Cardiopulmonary resuscitation By: Dr. Alaa El Kateb, MD Ain Shams University

Objectives Upon completion the student will be able to do : Basic life support Basic airway management and ventilation The universal ALS algorithm of Monitoring cardiac arrest rhythms Defibrillation Drugs used in resuscitation

Cardiopulmonary resuscitation: (CPR) is an emergency medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest.

- IHD is the leading cause of death. - 33% of people developing MI die before reaching hospital. Presenting rhythm in most of them is VF or pulseless VT. - 1 min delay→ ↓ chance of successful outcome about 10%.

Would you save a life? Healthy human brain may survive without oxygen for up to 4 minutes without suffering any permanent damage. Unfortunately, a typical EMS response may take 6, 8 or even 10 minutes.

Chain of survival

Early recognition and causes of cardiopulmonary arrest

Early recognition To: ↑ frequency of monitoring. Call ward doctor Call resuscitation team (MET- code blue). Also important to identify DNAR. UPVA CNS > < 35 Temp °C > < 8 Respiratory Rate > < 70 Systolic BP mmHg > < 40 Pulse (MEWS)

Causes of cardiorespiratory arrest: Most are caused by problems with: Airway Breathing Circulation.

Airway problems -Difficult talking. -Difficult breathing. -Noisy breathing: i.e. snoring, gurgling. -See-saw respiration -Working accessory muscles

Breathing problems Decreased respiratory drive CNS depression Decreased respiratory effort Muscle weakness Nerve damage Restrictive chest disease Pain from fractured ribs Lung disorders Pneumothorax Hemothorax Infection Acute exacerbation COPD Pulmonary embolus ARDS Shortness of breath, irritability, confusion, ↓ LOC due to ↑ CO2 & ↓ O2 ABG

Circulation problems Primary - Acute coronary syndromes - Dysrhythmias - Hypertensive heart disease - Valve disease - Drugs (e.g. digoxin, TCA) - Hereditary cardiac diseases - Electrolyte/acid base abnorm. - Electrocution Secondary - Asphyxia - Hypoxemia - Blood loss - Hypothermia - Septic shock Chest pain, ↓ HR, ↑ HR, ↓ BP, ↓ capillary refill time, ↓ UOP, ↓ LOC

How to examine a critical ill patient?

ABCDE approach: Airway Breathing Circulation Disability Exposure

A. Airway - Make sure the victim is not obstructed ( FB ) - Simple maneuvers to open airway e.g. chin lift, head tilt, jaw thrust - Simple adjuncts e.g. OPA, NPA - Advanced techniques e.g. LMA, endotracheal tube O2O2

B. Breathing Ventilate (if not spontaneous) using mouth to mouth, pocket mask, bag valve mask or mechanical ventilation. Keep an eye on his chest. Try not to over-inflate the victim's lungs as this may force air into the stomach. (?) Cricoid pressure

C. Circulation: Check: Central pulse Peripheral pulse Equality Regularity Rate Blood pressure Capillary refill time I.V canula Attach monitor

C. Circulation: - APVU score. - Blood sugar - Pupils D. Disability

E. Exposure - Accordingly - Avoid hypothermia - Respect patient’s dignity.

How to manage a collapsed patient ?

Safety Shake the victim gently and shout "Are you okay?" Shout for help

If responding, Try to assess what is wrong & reassess regularly If not responding: Look, Listen and Feel for any signs of life (pulse/breathing). (≤10sec)

2 hands, 2 inches, 30 times (3 compressions / 2 sec). If no signs of life …… 0- Call or resuscitation team 1- Start chest compression and ventilation in a rate of 30:2

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CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) 1 Shock J biphasic or 360 J monophasic Open Airway Look for signs of life Immediately resume CPR 30:2 for 2 min Call Resuscitation Team oxygen Give uninterrupted compressions when airway secure Give adrenaline every 3-5 min Consider: amiodarone, atropine, magnesium Immediately resume CPR 30:2 for 2 min

CPR 30:2 Until defibrillator/monitor attached Assess Rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Open Airway Look for signs of life Call Resuscitation Team

Shockable (VF) Bizarre irregular waveform No recognisable QRS complexes Random frequency and amplitude Uncoordinated electrical activity Coarse / fine Exclude artifact – movement – electrical interference

Shockable (VT) Monomorphic VT – broad complex rhythm – rapid rate – constant QRS morphology Polymorphic VT – torsade de pointes

Precordial thump Rapid treatment of a witnessed and monitored VF/VT cardiac arrest Used if defibrillator not immediately available

Assess Rhythm Shockable ( VF/Pulseless VT ) 1 Shock J biphasic or 360 J monophasic Immediately resume CPR 30:2 for 2 min If unsure, deliver 200 J (do not delay shock)

If VF/VT persists 2 nd and subsequent shocks J biphasic 360 J monophasic Minimise delays between CPR and shocks (< 10 s) Do not delay shock to give adrenaline Give amiodarone before 4 th shock If asystole, go to non VF/VT algorithm Deliver 2 nd shock Deliver 3 rd shock CPR for 2 min If VF/VT persists Adrenaline 1mg IV

Asses s Rhyth m Non-shockable (PEA/Asystole) Immediately resume CPR 30:2 for 2 min

Non-shockable Asystole Check leads are attached Adrenaline 1 mg IV every 3 – 5 min Atropine 3 mg IV

Non-shockable (PEA) Exclude / treat reversible causes Adrenaline 1 mg IV every 3-5 min Atropine 3 mg if PEA with rate < 60 min-1

Potential reversible causes: Hypoxia Hypovolaemia Hypo/hyperkalaemia & metabolic disorders Hypothermia Tension pneumothorax Tamponade, cardiac Toxins Thrombosis (coronary or pulmonary)

HOW TO SURVIVE A HEART ATTACK WHEN ALONE? The person whose heart stops beating properly, has only about 10 seconds left before losing consciousness. By coughing repeatedly and very vigorously. Repeat / two seconds without let up until help arrives. Deep breaths get oxygen into the lungs and coughing movements squeeze the heart and keep the blood circulating.

Oxygen & Self-inflating bag Oxygen conc. Expired breath 16—17% Self-inflating bag 21% + oxygen (10-15 L/min) 45% + reservoir system 85%

Face mask Signs of successful seal and ventilation include: - Foggy mask. - Rising chest. - Breath sounds auscultation. - A firm/taught/full bag. - Capnography.

Oropharyngeal airway (OPA) - Useful when tongue fall back in anesthetized or unconscious patients. - Poorly tolerated in conscious patients.

Nasopharyngeal airway Preferred in conscious patients. Contraindicated in anticoagulated & fracture skull base.

Laryngeal Mask Airway (LMA) The LMA comes in a variety of pediatric and adult sizes and successful insertion requires appropriate size selection.

Drugs Adrenaline Atropine Amiodarone Magnesium Thrombolytics Sodium bicarbonate

Adrenaline Actions:  agonist arterial vasoconstriction  agonist  heart rate  force of contraction  myocardial O 2 demand Indications: - VF/VT – give before 3rd shock - Non VF/VT – give immediately - Repeat every 3-5 min (alt cycles) 1 mg IV

Amiodarone Actions: - Lengthens duration of action potential - Prolongs QT interval - Mild negative inotrope - may cause hypotension Indication and dosage 300 mg IV give before 4th shock If unavailable give lidocaine 100 mg IV

Atropine Actions: - Blocks effects of vagus nerve - Increases sinus node automaticity - Increases atrioventricular conduction Indications and dosage: - 3 mg IV Asystole or PEA rate < 60 min-1 - Peri-arrest: Symptomatic sinus, atrial or nodal bradycardia 500 mcg IV increments to 3 mg

Magnesium Hypomagnesaemia often co-exists with hypokalaemia Actions: - Depresses neurological and myocardial function - A physiological calcium blocker Indications and dosage: 2 g (8 mmol) IV in: - VF / VT with hypomagnesaemia - Torsade de pointes - Digoxin toxicity

Sodium bicarbonate Actions: Alkalinising agent (increases pH) But can: increase carbon dioxide load inhibit release of oxygen to tissues impair myocardial contractility cause hypernatraemia Indications: 50 ml 8.4% sodium bicarbonate IV - Life-threatening hyperkalaemia - Tricyclic overdose - Severe metabolic acidosis (pH < 7.1)

Any questions?

Thank you Dr. Alaa El Kateb, MD anesthesia Ain Shams University