest Compressions Alert

• Be careful with your hand position
• For adults/children, keep your fingers off patient’s chest
• Do not give compressions over bottom tip of breast bone
• When compressing, keep elbows straight and hands in contact with patient’s chest at all times
• Compress chest hard and fast, but let chest recoil completely between compressions.
• Minimize amount of time used giving ventilations between sets of compressions.

​

CHEST COMPRESSION

CPR

CPR

Describe a way you can allow the chest to recoil completely after each chest compression.�

Allow the chest to expand completely between each compression.

CPR

A person shows signs of circulation after CPR was started.  What should you do?

�

Place the victim in the recovery position, lying on their side.

CPR

The purpose of the recovery position is to:�

Prevent aspiration.

Cartoon on first AID

CPR

Why it is important to give early defibrillation to an adult?

​

The most effective treatment for sudden cardiac arrest is synchronized cardioversion

CPR

What are the steps common to the operation of all AED's in the correct order?

�

Power on, attach pads, clear & analyze, clear & deliver shock if advised

CPR

After you power on an AED and attach the pads to the victim, what is the next step you should do?��

Clear the victim so the AED can analyze the heart rhythm

CPR

What might happen if you touch the victim while the AED is delivering a shock?

The AED could shock you while it is shocking the victim.

CPR

You are using an AED on an adult victim, and the AED gives a "no shock indicated" (or "no shock advised") message.  Until advanced care personnel arrive, what should you do next?�

Leave the pads in place and continue CPR

Cartoon on first AID

CPR

What is the best way to relieve severe choking in a responsive adult?

�

Perform abdominal thrusts

CPR

A choking adult becomes unresponsive while you are doing abdominal thrusts for severe choking.  You ease the victim to the floor and send someone to activate your emergency response system.  What should you do next?

�

Begin CPR, when you open the airway, look for and remove the object if seen, before giving breaths

CPR

• Which of the following statements best describes why you should minimize interruptions when giving chest compressions to any victim of cardiac arrest?

If you minimize interruptions, you increase the victims chance of survival.

CPR

Breathing stops but the heart still continues for 2-3 minutes.  What is this called?

�

Respiratory arrest.

CPR

You find a victim lying on his right side.  He is not breathing but has a pulse.  What should you do?

​

�

Give a rescue breath every 5 seconds.

CPR

What happens during a cardiac arrest?

​

The heart and breathing stop without warning.

CPR

Before starting chest compressions, you need to check for a pulse.  What pulse site should you use?

�

Carotid

​

Advanced Life Support in perspective

• Chain of survival:

1. Early access to emergency services [911].

2. Early Basic life Support [by hands only].

3. Early defibrillation .

4. Early Advanced Life Support.

44

Causes & prevention of Cardio respiratory arrest

• Definition: A respiratory arrest is when breathing stops (apnea). A cardiac arrest is when the heart stops contracting & pumping blood.

​

• Causes:

1. Airway problems.

2. Breathing problems.

3. Cardiovascular problems.

45

Airway Obstruction

• Complete airway obstruction will rapidly result in cardiac arrest.
• Partial airway obstruction may lead to cerebral or pulmonary edema , hypoxic brain damage as well as cardiac arrest .
• Causes of airway obstruction [ blood , vomitus , F.B. , direct throat / face trauma , CNS depression , epiglottitis , epileptic fit , bronchial secretions , mucosal edema , laryngeospasm , bronchospasm ].

46

Cardiac Abnormalities

• Primary causes [ventricular fibrillation]:

1. Ischemia.

2. M.I.

3. Drugs [digoxin , quinidine , phenothiazide , tricyclic antidepressant].

4. Alcohol abuse.

5. Acidosis .

6. Abnormal electrolytes conc.[Ca, Mg & K].

47

• Secondary causes of cardiac abnormalities:

1.asphyxia.

2. Apnea.

3. Acute sever blood loss.

4. Acute pulmonary edema.

5. Suffocation.

6. Hypoxemia , anemia , hypothermia , end-stage septic shock are having longer heart effect.

48

Clinical approach to resuscitation

• Prevention:

1. History, examination & investigation when needed.

2. Breathing problems is pre cardio respiratory arrest clinical abnormalities.

3. Hypotension , confusion , restlessness lethargy & L.O.C. should be considered .

4. Metabolic abnormalities particularly acidosis.

5. Consider ICU admission in your plan.

49

Ventilation

• Face mask: [ 45 - 50% if more than 6 L/m ].
• Nasal Cannulae: [ 30 - 35% on 3 L/m].
• Ventorie: [ 24 – 90% ].
• Non re-breathing mask: [ 90% ].
• Laryngeal mask airway: [100% ].
• Endo tracheal tube: [100% ].
• Needle cricothyroidotomy: [full neck extension , feel the cricoid & prick 0.5 cm below it ].

50

Cardiac Monitoring & rhythm Recognition

• Remember: Treat the patient not the ECG.
• A normal HR is defined as 60 –100 b/m , a rate below 60 is known as bradycardia & a rate of 100 is known as tachycardia.
• Rhythms causing cardiac arrest:

1. Supra-ventricular tachycardia [ above bundle of His bifurcation ].

2. Ventricular tachycardia [distal to bifurcation].

51

Supraventricular arrhythmias

• Supra-ventricular tachycardia:

1. Atrial fibrillation: [absent P wave & normal QRS complex].

2.Atrial flutter: [there is P wave but saw tooth in appearance & rate more than 200/m (250-300/m) with regular QRS complex].

3.supra-ventricular tachycardia: [ you might find P wave or not , because it might start from A/V node ].

52

Malignant arrhythmias

• Ventricular tachycardia:

1.wide QRS complex.

2. rare more than 100/m.

3. may sustain for more than 30 seconds (take it seriously). But if it was for less than 30 seconds it might be d.t. lytes imbalance or hypoxia.

• Ventricular Fibrillation :

1. no pulse.

2. ECG show absent QRS & T wave & replaced by cont., very rapid, bizarre, irregular appearance of apparently random frequency & amplitude.

53

Drugs & Their delivery

• Priority in drug delivery :

1. central line [30 seconds].

2. Peripheral line [5 minutes].

3. E.T. Tube [but we double or triple the IV dose].

4. Intra Cardiac [ not used any more]:

a) technically difficult.

b) while doing the procedure CPR should stopped.

c) high rate of complications:� 1.coronary laceration.

2.intra mural injections.

3.pneumothorax.

54

Defibrillation

• We paralyze the heart, to let S. A. Node to start working again .
• The delay in DC >>>the sever the arrhythmia >>> less favorable prognosis & less responsive to treatment.
• Types:

1. Synchronized Cardio-version.

2. A synchronized Cardio-version.

55

Defibrillators

2. Biphasic :

less Jules (electric shock waves move from 1 pad to the other then go in reverse direction).

Types of Biphasic Defibrillator:

1. Manual (which we are using).

2. Shock Advisor (for non-expert people),with big electrodes they can read the rhythm then talk or write the order to be done.

3. Automated External (you just connect it to the patient & it will work & calculate the electric wave by it self & when to give it).

56

AED application

• Position:

1. Right of the upper sternum below the clavicle

2. left 5^th inter-costal space ant. Axillary's line.

• Technique:

1. apply pressure to the paddle [10kg] to decrease thoracic impedance (the distance by pr. The fat).

2. keep the defibrillator paddles at least 12.5 cm from the pace maker if there is.

3. Keep oxygen flow away from from paddle (not to kill the patient by burning instead of arrest)

4. Don’t remove the paddle until 3 DC shock performed.

​

57

Correct Reversible Factors

[Correct Reversible causes (4 H’s & 4T’s)]

1. Hypoxia.

2. Hypovolemia.

3. Hypo/Hyperkalemia & metabolic disorders.

4. Hypothermia.

5. Tension pneumothorax.

6. Tamponade.

7. Toxic/Therapeutic disturbances.

8. Thrombo-embolic/mechanical obstruction.

​

58

Cardiac Arrest in special Circumstances

• Hypothermia.
• Near drowning.
• Pregnancy.
• Poisoning.
• Electrocution.
• Anaphylaxis.
• Acute severe asthma.

​

​

59

Drug Poisoning or toxicity

• Antidote:

- Opiod X Naloxone 1.2mg

- Bradyarrhythmia X atropine 2mg or isoprenaline 10-100ug/min.

- B.blockers X glucagon 5mg IV.

- Organophosphate insecticides X high-dose atropine.

- Cyanides X dicobalt edetate.

- Digoxin toxicity X digoxin specific FAB.

• Pass NGT & lavage stomach from ingested toxins & give activated charcoal.

​

60

Electrocution

• The severity of injury depends on the area & the magnitude & the path of the current.
• Electricity tends to pass along muscles, nerves & vessels. It may therefore paralyze the respiratory muscles or disturb the myocardium, leading to respiratory or cardiac arrest (V. Fibrillation, immediate asystole, extra pace maker).
• Electrocution is like a bullet goes in & out, but if it remains in it will settle at the heart.
• Those who have survived an electric shock should be monitored in hospital if they have suffered (L.O.C, cardiac arrest, ECG abnormalities, contact injury)

61

Anaphylaxis

• Due to (insect bite, food, blood products & drugs) 🡪IgE Anti bodies 🡪 histamine release 🡪 increase vascular permeability & peripheral V.D.( decrease V.R. & C.O.P.) 🡪 sudden collapse & death.
• Anaphylactoid reaction (there is no IgE mediators & no previous sensitization).
• Resuscitation with:

1) 100% oxygen.

2) Adrenaline (if stridor, wheeze or respiratory distress) 0.5cc 1/1000 I.M. & repeat Q5 minutes if no clinical improvement is clear.

3) CPR or ALS.

4) Antihistamines.

5) Hydrocortisone.

6) IV Colloids.

62

Acute Severe Asthma

• Normal or low PCO2.
• Resuscitated with:

1) ABGs.

2) Intubation.

3) Exclude pneumothorax & consider open cardiac message.

• Resist arrhythmias in case of metabolic disorders.

63

Cardiac Pacing

• SAN (60 - 70 beats/minute).
• AVN (40 -50 beats/minute) [narrow QRS].
• His/Purkinje fibers (30 beats/minute) [wide QRS].

​

​

N.B.

In open heart surgery the pace maker should be 100 beats/minute to over come SAN.

64

Pacemakers

Artificial pacemakers classification:

• Non-invasive:
• Percussion pacing (decrease HR 🡪 decrease COP).
• Transcutaneous pacing (stickers).

​

• Invasive:
• Temporary transvenous pacing (central line placed in Rt. ventricle).
• Permanent implanted pacing (catheter with patery).
• Implantable cardioverter defibrillators.

65

66

Thank you

Thank you

National Ambulance Services in Nigeria

• Policy documents will set the tone for the process of structuring and harmonizing the emergency medical and rescue service and consolidating and networking national ambulance services
• However resources remain underutilized due to poor public awareness, lack of intelligent dispatch processes, and lack of requisite investment in human resources. 
• A key information gap identified was hospital classification by care delivery (resource) capacity to guide intelligent decision making by transporters.

​

67

Ambulance

Interior

Panels in the interior

68

Flying Doctors of Nigeria is an air ambulance service established by Dr Ola Orekunrin, 2014

.

​

​

​

​

​

​

​

• Company set up by young British-Nigerian medic boosts healthcare with its 20 aircraft and ‘flying doctors

69

Pre-hospital care in Nigeria: A country without emergency medical services. Nigerian journal of clinical practice 12(1):29-33 · April 2009

• Efficient pre-hospital transport (emergency medical services, EMS) is associated with improved outcomes in medical emergencies. This study aims to discover possible interventions in the existing mode of transport.

​

• This study has identified three groups of persons involved in pre-hospital transport with nearly 50% getting to ER within 1 hour without any intervention or prior notification of ER. Absence of EMS obscures pre-hospital death records.- DBA (dead before arrival)

​

• Most victims are transported by relatives or friends who have no training like BLS, BTLS.

​

70

Other challenges of Cardiovascular emergencies management

Devil ??????

Other factors

• Religion
• “Witch craft”
• Poverty
• Ignorance

​

71

END

• END