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

2. 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?

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

4. Concepts of Resuscitation
2 theories:
Cardiac pump
Thoracic pump
Cardiac output reduced to 30% at best
Brain %
Heart %
Abdominal 5%

5. Algorithms: Basic & Advanced life Support

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

7. Basic Life Support

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

9. Who are you going to call ?

10. Who are you going to call
10177
112 from cellphone
will get you through to the call centre
– Netcare ambulance
– ER24 ambulance

11. 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

12. 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

13. 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

14. Shockable arrest rhythms

15. Ventricular Fibrillation

16. Pulseless Ventricular Tachycardia VTach

17. Non-shockable arrest rhythms

18. Asystole

19. Pulseless Electrical Activity

20. Advanced Life Support

21. 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

22. 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)

23. 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

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

25. Groote Schuur Hospital
Phillips Hearstart
Groote Schuur Hospital

26. Nihon Kohden
Red Cross Hospital

27. 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

28. 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

30. 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

31. 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

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

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