2011 cpr

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CPR 2011 overview:

CPR 2011 overview

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Copyright ©2010 American Heart Association Berg, R. A. et al. Circulation 2010;122:S685-S705 Simplified adult BLS algorithm

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Copyright ©2010 American Heart Association Berg, R. A. et al. Circulation 2010;122:S685-S705 BLS healthcare provider algorithm

1- CPR Sequence:

1- CPR Sequence Change: From A-B-C to C-A-B . Initiate chest compressions before ventilations . Why? I- Goal: To reduce delay to CPR, sequence begins with skill that everyone can perform. II- Emphasize primary importance of chest compressions for professional rescuers.

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Copyright ©2010 American Heart Association Berg, M. D. et al. Circulation 2010;122:S862-S875 Pediatric Chain of Survival

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Copyright ©2010 American Heart Association Berg, M. D. et al. Circulation 2010;122:S862-S875 Pediatric BLS Algorithm

key changes from the 2005 ACLS Guidelines include:

key changes from the 2005 ACLS Guidelines include Continuous quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement. Cardiac arrest algorithms are simplified and redesigned to emphasize the importance of high-quality CPR (including chest compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions and avoiding excessive ventilation). Atropine is no longer recommended for routine use in the management of pulseless electrical activity (PEA)/ asystole .

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There is an increased emphasis on physiologic monitoring to optimize CPR quality and detect ROSC. Chronotropic drug infusions are recommended as an alternative to pacing in symptomatic and unstable bradycardia . Adenosine is recommended as a safe and potentially effective therapy in the initial management of stable undifferentiated regular monomorphic wide- complextachycardia .

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Airway

2010 New Science: Airway:

2010 New Science: Airway Unrecognized endotracheal tube misplacement remains unacceptably high . Wirtz , 2007, 213; Timmermann 2007, 619 Waveform capnography verifies tracheal tube position in victims of cardiac arrest with 100% sensitivity and 100% specificity . Silvestri , 2005, 497; Grmec 2002, 701;Trikha, 1999, 347; Tong, 2002, 159; Zaleski , 1993, 244; Holland, 1993, 608; Ko , 1993, 91; Linko , 1983, 199; Wayne, 1999, 107; Williamson, 1993,511 Confirmation and Monitoring of Endotracheal Tube Placement

2010 New Science: Airway:

2010 New Science: Airway Confirmation and Monitoring of Endotracheal Tube Placement Non-waveform capnometry, colorometric EtCO 2 detectors, and mechanical devices (syringe aspiration and inflating bulb esophageal detectors) do not exceed the accuracy of auscultation and direct visualization for confirming the tracheal position of a tracheal tube in victims of cardiac arrest.

Endotracheal Intubation:

Endotracheal Intubation Continuous waveform capnography is recommended in addition to clinical assessment as the most reliable method of confirming and monitoring correct placement of an endotracheal tube (Class I, LOE A). Providers should observe a persistent capnographic waveform with ventilation to confirm and monitor endotracheal tube placement in the field, in the transport vehicle, on arrival at the hospital, and after any patient transfer to reduce the risk of unrecognized tube misplacement or displacement.

Waveform Capnography:

Waveform Capnography After intubation, exhaled carbon dioxide is detected as a waveform corresponding to each breath confirming tracheal tube placement. End-Tidal CO 2 (PETCO 2 ) is the highest value at end-expiration . PETCO 2

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Copyright ©2010 American Heart Association Neumar , R. W. et al. Circulation 2010;122:S729-S767 ACLS Cardiac Arrest Algorithm

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© 2010 American Heart Association. All rights reserved.

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CPR Quality Mechanical Parameters: Push hard (≥2 inches [5 cm]). Push fast (≥ 100/min). Allow complete chest recoil. Minimize interruptions in compressions. Avoid excessive ventilation.

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CPR Quality Physiologic Parameters: Quantitative waveform capnography : - If PETCO 2 <10 mm Hg attempt to improve CPR quality. Intra-arterial pressure: - If relaxation phase (diastolic) pressure <20 mm Hg attempt to improve CPR quality.

Waveform Capnography During CPR:

Waveform Capnography During CPR

Intra-Arterial Pressure During CPR:

Intra-Arterial Pressure During CPR Arterial relaxation phase (diastolic) pressure < 20 mm Hg Arterial relaxation phase (diastolic) pressure 40 mm Hg Blood flow generated by CPR unlikely to result in ROSC Improved chance of ROSC

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Post-Cardiac Arrest Care

Post-Cardiac Arrest Care:

Post-Cardiac Arrest Care 60-80% of patients that regain a pulse after cardiac arrest die before hospital discharge. Implementation of comprehensive systems of care for post-cardiac arrest patients consistently results in improved survival with good neurologic function.

Post-Cardiac Arrest Care:

Post-Cardiac Arrest Care A comprehensive, structured, multidisciplinary system of care should be implemented in a consistent manner for the treatment of post-cardiac arrest patients (Class I, LOE B) Programs should include: Therapeutic hypothermia Optimization of hemodynamics, ventilation, and oxygenation Immediate coronary reperfusion with PCI when indicated Glycemic control Neurological diagnosis, management, and prognostication © 2010 American Heart Association. All rights reserved.

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Adult Immediate Post-Cardiac Arrest Care Return of Spontaneous Circulation (ROSC) Optimize ventilation and oxygenation Maintain oxygen sat. > 94 % Consider advanced airway and waveform capnography . Do not hyperventilate. Treat hypotension (SBP < 90mmHg) IV/IO bolus Vasopressor infusion. Consider treatable causes. 12-lead ECG. Follow commands? STEMI Or high suspicion of AMI Consider induced hypothermia Coronary reperfusion Advanced critical care No No Yes Yes

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Copyright ©2010 American Heart Association Neumar, R. W. et al. Circulation 2010;122:S729-S767 Bradycardia Algorithm

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Copyright ©2010 American Heart Association Neumar, R. W. et al. Circulation 2010;122:S729-S767 Tachycardia Algorithm

Thank you :

Thank you

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Copyright ©2010 American Heart Association Peberdy, M. A. et al. Circulation 2010;122:S768-S786 Post-cardiac arrest care algorithm

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Ventilation Hemodynamics Cardiovascular Neurological Metabolic Capnography Rationale: Confirm secure airway and titrate ventilation Endotracheal tube when possible for comatose patients PETCO 2 35–40 mm Hg Paco 2 40–45 mm Hg Frequent Blood Pressure Monitoring/Arterial-line Rationale: Maintain perfusion and prevent recurrent hypotension Mean arterial pressure 65 mm Hg or systolic blood pressure 90 mm Hg Continuous Cardiac Monitoring Rationale: Detect recurrent arrhythmia No prophylactic antiarrhythmics Treat arrhythmias as required Remove reversible causes Serial Neurological Exam Rationale: Serial examinations define coma, brain injury, and prognosis Response to verbal commands or physical stimulation Pupillary light and corneal reflex, spontaneous eye movement Gag, cough, spontaneous breaths Serial Lactate Rationale: Confirm adequate perfusion Chest X-ray Rationale: Confirm secure airway and detect causes or complications of arrest: pneumonitis , pneumonia, pulmonary edema Treat Hypotension Rationale: Maintain perfusion Fluid bolus if tolerated Dopamine 5–10 mcg/kg per min Norepinephrine 0.1–0.5 mcg/kg per min Epinephrine 0.1–0.5 mcg/kg per min 12-lead ECG/ Troponin Rationale: Detect Acute Coronary Syndrome/ST-Elevation Myocardial Infarction; Assess QT interval EEG Monitoring If Comatose Rationale: Exclude seizures Anticonvulsants if seizing Serum Potassium Rationale: Avoid hypokalemia which promotes arrhythmias Replace to maintain K >3.5 mEq /L

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Ventilation Hemodynamics Cardiovascular Neurological Metabolic