Slide 1: بسم الله الرحمن الرحیم Can you save a life? In an emergency, when every second is criticial, would you know what to do? : Can you save a life? In an emergency, when every second is criticial, would you know what to do? According to recent statistics sudden cardiac arrest is rapidly becoming the leading cause of death in America.
Once the heart ceases to function, a healthy human brain may survive withoAut oxygen for up to 4 minutes without suffering any permanent damage.
Unfortunately, a typical EMS response may take 6, 8 or even 10 minutes. Cardio polmunary resusitation (CPR) : Cardio polmunary resusitation (CPR) Dr. M Alimardani MD, MPH
Board Certified in Infectious Disease
Abhar - Iran Basic cardiovascular life support : Basic cardiovascular life support Phases of resuscitation
Pulse checks Phases of resuscitation : Phases of resuscitation the electrical phase (the first four to five minutes of arrest due to ventricular fibrillation (VF). Immediate DC cardioversion is needed to optimize survival of these patients.
the hemodynamic phase: the period from 4 to 10 minutes after sudden cardiac arrest during which the patient may remain in VF. Although early defibrillation has been advocated for all patients found in VF, evidence reveals that patients with low amplitude fibrillation, due to prolonged pulselessness, may benefit from well-performed CPR to generate adequate cerebral and coronary perfusion, prior to initial attempts at defibrillation. Phases of resuscitation : Phases of resuscitation the metabolic phase: defined as greater than 10 minutes of pulselessness, stresses post resuscitative measures, including hypothermia therapy.
If not quickly converted into a perfusing rhythm, patients in this phase generally do not survive. Chest compressions : Chest compressions Chest compressions are thought to be the most important element of CPR
push hard and fast on the center of the chest.
When performed at a rate of 100 / minute, with a down-stroke of at least 38 mm, and allowing the chest to fully recoil between each down-stroke, coronary perfusion pressures are optimized, and return of spontaneous circulation (ROSC) is maximized. Chest compressions : Chest compressions Interruptions in compressions, no matter how brief, result in unacceptable declines in coronary perfusion pressures and worse outcomes.
Evidence suggests that manual compressions become less effective after a few minutes of consistent and uninterrupted performance, mostly due to operator fatigue and inexperience Ventilations : Ventilations During the initial phase of cardiac arrest the importance of compressions supersedes ventilations.
the initiation of chest compressions is the first step to improving oxygen delivery to the tissues.
pulselessness persists, however, properly performed ventilations become more important.
In this, the metabolic phase of resuscitation, clinicians must continue to ensure that ventilations do not interfere with the cadence and continuity of compressions.
deliver ventilations at a rate of 2 ventilations for each 30 compressions in the patient without an advanced airway, and one asynchronous ventilation 8 to 10 times per minute in the patient with an advanced airway Ventilations… : Ventilations… Ventilations should be delivered in as short a period as possible, not exceeding one second per breath
Only enough tidal volume to confirm initial chest rise should be given.
Care must be taken to avoid excessive ventilation, either through high rates or increased volumes.
Positive pressure ventilation raises intrathoracic pressure which causes a decrease in venous return.
over-ventilation reduces defibrillation success rates and decreases overall survival. Compression-ventilation ratio : Compression-ventilation ratio In all but infants and children, CPR should be performed at a rate of 100 / minute with a ratio of 30 compressions to 2 ventilations until an advanced airway has been placed.
Following placement of an advanced airway, compressions are continuous, and asynchronous ventilations are delivered 8 to 10 times per minute.
In the infant or child, the healthcare provider should use a ratio of 15 compressions to 2 ventilations. Defibrillation : Defibrillation The effectiveness of early defibrillation of patients with ventricular fibrillation (VF) and short "downtimes" is well supported by the resuscitation literature and encouraged in the American Heart Association
We recommend that all defibrillations be delivered at the highest available energy in adults (generally 360 J for a monophasic defibrillator and 200 to 360 J for a biphasic defibrillator).
In children, the guidelines continue to recommend 2 J/kg for the first defibrillation and 4 J/kg for subsequent doses with either monophasic or biphasic defibrillators. Pulse checks : Pulse checks Observational studies suggest that even short delays in the initiation or interruptions in the performance of cardiopulmonary resuscitation (CPR) correlate with poor coronary perfusion pressures and poor outcomes
Any interruption in compressions reduces blood flow and sustained compressions are needed to regain preinterruption flow rates.
guidelines recommend that CPR performed by the lay rescuer or healthcare provider be initiated immediately, without a pulse check, upon determining unconsciousness in a patient without signs of respiratory effort. Pulse checks : Pulse checks guidelines also recommend that CPR be resumed for two minutes, without a pulse check, after defibrillation, regardless of the resulting rhythm.
Data suggest the post-defibrillation heart does not provide effective cardiac output, and CPR may improve post defibrillation perfusion
All healthcare providers should receive standardized training in CPR and be familiar with the operation of automated external defibrillators (AED). Basic life support algorithm : Basic life support algorithm Check responsiveness
Activate EMS response system
Open the airway
Give two effective breaths
Compress chest, if no signs of circulation detected
Early defibrillation advanced cardiovascular life support (ACLS) : advanced cardiovascular life support (ACLS) ACLS includes knowledge and skills necessary to provide appropriate early treatment for cardiopulmonary arrest and includes:
Basic life support,
Use of advanced equipment and special techniques for establishing effective ventilation and circulation, including defibrillation; oxygenation, ventilation, and airway control; and devices to assist circulation ACLS… : ACLS… ECG monitoring, 12-lead ECG interpretation, and arrhythmia recognition
Establishment and maintenance of intravenous access
Therapies for the treatment of patients with cardiac and respiratory arrest, including postarrest stabilization; this includes adequate knowledge about the antiarrhythmic agents and drugs for optimizing cardiac output and blood pressure Attach defibrillator/monitor : Attach defibrillator/monitor When an in-hospital cardiac arrest occurs
Responders should attach a defibrillator
Monitor while the basic life support algorithm is activated
The victim's rhythm should be immediately assessed
Early defibrillation considered.
Early defibrillation during an in-hospital cardiac arrest is defined as a shock within three minutes of the cardiac arrest. Slide 22: If the monitor displays VT or VF, a single shock should be applied with immediate resumption of CPR (30 compressions to 2 ventilations)
The recommended initial energy is 150 to 200 J for biphasic defibrillators and 360 J for monophasic defibrillators.
If available, a biphasic waveform defibrillator is preferable since the success rate for defibrillation is higher than with monophasic waveforms Slide 23: After two minutes of uninterrupted CPR, the cardiac rhythm should be reassessed and another shock applied, if indicated.
Second and subsequent shocks should be 150 to 360 J for biphasic defibrillators and 360 J for monophasic defibrillators.
Again, defibrillation should be followed by two minutes of uninterrupted CPR;
After this period the cardiac rhythm should be reassessed.
If VT/VF are refractory to defibrillation, additional interventions are necessary Slide 24: If there is any doubt whether the rhythm is asystole or fine VF, defibrillation should not be attempted
Instead, chest compressions and ventilation should be continued. Arrhythmia other than VT or VF : Arrhythmia other than VT or VF Primarily asystole or pulseless electrical activity (PEA), is seen on the monitor,
The pulse should be immediately checked to determine if the nonshockable rhythm is producing a spontaneous circulation.
If no pulse is detected, CPR is initiated and continued for approximately three minutes
The rhythm is then reassessed for the presence of VT or VF or spontaneous return of an organized rhythm in a beating heart.
If an organized rhythm is not present, additional interventions are necessary. Additional interventions : Additional interventions A tracheal tube should be placed
Oxygenation and ventilation are then confirmed with end-tidal CO2 and oxygen saturation monitors.
Intravenous access should be obtained and an intravenous infusion started.
Appropriate medications, including epinephrine, vasopressin, buffers, or antiarrhythmic drugs, should be administered
Pacing, if indicated Reversible causes should be sought and corrected VF/pulseless VT : VF/pulseless VT The ACLS guidelines have traditionally assumed that most cardiac arrest is due to VF or pulseless VT; thus, algorithms place a strong emphasis on the immediate recognition and treatment of these arrhythmias. Drug therapy : Drug therapy The use of drugs, including sympathomimetic agents, antiarrhythmic drugs, and buffers has been relegated to a secondary role since there is little evidence that these agents are of benefit
Epinephrine (1 mg intravenous push) is administered if VF or pulseless VT persists after a second shock.
It is repeated every three to five minutes thereafter if VF or pulseless VT persists.
we do not suggest the use of higher doses of epinephrine. Drug therapy… : Drug therapy… Vasopressin is an acceptable alternative to epinephrine.
It is recommended for asystole, VT, or VF; but not for PEA.
A single intravenous dose of 40 U is given once (since the half life is 10 to 20 minutes compared to 3 to 5 minutes with epinephrine).
Amiodarone is administered as a 300 mg intravenous push if VF or pulseless VT persists after three shocks . If VF or pulseless VT recurs or remains refractory, a further dose of 150 mg dose can be given, followed by an infusion of 900 mg over 24 hours. Drug therapy… : Drug therapy… Lidocaine can be used as an alternative to amiodarone, but should not be administered if amiodarone has already been given.
Lidocaine is administered at a dose of 1 mg/kg as an intravenous push and can be repeated every 3 to 5 minutes; it should not exceed a total dose of 3 mg/kg during the first hour.
Procainamide, administered at a dose of 30 mg/min intravenously up to a maximum dose of 17 mg/kg is acceptable but not recommended since the prolonged time for administration is unsuitable for a cardiac arrest. Drug therapy… : Drug therapy… Magnesium sulfate, 1 to 2 grams intravenously is recommended for the treatment of polymorphic VT (torsade de pointes) and suspected hypomagnesemic states.
Sodium bicarbonate, 1 meq/kg intravenously, is indicated for severe conditions known to provoke sudden death, such as hyperkalemia, preexisting metabolic acidosis, or certain drug overdoses.
Defibrillation, should be attempted after each medication is administered or after each minute of CPR. Pulseless electrical activity : Pulseless electrical activity is defined by the presence of electrical activity (other than VT or VF) in the absence of a detectable pulse. PEA is often associated with specific clinical states that can be reversed when identified early and effectively treated.
Survival is poor when the electrical activity is wide and/or slow; these rhythms often represent the last electrical activity of a dying myocardium or may be associated with hyperkalemia, hypothermia, hypoxia, preexisting acidosis, or a variety of drug overdoses.
In contrast, electrical activity that is narrow complex and rapid suggests that a relatively normal heart has received a major insult (eg, hypovolemia, infection, pulmonary embolism, or cardiac tamponade) Slide 35: Epinephrine (1 mg intravenous push) should be given as soon as intravenous access is established and repeated every three to five minutes thereafter until return of spontaneous circulation is achieved.
There is no evidence to support the routine use of vasopressin for PEA.
Sodium bicarbonate: It is indicated for patients with preexisting hyperkalemia. acidosis, tricyclic antidepressant overdose, and to alkalinize the urine in aspirin or other drug overdoses. It is not routinely used for acute lactic acidosis associated with CPR, but may be considered if the initial interventions have been ineffective. The use of bicarbonate is acceptable in intubated and ventilated patients with a long arrest interval or upon return of circulation after a long arrest interval; however, there is only fair evidence for its efficacy in these settings. The use of bicarbonate is harmful and not indicated for respiratory acidosis.
Atropine — The administration of atropine (1 mg every three to five minutes) is possibly helpful for PEA when the rate is slow (ie, absolute bradycardia with a rate <60 beats/min, or a heart rate less than expected relative to the underlying condition). ulseless electrical activity : ulseless electrical activity Asystole : Asystole Patients with asystole have a dismal rate of survival, as low as 1 or 2 percent.
Medical therapy — Administration of epinephrine versus vasopressin for cardiac arrest due to asystole is controversial.
We suggest immediate administration of vasopressin 40U IV as the preferred therapy in patients with asystolic cardiac arrest. In patients that do not respond to two doses of vasopressin, we suggest the administration of epinephrine.
The medical treatment of asystole is otherwise identical to that of PEA.
Transcutaneous pacing: may be effective if performed early and when combined with drug therapy. However, there is no evidence to support the routine use of pacing. Persistent asystole : Persistent asystole When asystole persists, the decision about ceasing further CPR efforts must be made; consideration is given to the quality and duration of CPR. Was tracheal intubation performed? Was effective ventilation achieved? Was VF, if present, adequately shocked? Was intravenous access obtained? Were intravenous epinephrine and atropine given? Was a reversible cause ruled out or corrected, if identified? Was asystole continuously documented for more than 5 to 10 minutes after all of the above were accomplished? Bradycardia : Bradycardia Bradycardia may be the cause of cardiac arrest but it is more often associated with signs and symptoms of a low cardiac output.
These include chest pain, shortness of breath, decreased level of consciousness, low blood pressure, shock, pulmonary congestion, and/or heart failure.
Atropine is effective for treating symptomatic sinus bradycardia.
It may be beneficial for AV nodal block or ventricular asystole; it should not be used when infranodal (Mobitz type II block) is suspected.
… Bradycardia… : Bradycardia… If the patient is symptomatic, atropine should be given as initial drug therapy (0.5 to 1 mg every three to five minutes up to a total of 0.03 to 0.04 mg/kg);
however, transcutaneous pacing should not be delayed while waiting for intravenous access or for atropine to take effect.
Patients who have had a heart transplant will not respond to atropine; as a result, pacing and/or catecholamine infusion should be used initially.
A transvenous pacemaker should be inserted if second- or third- degree heart block is present or bradycardia persists after atropine and/or catecholamine infusion; transcutaneous pacing may be used prior to the insertion of a transvenous pacemaker.
Antiarrhythmic drugs, particularly lidocaine, should not be used in patients with third degree heart block. TERMINATION OF THE CPR : TERMINATION OF THE CPR Duration of resuscitative effort >30 minutes
Initial rhythm of asystole
Prolonged interval between estimated time of arrest and initiation of resuscitation
Patient age and severity of comorbid disease
Absent brainstem reflexes
A very low end tidal CO2 (<10 mmHg) following prolonged resuscitation (>20 minutes) is a sign of absent circulation and an excellent predictor of acute mortality. Slide 44: Any Question? Slide 45: THE END Thank you for your attention