4. Cardiorespiratory Arrest-dt.takdir Musbah, Sp.an

A.M. TAKDIR MUSBA

EMERGENCY AND TRAUMATOLOGY , 2010

Cardiorespiratory arrest is the sudden, unexpected cessation of respiration and functional circulation.

CPCR Principle

4 – 6 minutes

CPCRDuring respiratory and cardiac arrest, CPCR may be successful if performed before biological death of vital tissue develops.

1. Degree of preexisting hypoxia of the cells.

2.  The brain depends totally on oxygen and is the organ least able to withstand hypoxia.

3. The whether circulatory or respiratory arrest occurs first.

A. Cardiac asystole. B. Ventricular fibrillation or Pulseless VT Electrical defibrillation is required to

reestablish spontaneous and effective cardiac electrical activity.

C. Electromechanical dissociation circulatory collapse that occurs despite satisfactory electrical complexes on the ECG

1. Low cardiac output.2. Hyparcapnia. 3. Hyperkalemia. 4. Hypoxia and vagal stimulation.5. Stimulation of the heart. 6. Coronary occlusion. 7. Overdosage. 8. Hypothermia. 9. Hyperthermia 10. Acidosis

1. Airway obstruction by vomitus, foreign body, blood, secretions, solid material, mucous plugs, laryngeal or bronchial spasm, or tumor.

2. CNS depression: caused by stroke, head trauma, hypercapnia, barbiturates,narcotics, tranquilizers, or anesthetics.

3. Neuromuscular failure secondary to poliomyelitis, muscular dystrophy, myasthenia, or muscle relaxant drugs.

Flail chestPneumothoraxMassive atelectasisAcute pulmonary embolismCongestive heart failure Overwhelming pneumoniaGram-negative septicemiaLung burnsCarbon monoxide poisoningMassive blood loss.

In geriatric or pediatric patients. In patients with a history of arrhythmias, heart block, digitalis toxicity, myocarditis , myocardial infarction, congestive heart failure, electrolyte imbalance , or dehydration.

In massive hemorrhage. During or following heart surgery.

The initial goal of therapy is BRAIN oxygenation

The second goal is restoration of circulation.

Underlying condition must be corrected.

CPCR is not indicated for all patients. Natural death in the aged or in the terminal stages of a chronic illness

CPCR should be performed in cases of reversible unexpected death

Basic Life support (BLS):Airway, Breathing, Circulation, Drug (Defibrillation )

Advanced life support (ALS): Airway, Breathing, Circulation, Drug

(Defibrillation), ECG, Fluid, Gauge, ICU

ABCD steps A, airway. B, breathing. C, circulation. D, drugs and definitive therapy.

In a witnessed cardiac arrest (when treatment can be initiated within 1 min of the onset of arrest), the ABCD sequence should include use of a precordial thump.

Precordial Thumb

OPEN AIRWAY

BREATHE

CHECK BREATHING

Shake and shout

Head tilt / Chin lift

Look, listen and feel

2 effective breaths

CHECK RESPONSIVENESS

If breathing:recovery position

Adult Basic Life Support

CIRCULATION PRESENTContinue Rescue Breathing

NO CIRCULATIONCompress Chest

Check circulationEvery minute

100 per minute15:2 ratio

Send or go for help as soon as possible according to guidelines

ASSESS10 secs only Signs of a circulation

1. vertically downward 4-5 cm 2. Push hard push fast 3. 100 x/min.4. Ratio Comp : Vent 30 : 2

External Cardiac Compression

Cardiac Compression

Defibrillate up to 3 times

Epinephrine – several dose options

Antiarrhythmic agentsLidocaineBretyliumMagnesiumProcainamide

Ventricular fibrillation

• Search for reversible causes and treat • Epinephrine• Atropine for absolute or relative bradicardia

EpinephrineAtropineConsider transcutaneous pacing

Search for reversible causes and treat if possible

AtropineAtropineDopamineDopamineEpinephrineEpinephrineTranscutaneous pacingTranscutaneous pacingTransvenous pacingTransvenous pacing

Immediate cardioversionImmediate cardioversionPremedicate when possiblePremedicate when possibleSynchronized settingSynchronized setting

Narrow-complexNarrow-complexAdenosineVerapamilVerapamilDiltiazemDiltiazem-blockers-blockersDigoxinDigoxin

Synchronized Synchronized cardioversioncardioversion

• Wide-complex– Lidocaine– Procainamide– Bretylium– Consider adenosine

• Synchronized cardioversion

It is critical to survival from sudden cardiac arrest (SCA) for several reasons: (1) the most frequent initial rhythm in

witnessed is ventricular fibrillation (VF), (2) the treatment for VF is electrical

defibrillation, (3) The probability of successful

defibrillation diminishes rapidly over time, and

(4) VF tends to deteriorate to asystole within a few minutes.

Defibrillation delivery of current through the chest and to the heart to depolarize myocardial cells and eliminate VF.

The energy settings for defibrillators are designed to provide the lowest effective energy needed to terminate VF.

Electrophysiologic event that occurs in 300 to 500 milliseconds after shock delivery.

Defibrillation (shock success) is typically defined as termination of VF for at least 5 seconds following the shock.

Biphasic defibrillator (initial shock) : selected energies of 150 J to 200 J

(biphasic truncated exponential waveform) or

120 J (rectilinear biphasic waveform).For second and subsequent shocks, use

the same or higher energy

Monophasic defibrillator : select a dose of 360 J for all shocks.

If VF is initially terminated by a shock but then recurs later in the arrest, deliver subsequent shocks at the previously successful energy level.

Shock delivery that is timed (synchronized) with the QRS complex.

The energy (shock dose) used is lower than that used for unsynchronized shocks (defibrillation).

These low-energy shocks if delivered as unsynchronized are likely to induce VF.

If cardioversion is needed and it is impossible to synchronize a shock (eg, the patient’s rhythm is irregular), use high-energy unsynchronized shocks.

Ventricular tachycardiaVentricular tachycardia with a pulse

responds well to cardioversion using initial monophasic energies of 200 J.

Use biphasic energy levels of 120—150 J for the initial shock.

Give stepwise increases if the first shock fails to achieve sinus rhythm.

Electrode Position

Drugs should be considered only after initial shocks have been delivered (if indicated) and chest compressions and ventilation have been started.

Three groups of drugs relevant to the management of cardiac arrest (2005 Consensus Conference): vasopressors, anti-arrhythmics and other drugs.

Adrenaline - the primary sympathomimetic agent for the management of cardiac arrest for 40 years.

Alpha-adrenergic actions, vasoconstrictive effects systemic vasoconstriction, which increases coronary and cerebral perfusion pressures.

Beta-adrenergic actions, (inotropic, chronotropic) may increase coronary and cerebral blood flow.

.

IndicationsAdrenaline is the first drug used in cardiac arrest of

any aetiology: it is included in the ALS algorithm for use every 3—5 min of CPR.

Adrenaline is preferred in the treatment of anaphylaxis.

Adrenaline is second-line treatment for cardiogenic shock.

Dose. During cardiac arrest, the initial intravenous dose of adrenaline is 1 mg.

When intravascular (intravenous or intra-osseous) access is delayed or cannot be achieved, give 2—3 mg, diluted to 10 ml with sterile water, via the tracheal tube. Absorption via the tracheal route is highly variable.

Amiodarone is a membranestabilising anti-arrhythmic drug that increases the duration of the action potential and refractory period in atrial and ventricular myocardium.

Atrioventricular conduction is slowed, and a similar effect is seen with accessory pathways.

Amiodarone has a mild negative inotropic action and causes peripheral vasodilation through non-competitive alpha-blocking effects.

Indications. refractory VF/VThaemodynamically stable ventricular tachycardia

(VT) and other resistant tachyarrhythmiasDose. Consider an initial intravenous dose of

300 mg amiodarone, diluted in 5% dextrose to a volume of 20 ml (or from a pre-filled syringe), if VF/VT persists after the third shock.

Amiodarone can cause thrombophlebitis when injected into a peripheral vein; use a central venous catheter if one is in situ but,if not, use a large peripheral vein and a generous flush.

Indications. Lidocaine is indicated in refractory VF/VT (when amiodarone is unavailable).

Dose. an initial dose of 100 mg (1—1.5 mg/kg) for VF/pulseless VT refractory to three shocks.

Give an additional bolus of 50 mg if necessary.

The total dose should not exceed 3 mg/kg during the first hour.

Atropine. antagonises the action of the parasympathetic neurotransmitter acetylcholine at muscarinic receptors.

Blocks the effect of the vagus nerve on both the sinoatrial (SA) node and the atrioventricular (AV) node, increasing sinus automaticity and facilitating AV node conduction.

is indicated in:asystolepulseless electrical activity (PEA) with

a rate <60/min.sinus, atrial, or nodal bradycardia when

the haemodynamic condition of the patient is unstable.

The recommended adult dose of atropine for asystole or PEA with a rate <60 /min is 3 mg i.v. in a single bolus.

CPR must be continued untilCardiopulmonary system is

stabilized The patient is pronounced death Alone rescuer is physically unable

to continue