CPR 3.pptx

Cardiopulmonary Resuscitation (CPR) Indications and contraindications • CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of th...

Cardiopulmonary Resuscitation (CPR) Indications and contraindications • CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options. • Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following: • Ventricular fibrillation (VF) • Pulseless ventricular tachycardia (VT) • Pulseless electrical activity (PEA) • Asystole • Pulseless bradycardia • CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established. Contraindications • The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest. A relative contraindication to performing CPR is if a clinician justifiably feels that the intervention would be medically futile. Technique • In its full, standard form, CPR comprises the following 3 steps, performed in order: • Chest compressions • Airway • Breathing • Positioning for CPR is as follows: • CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum • Delivery of CPR on a mattress or other soft material is generally less effective • The person giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest • For an unconscious adult, CPR is initiated as follows: • Give 30 chest compressions • Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing • Before beginning ventilations, look in the patient’s mouth for a foreign body blocking the airway Chest compression • The provider should do the following: • Place the heel of one hand on the patient’s sternum and the other hand on top of the first, fingers interlaced • Extend the elbows and the provider leans directly over the patient (see the image below) • Press down, compressing the chest at least 2 in • Release the chest and allow it to recoil completely • The compression depth for adults should be at least 2 inches (instead of up to 2 inches, as in the past) • The compression rate should be at least 100/min • The key phrase for chest compression is, “Push hard and fast” • Untrained bystanders should perform chest compression–only CPR (COCPR) • After 30 compressions, 2 breaths are given; however, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute • This entire process is repeated until a pulse returns or the patient is transferred to definitive care • To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR Ventilation • If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bag-valve-mask (BVM). If available, a barrier device (pocket mask or face shield) should be used. • To perform the BVM or invasive airway technique, the provider does the following: • Ensure a tight seal between the mask and the patient’s face • Squeeze the bag with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs To perform the mouth-to-mouth technique, the provider does the following: • Pinch the patient’s nostrils closed to assist with an airtight seal • Put the mouth completely over the patient’s mouth • After 30 chest compression, give 2 breaths (the 30:2 cycle of CPR) • Give each breath for approximately 1 second with enough force to make the patient’s chest rise • Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion • After giving the 2 breaths, resume the CPR cycle Complications • Fractures of ribs or the sternum from chest compression (widely considered uncommon) • Gastric insufflation from artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, BVM); this can lead to vomiting, with further airway compromise or aspiration; insertion of an invasive airway (eg, endotracheal tube) prevents this problem • Although management of cardiac arrest begins with BLS and progresses sequentially through the links of the chain of survival, there is some overlap as each stage of care progresses to the next. Generally, in the three guidelines, ACLS comprises the level of care between BLS and post–cardiac arrest care. AHA adult cardiac arrest algorithm for ventricular fibrillation (VF) or pulseless ventricular tachycardia • Activate emergency response system • Initiate CPR and give oxygen when available • Verify patient is in VF as soon as possible (ie, AED or quick look with paddles) • Defibrillate once: Use a device-specific recommendation (ie, 120-200 J for biphasic waveform and 360 J for monophasic waveform); if unknown, use the maximum available • Resume CPR immediately without pulse check and continue for five cycles. One cycle of CPR equals 30 compressions and two breaths; five cycles of CPR should take roughly 2 minutes (compression rate 100 per minute); do not check for rhythm/pulse until five cycles of CPR are completed. • During CPR, minimize interruptions while securing intravenous (IV) access and performing endotracheal intubation. Once the patient is intubated, continue CPR at 100 compressions per minute without pauses for respirations, and administer respirations at 10 breaths per minute. • Check rhythm after 2 minutes of CPR. • Repeat a single defibrillation if the patient is still in VF/pVT with rhythm check. Selection of fixed versus escalating energy for subsequent shocks is based on the specific manufacturer’s instructions. For a manual defibrillator capable of escalating energies, higher energy for the second and subsequent shocks may be considered. • Resume CPR for 2 minutes immediately after defibrillation. • Continuously repeat the cycle of (1) rhythm check, (2) defibrillation, and (3) 2 minutes of CPR • Administer epinephrine,1 mg every 3–5 minutes during CPR, before or after shock, when IV or intraosseous (IO) access is available (Note that vasopressin has not been shown to have benefit in addition to epinephrine, so for simplicity it has been removed from the algorithm for most cases.) • Administer amiodarone 300 mg IV/IO once, if dysrhythmic during CPR, before or after shock; then consider administering an additional 150 mg once. In addition, correct the following if necessary and/or possible: • Hypovolemia • Hypoxia • Hydrogen ion (acidosis): Consider bicarbonate therapy • Hyperkalemia/hypokalemia and metabolic disorders • Hypoglycemia: Check fingerstick or administer glucose • Hypothermia: Check core rectal temperature • Toxins • Tamponade, cardiac: Check with ultrasonography • Tension pneumothorax: Consider needle thoracostomy • Thrombosis, coronary or pulmonary: Consider thrombolytic therapy if suspected • Trauma According to the AHA, if all the following are present, termination of resuscitation in OHCA may be considered • Arrest was not witnessed by EMS personnel • No return of spontaneous circulation (ROSC) prior to transport • No AED shock delivered prior to transport • In addition, in intubated patients, failure to achieve an end-tidal carbon dioxide (ETCO2) level of greater than 10 mm Hg by waveform capnography after 20 minutes of CPR may be considered as one component of a multimodal approach to decide when to end resuscitative efforts. However, no studies of nonintubated patients have been reviewed, and ETCO2 should not be used as an indication to end resuscitative efforts in those cases Defibrillation • Use defibrillators (using , or monophasic waveforms) to treat atrial and ventricular arrhythmias (class I) • Defibrillators using biphasic waveforms (BTE or RLB) are preferred (class IIa) • Use a single-shock strategy (as opposed to stacked shocks) for defibrillation (class IIa) • Overall, the ERC and ILCOR guidelines concur with the AHA, but ERC guidelines include an additional recommendation for self-adhesive defibrillation pads, which are generally preferred over manual paddles. Airway control and ventilation • Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for cardiac arrest • If advanced airway placement will interrupt chest compressions, consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates return of spontaneous circulation • The routine use of cricoid pressure in cardiac arrest is not recommended (class III) • Either a bag-mask device or an advanced airway may be used for oxygenation and ventilation during CPR in both the in-hospital and out-of-hospital setting (class IIb); t • For healthcare providers trained in their use, either a supraglottic airway (SGA) device or an may be used as the initial advanced airway during CPR (class IIb) • Providers who perform endotracheal intubation should undergo frequent retraining (class I) • To facilitate delivery of ventilations with a bag-mask device, oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex and should be inserted only by trained personnel (class IIa) • In the presence of known or suspected basal skull fracture or severe coagulopathy, an oral airway is preferred • Continuous waveform capnography in addition to clinical assessment is the most reliable method of confirming and monitoring correct placement of an ETT (class I) • If continuous waveform capnometry is not available, a nonwaveform carbon dioxide detector, esophageal detector device, and ultrasound used by an experienced operator are reasonable alternatives (class IIa) • Automatic transport ventilators (ATVs) can be useful for ventilation of adult patients in noncardiac arrest who have an advanced airway in place in both out-of-hospital and inhospital settings (class IIb) Medication management • Amiodarone may be considered for or pVT that is unresponsive to CPR, defibrillation, and a vasopressor; lidocaine may be considered as an alternative (class IIb) • Routine use of magnesium for VF/pVT is not recommended in adult patients (class III) • Inadequate evidence exists to support routine use of lidocaine; however, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT (class IIb) • Inadequate evidence exists to support the routine use of a beta-blocker after cardiac arrest; however, the initiation or continuation of a beta-blocker may be considered after hospitalization from cardiac arrest due to VF/pVT (class IIb) • Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic benefit (class IIb) • There is insufficient evidence for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC from cardiac arrest • Standard-dose epinephrine (1 mg every 3-5 min) may be reasonable for patients in cardiac arrest (class IIb); highdose epinephrine is not recommended for routine use in cardiac arrest (class III) • Vasopressin has been removed from the Adult Cardiac Arrest Algorithm and offers no advantage in combination with epinephrine or as a substitute for standard-dose epinephrine (class IIb) • It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (class IIb) Post–Cardiac Arrest Care Guidelines • Therapeutic hypothermia • Optimization of hemodynamics and gas exchange • Immediate coronary reperfusion, when indicated for restoration of coronary blood flow, with percutaneous coronary intervention (PCI) • Glycemic control • Neurological diagnosis, management, and prognostication • The key issues and major changes in the 2015 AHA guidelines update for post–cardiac-arrest care include the following Emergency coronary angiography is recommended for all patients with ST elevation and for hemodynamically or electrically unstable patients without ST elevation in whom a cardiovascular lesion is suspected; the decision to perform revascularization should not be affected by the patient’s neurological status, which can change • Targeted temperature management (TTM) with a range of acceptable temperatures from 32-36˚C is recommended (at least for the first 24 h). • Identification and correction of hypotension is recommended in the immediate post–cardiac-arrest period • Prognostication no sooner than 72 hours after the completion of TTM Targeted temperature management • The 2010 AHA guidelines strongly advised induced hypothermia (3234˚C) for patients with out-ofhospital VF/pVT cardiac arrest and post-ROSC coma (the absence of purposeful movements) and encouraged consideration of induced hypothermia for most other comatose patients after cardiac arrest. However, the precise duration • Because a range of temperatures is used, the term “targeted temperature management” (TTM) has been adopted. This term encompasses both induced hypothermia and active control of temperature at any target The revised 2015 recommendations for TTM include • TTM for comatose adult patients with ROSC (class I) • A constant temperature of 32-36° C during TTM (class I) • TTM for at least 24 hours after achieving target temperature (class IIa) • Routine prehospital cooling of patients after ROSC with rapid infusion of cold IV fluids is not recommended (class III) • Prevention of fever in comatose patients after TTM may be reasonable (class IIb) • Use of sedation and analgesia in critically ill patients who require mechanical ventilation or shivering suppression during induced hypothermia after cardiac arrest is reasonable (class IIb) Do we need an airway, oxygenation and ventilation during CPR? • Current guidelines recommend that, after a primary cardiac arrest, restoring a circulation with chest compressions and, if appropriate, attempted defibrillation to restart the heart take priority over airway and ventilation interventions . • ¸ The premise is that there is an adequate oxygen reservoir at the time of cardiac arrest and further oxygen is only required after about 4 minutes. When cardiac arrest follows airway and/or breathing problems (asphyxial cardiac arrest), earlier interventions to restore adequate oxygenation to the vital organs may be preferable. • Current guidelines for CPR emphasise chest compressions for all cardiac arrests because: • Chest compressions are easy to learn and do for most rescuers and do not require special equipment. Studies show that lay rescuer compressiononly CPR is better than no CPR • Sudden cardiac arrest, with an initial shockable rhythm (ventricular fibrillation or pulseless ventricular tachycardia [VF/pVT]) has good outcomes with early CPR and early defibrillation. • Survival after a non-cardiac cause of cardiac arrest, such as asphyxial cardiac arrest and which more commonly lead to an initial nonshockable cardiac arrest rhythm (pulseless electrical activity (PEA) or asystole), is relatively poor even if there is ROSC. Patients often have severe brain injury associated with hypoxaemia and low blood flow preceding cardiac arrest, a period of no or low flow during CPR and reperfusion injury following ROSC. • As VF/pVT has a better response to treatment, CPR interventions prioritise treatment for VF/pVT at the expense of those that may be helpful for PEA or asystole. Airway and ventilation techniques during CPR Bag-mask ventilation • On arrival of trained rescuers, bag-mask ventilation with supplemental oxygen is the most common initial approach and can be aided with an oropharyngeal or nasopharyngeal airway. During CPR, the bag-mask is used to give two breaths after every 30 compressions. • A large RCT of bag-mask ventilation without pausing compressions in OHCA found no difference in survival when compared with pausing for ventilation after every 30 compressions [. A pre-specified per-protocol analysis reported a significantly higher survival to discharge among those who actually received conventional CPR (30:2) compared with those who received continuous compressions. Supraglottic airways • Supraglottic airway (SGA) use has increased during CPR as SGA insertion is easier to learn than tracheal intubation and feasible with fewer and shorter interruptions in chest compression. Observational data show classic laryngeal airway mask (cLMA) use during CPR is associated with a lower incidence of regurgitation of gastric contents than bag-mask ventilation. • Second-generation SGAs (e.g. i-gel and LMA Supreme (LMAS)) have potential advantages over first-generation SGAs, including improved pharyngeal seal pressure, oesophageal drainage tubes and integrated bite blocks. A pig study raised concerns that a supraglottic cuff compresses the internal and external carotid artery, decreasing cerebral blood flow during CPR. A human radiographic study did not, however, observe any evidence of mechanical compression of the carotid arteries Tracheal intubation • Tracheal intubation enables chest compressions to continue uninterrupted while the lungs are ventilated, avoids gastric insufflation and protects the lungs from aspiration of gastric contents: an observational study, however, showed onethird of OHCA patients had regurgitation, and in two-thirds this occurred before EMS arrival and in a quarter between EMS arrival and tracheal intubation . • Studies suggest more than 50 successful intubations are required to achieve an insertion success rates of over 90% during CPR . • Current European guidelines recommend a pause in compressions of less than 5 s for tracheal tube insertion. • Videolaryngoscopy (VL) for tracheal intubation may have a role in tracheal intubation during CPR [25], although there are few studies of VL use during CPR. In one study of experienced clinicians, VL was associated with significantly fewer episodes of prolonged (> 10 s) interruptions in chest compressions; the intubation success rate was not significantly different [26]. In a further study, VL use was associated with shorter pauses in compressions compared with direct laryngoscopy when initial tracheal intubation was not successful [27]. • Videolaryngoscopy (VL) for tracheal intubation may have a role in tracheal intubation during CPR , although there are few studies of VL use during CPR. In one study of experienced clinicians, VL was associated with significantly fewer episodes of prolonged (> 10 s) interruptions in chest compressions; the intubation success rate was not significantly different . • In a further study, VL use was associated with shorter pauses in compressions compared with direct laryngoscopy when initial tracheal intubation was not successful . How much oxygen during CPR and after ROSC? • The optimal oxygen requirement for CPR and after ROSC remains uncertain—too little is harmful, too much could be harmful, and what’s just right and how it should be measured and targeted are uncertain. • Current guidelines recommend giving the maximum feasible inspired oxygen during CPR based on the premise that restoring depleted oxygen levels and correcting tissue hypoxia improves survival. • Observational data show an association between higher arterial oxygen partial pressures during CPR and improved ROSC. Due to the low flow cardiac output state, despite administration of a high inspired fraction of oxygen, target tissue mitochondrial oxygen tension is unlikely to be high. How much ventilation during CPR and after ROSC? • In the absence of an advanced airway during CPR, current guidelines based on very limited evidence recommend two positive pressure breaths after every 30 chest compressions. These breaths should be of an inspiratory time of 1 s and produce a visible chest wall rise. • Observations in anesthetised adults show a visible chest rise occurs with a mean tidal volume of 384 ml (95% CI 362 to 406 ml) • Once an advanced airway is in place, a ventilation rate of 10 /min− without interrupting chest compressions is recommended. Continuous uninterrupted chest compressions are not always feasible with a SGA and there may be a need to pause after every 30 chest compressions in order to give two rescue breaths. • The recommended ventilation rate of 10/ min− with a tracheal tube is based predominantly on animal studies, which followed observations that hyperventilation was common during human CPR • A pig study showed a respiratory rate of 30/ min compared to 12 /min caused increased intrathoracic pressure, a decrease in coronary and cerebral perfusion and decreased ROSC • Furthermore, the authors included human observational data and reported no survivors from cardiac arrest with an advanced airway when the respiratory rate was greater than 10/ min and the inspiratory time greater than 1 s. • A reduced ventilation rate may be sufficient to maintain a normal ventilation perfusion ratio during CPR as the cardiac output generated by chest compressions is also markedly reduced. • Current guidelines for post-ROSC care recommend using low tidal volume ventilation (6–8 ml kg− 1 IBW) with titrated levels of PEEP and aiming for normocapnia • After ROSC, inadequate ventilation and resultant hypercapnia will exacerbate any existing metabolic acidosis and potentially worsen any haemodynamic instability. In addition, hypercapnia produces cerebral vasodilatation if cerebrovascular reactivity is preserved: whether this is detrimental or beneficial is not known. • Hypercapnia may lead to an elevation in intracranial pressure and worsening of hyperaemia in a vulnerable brain, or increased blood flow may improve cerebral ischaemia and be neuroprotective. One observational study showed improved survival to hospital discharge and neurological outcomes associated with exposure to mild hypercapnia compared to normocapnia or hypocapnia, whereas another showed worse survival to discharge with hypercapnia compared to normocapnia or hypocapnia • A post-ROSC lung protective ventilation strategy is based on guidance for acute lung injury ventilation. One study comparing a tidal volume less than or greater than 8 ml kg− 1 in OHCA survivors observed a lower tidal volume in the first 48 h post-ROSC was associated with a favourable neurocognitive outcome, more ventilator and shock-free days , whereas an IHCA study found no association between a tidal volume of less or greater than 8 ml kg− 1 in the first 6 or 48 h post-ROSC and survival to discharge and neurological outcome . • In the TTM trial, the end of TTM median tidal volume was 7.7 ml kg− 1 predicted body weight, 60% of patients had a tidal volume less than 8 ml kg− 1, median PEEP was 7.7 cmH2O (6.4–8.7), mean driving pressure was 14.6 cmH2O (± 4.3) and median FiO2 was 0.35 (0.30–0.45) . Non-survivors compared with survivors at 28 days had worse oxygenation, higher respiratory rates, driving pressures and plateau pressures and lower compliance compared to survivors. • After ROSC, interventions for oxygenation and ventilation in combination with a bundle of interventions that adjust other physiological variables, including temperature, blood pressure, glucose and seizure control, are probably required for a good outcome . • The optimal targets and combinations are uncertain and the subject of ongoing studies. • Thank You cardioversion non-emergency or elective cardioversion - treat arrhythmias.