Cardiopulmonary Resuscitation Rose Mulder Department of Anaesthesia, GSH 23 March 2009

How successful are we today at cardiopulmonary resuscitation? Not very! Overall survival-to-hospital-discharge for out of hospital cardiac arrest is at best 6% In hospital arrests survival rate is even less What are we doing wrong?

What happens when your heart stops? Pathophysiology of CPR: What happens when your heart stops?

Concepts of Resuscitation 2 theories: Cardiac pump Thoracic pump Cardiac output reduced to 30% at best Brain 50-90% Heart 20-50% Abdominal 5%

Algorithms: Basic & Advanced life Support

Chain of Survival early awareness early access early CPR early defibrillation early advanced care early analysis

Basic Life Support

Call for assistance + Defibrillator/AED Hazards? Ensure scene is safe H Hello? Check responsiveness H Help? Call for assistance + Defibrillator/AED H

Who are you going to call ?

Who are you going to call 10177 112 from cellphone will get you through to the 10177 call centre 082 911 – Netcare ambulance 082 124 – ER24 ambulance

Phone First or Fast CPR ?? Phone first Fast do CPR Most situations you want to call for help Sudden arrests in adults are usually due to a heart problem Need defibrillator ASAP Fast do CPR Arrest from a Respiratory Cause Children (Cardiac cause is RARE) Drowning Trauma Overdose

A B C Open Airway Breathe Compressions Remove visible foreign material Look for adequate breathing A Breathe Give 2 effective breaths at 1 sec/breath ( ± O2) Feel for pulse for up to 10 sec Is a definite pulse present? B Compressions Compress chest: 100/minute Push hard / Push fast / Ensure full chest recoil Minimize interruptions CPR ratios 1-rescuer 30:2 2-rescuer (child) 15:2 C

D Analyse Rhythm Shockable VF/Pulseless VT Non-shockable PEA/Asystole Give 1 Shock Biphasic: 120 – 200J (4J/kg) Monophasic: 360J (4J/kg) Immediately resume CPR for 2 minutes Immediately resume CPR for 2 minutes

Shockable arrest rhythms

Ventricular Fibrillation

Pulseless Ventricular Tachycardia VTach

Non-shockable arrest rhythms

Asystole

Pulseless Electrical Activity

Advanced Life Support

A B C Advanced Airway ETT / LMA Breathe Compressions 10 breaths per minute with supplemental O2 B Compressions Compress chest: 100/minute Push hard / Push fast / Ensure full chest recoil Minimize interruptions No ratios – continuous compressions C

Contributing Causes During CPR Hypoxia Tension Pneumothorax Check electrode/paddle position + contact Attempt: Tracheal intubation/ adjuncts Vascular Access Give Adrenaline 1mg iv/10ml every 4 minutes Consider: 1. Amiodarone 300mg iv/10ml if VF/VT 2. Atropine 1mg iv/10ml every 4 minutes if brady/asystole (max 3mg) 3. Magnesium 2g iv/10ml if TDP or hypomagnesaemic Correct Contributing Causes Contributing Causes Hypoxia Tension Pneumothorax Hypovolaemia Tamponade H+ Acidosis Toxins Hyper/hypokalaemia Trauma Hyper/hypoglycaemia Thrombosis (pulmonary) Hypothermia Thrombosis (coronary)

Chest compressions first If time from collapse > 5 minutes without CPR, first perform CPR for 2 minutes before analysing rhythm . Resuscitation Council of South Africa NO evidence that this has any benefit Also no evidence that it does any harm May be deleted in future algorithms

Defibrillation Children Adults Mono- and Biphasic: 4J / kg Monophasic: 360J Biphasic: ±120-200J (As per manufacturers instructions)

Groote Schuur Hospital Phillips Hearstart Groote Schuur Hospital

Nihon Kohden Red Cross Hospital

Drugs 1st line Adrenaline Atropine 1mg / amp Dose: 1mg IV every 4 min, flush with 10 ml saline Alternate routes Indications: All cardiac arrests MOA: Increased force of heart muscle contraction and increased heart rate vasocontriction Atropine Usually 0.5mg / amp Dose: 1mg IV (max 3mg) Indications: Asystole / PEA Severe Bradycardia MOA: Increases heart rate HOWEVER NO evidence that Atropine has any advantage over Adrenaline – Will not appear as a 1st line drug in the next algorithm

Drugs 2nd line Amiodarone Magnesium Indications MOA: 2g IV Indications VF or Vtach refractory to defibrillation MOA: Anti-arrhythmic Magnesium 2g IV Indications Torsades des pointes type of Ventricular Fibrillation MOA: Stabilising effect on heart

Drugs 2nd line Bicarbonate Calcium Dose: 50mmol per every 10 minutes of arrest Indications: Acidosis caused arrest Prolonged resuscitation Calcium 2 types: Calcium chloride Calcium gluconate Dose: 0.5 – 1.0g Indications: PEA Hyperkalaemia (↑ K+) Massive blood transfusion

Drugs 2nd line Lignocaine Atropine ! Dose: 1mg/kg bolus every 5 min Indications: VF or pulseless Vtach unresponsive to Older guidelines Not very useful Atropine ! In the next algorithm

Anaesthetists are doing it in their sleep Intra-op cardiac arrest is rare 0.02 – 0.2% Early intervention is critical 90% survival

‘‘People die from eating too much, smoking too much, drinking too much and talking too much’’ Professor Paul Zoll