A.The initial goal of therapy is oxygenation of the brain.
The second goal is restoration of circulation. In addition the underlying conditions must be corrected(2).
1. CPR is not indicated for all patients,natural death in the aged or the terminal stages of chronic illness should not be reversed in this manner.
2. CPR should be performed in cases of reversible unexpected death.
That occur as a result of myocardial infarction, general and local anesthetic drugs,electric shock,cardiac catheterization or suffocation.
OLD GUIDELINES :
B. Emergency CPR includes the following ABCD steps which should always be started as quickly as possible (2)
1.A ----(Airway)
2.B-----(Breathing)
3.C-----(Circulation)
4.D-----(Drugs and definitive therapy)
5. In a witness cardiac arrest when treatment can be initiated within one minute of the arrest the ABCD sequence should include use precordial pump.
1.AIRWAY : (A)(2)
Time is the critical factor,establishment of an airway as soon as possible. To make the airway clear and clear the airway.
Artificialventilation and circulation must be initiated within 2-4 minutes.
a.Immediate opening the airway
This can be easily and quickly by tilting the patient brow(head) backward as fare as possible. But in newborn not too excessive that worsen airway obstruction because the neck is flexible.
Many times this manuver can resume breathing spontaneously.
The rescuer places one hand beneath the victim's neck and the other hand on the victim's forehead to carry out head tilt. Then the neck is raised by rescuer with one hand and the head is tilted backward by pressure with the other hand on forehead, this effort raised the tongue away from the back of the throat, this relieved anatomic obstruction of
the airway created by the tongue dropping against the back of the throat.
b. If head tilt not successful in opening the airway satisfactorily additional forward displacement of the lower jaw, jaw thrust, maybe necessary but not recomended for the lay people.
c.This can be done by triple airway maneuver :
1.The rescuer places his fingers behind the angles of the patient jaw and forcefully displaces the mandible forward.
2. He tilts the head backward.
3. He uses his thumbs to retract the lower lips to allow the patient to breath through the mouth and nose.
2.BREATHING (B):
If the patient does not promptly resume spontaneous breathing after the airway is opened, artificial ventilation must be started immediately by mouth to mouth or mouth to nose or mouth to mask breathing.
After opening the airway by tilting the head backward and displacing mandible forward, clearing the mouth of secretions, and beginning mouth to mouth ventilation.Keep the head tipped, and close the nose to keep air from escaping by squeezing between the left thumb and index finger.(3)
Take a deep breath and cover the patient's mouth with rescuer's mouth.
Give 2-4 big breaths as rapidly as possible without allowing time for the lungs to collapse between breaths.(4)
But in young children and infant ventilates with exhale volume smaller than an adult.
And in newborn exhale with a mouthful volume is adequate
There after two breaths are interposed between every 30 chest comppression (3).
In children both mouth and nose are covered by the rescuer's mouth and distension of the stomach is prevented by epigastric pressure with the right hand,the chin being held forward with the left.(3)
There is enough oxygen (16%) in expired air to secure oxygenation of a patient's circulating blood, by doubling normal tidal volume the rescuer increase the expired oxygen to 18%. During CPR, cardiac output(CO) is (25-30)% of normal so oxygen uptake from the lung and CO2 delivery
to the lungs are also reduced. As result low minute ventilation (lower than normal tidal volume and respiratory rate) can maintain effective oxygenation and ventilation during CPR.
It is also recognized that rescuers are frequently unwilling to carry out mouth to mouth ventilation for a variety of reasons including for infection and distate for the procedures. For these reasons and to emphasize the periority of chest compression it is recomended that in
adults, CPR should start with chest compression rather than initial ventilation.(Guidelines 2010) (6)
Alternative methods :
a. A self filling non rebreathing bag and wellfitting anesthesia mask,with oxygen supplied from a cylinder of compressed oxygen may be used as soon as they are available/will add the efficiency and convenience of
resuscitation.(2,4).
b. Endotracheal intubation must be carried out at the earliest possible moment but not before ventilation is produced for a few minutes by another methode.
Intubation should be performed by trained personal,with a cuffed endotracheal.Tube permits easy tracheobronchial toilet, facilitates the connection to a mechanical ventilator, prevent gastric dilatation and regurgitation and decrease dead space.(4)
c. An emergency tracheostomy is indicated when an adequate airway cannot otherwise be effective.
Alternative methodes are :
1.Crycothyrotomy
2.Transtracheal catheter ventilation or oesophageal obturator airway.
d. In a patient with a laryngectomy,direct mouth to stoma artificial respiration must be carried out.The head tilt and jaw thrust are unnecessary.
During artificial ventilation the following adverse effects may take place :
1.Inflation of the patients stomach with air,followed by regurgitation and/or transmission of infection to the rescuer.
These may occur when there is no tracheal tube in place.
2.Rupture of the patient's lungs.
3.ARTIFICIAL CIRCULATION: (C)
A search for a pulse should always be made following artificial ventilation and before starting sternal compression.
Artificial circulation can be carried out by external cardiac compresision.
Which must be started at once because anoxia may cause irreversible damage to the brain after 4 minutes; if resuscitation is successful the patient will probably remain decerebrate.(4)
Proper application of external cardiac compression requires that the patient be in horizontal position and on a firm surface.
Application of pressure must be restricted to the mid of the sternum not half lower of sternum especially not over the xiphoid process to obtain maximum compression of the heart to minimize the dangers of fractured ribs and damage to the liver.
The heel only one hand is placed in the center of the chest over the mid of sternum and the heel of the other hand is placed on top of heel of the first hand. It is very important that fingers be kept elevated at all times and not allowed to touch the chest wall.(4)
Adequate force must be exerted vertically downward to move the lower sternum 4-5 inches toward the vertebral collume, forcing blood into the pulmonary and systemic arteries but for infants and young children, less pressure is required. Following sternal compression the sternum is
released,and one cycle is repeated.
When the pressure is released,the chest expands and the heart fills with oxygenated blood which is circulated through the tissues with the next compression of the heart.
Pressure with the finger tips alone on the middle of the sternum is recomended for infants. For children up to 9-10 years of age the use one hand is considered adequate.The compression rate should 100 times perminute with 2 ventilation every 30 compression wether there are one or two rescuers of infant, child or adult is recomended. In the patient trachea has been intubated,the compression rate can be 80 times perminute no pause in compression should be made for ventilation. Synchronizing ventilation between compression is also unnecessary.(2)
Under optimal condition external heart compression produces only 30-40% of the normal amount of blood flow.
During the first few minutes after non asphyxial cardiac arrest the blood oxygen content remain high and myocardial or cerebral oxygen delivery is limited more by diminished cardiac output than a lack of oxygen in the lungs.Ventilation is therefore, initially less important than chest compression or compression is the first step.( C,A,B )
So initial steps of resuscitation may include for the nonasphyxial cardiac arrest :
Guidlines 2010 :
1.Cardiac compression 30 times (C)
2.Opening the airway and clear the airway.(A)
3.Giving two breaths using compression ventilation ratio of
30:2 (B)D
Main changes in adullt basic life support (BLS)---> guidelines 2005.(6)
- Start CPR when victim is unresponsive and not breathing normally agonal gasp are common in the early stages of cardiac arrest.
- Airway ---> tracheal intubation (A)
- Breathing --- AMBU/Ventilator/O2 (B)
- Circulation --- Cardiac compression (C)
- Defibrillation (D)
Shockable rythm are Venricular tachycardia(VT-pulseless),Ventricular fibrillation (VF). Non shockable are Asystole and Electro mechanical discociation EMD)or Pulseless electro activity (PEA).
Automatic External Defibrillator)(AED) :
Public Access Defibrillation (PAD) Program are recomended for the locations where the expected use of an AED for witnessed cardiac arrest exceeds once in 2 years.
A single shock is delivered immediately followed by two minutes of uninterrupted CPR without a check for signs of life or a pulse.
If VF appears give the first shock recomendation for higher energy (360 Joule) when using monophasic waveform, immediately begin chest compression.
Don't interrupt chest compression to check rhythm or pulse until 5 cycles or 2 minutes of CPR are given.
Biphasic : Monophasic ( 96% vs 54% )
When biphasic is given before 5 minutes > ( 50- 70)% probably recovery of spontaneous circulation (ROSC).
Main changes in AED :
PAD programmes are --> A single defibrillatory shock (at least 150 Joule)(biphasic) or 360 Joule(monophasic) is delivered immediately followed by two minutes of uninterrupted CPR without a check for termination of VF or check for signs of live or a pulse.
CARDIAC ARREST
I
------------------------------
I I
unwitness witness
I I
CPR 2 min single shock
I contnued with
evaluate CPR 2 min -----> evaluate
I I
--------------------> <---- ------------ unshockable unshockable shockable
I I I CPR 2 min single shock CPR 2 min c
adrenaline continued with adrenaline
CPR 2 min I?
I ? I?
Main changes in Adult Advance Life Support (6)
-----------------------------------------------------------
1. CPR before decfibrillation
2. Defibrillation strategies
3. Fine VF
4. Adrenaline
5. Anti arrhythmia drugs
6. Thrombolytic theraphy for cardiac arrest
7. Post resuscitation care.--therapeutic hypothermia.
CPR before defibrillation :
Unwitness : Give CPR 2 minutes about 5 cycles at 30:2 before defibrillation dont delay defibrillation if an out of hospital arrest is witnessed by a healthcare professional. Dont delay defibrillation for in hospital arrest.
Defibrillation strategy :
Treat VF/pulseless VT with a single shock followed by immediate resumption of CPR ( 30 compression to 2 ventilation). Do not reasses the rhythm or feel for a pulse.
After 2 minutes of CPR check the rhythm and give another shock (if indicated).
The recomended initial energy for biphasic defibrillators is 150-200 J. Give second and subsequent shocks at 150-360 J. The recomended energy when using monophasic defibrillators is 360 J for both the initial and subsequent shocks. The children 2 joule/kg.
Fine Fibrillation :
If there is doubt about another the rhythm is asystole or fine VF do not attempt defibrillation,instead,continue chest compression and ventilation.
For VF/VT give adrenaline 1 mg iv if VF/VT persist after a second shock. Repeat the adrenaline every 3-5 minutes thereafter if VF/VT persist. For Pulseless electrical activity(PEA)/asystole,give adrenaline 1 mg iv as soon as intravenous access is obtained and repeat every 3-5 min thereafter up to return of ROSC is achieved.
If VT with palpable carotid pulse give lidocaine 1 mg /kg iv or amiodaron 300mg. Pulseless VT give a single shock 360 J immediately CPR 30:2 in 2 minutes. Lidocaine 1-1,5 mg/kg every 3-5 minutes maximal 3 mg/kg in 1 hour.
INTERNATIONAL LIAISON COMMITEE ON RESUSCITATION (ILCOR) guidelines 2005 (6)
1. Adrenaline 1 mg iv repeated every 3-5 minutes.
2. Amiodaron 300 mg iv bolus,if VT/VF persist after 3 shocks. Doses of 150mg may be given for recurrent or refractory VF/VT followed by an infusion of 900 mg over 24 hours.
3. Lidocaine 1 mg/kg, iv if amiodaron is not available,do not exceed a total dose of 3 mg/kg during the first hour. Do Not give lidocaine if amiodaron has already been given. Atropine,adrenaline and lidocaine may be given intravenously,intratracheal or transtracheal the dosis 3-10 times intraveneously or intraosseus but Not intra cardiac.
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