case report.ppt

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Cardiopulmonary ArrestCase Report

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Causes of cardiac arrest

cardiac

extracardiac

Primary lesion of cardiac muscle leading to the progressive decline of contractility, conductivity disorders, mechanical factors

all cases accompanied with hypoxia

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Causes of circulation arrest

Cardiac• Ischemic heart disease

(myocardial infarction, stenocardia)

• Arrhythmias of different origin and character

• Electrolytic disorders• Valvular disease• Cardiac tamponade• Pulmonary artery

thromboembolism• Ruptured aneurysm of aorta

Extracardiac• airway obstruction

• acute respiratory failure

• shock

• reflector cardiac arrest

• embolisms of different origin

• drug overdose

• electrocution

• poisoning

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Sequence of operations• Check responsiveness• Call for help• Correctly place the victim and ensure the

open airway• Check the presence of spontaneous

respiration• Check pulse• Start external cardiac massage and

artificial ventilation

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In case of unconsciousness it is necessary to estimate

quickly

• The open airway• Respiration• Hemodynamics

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Main stages of resuscitationC (Circulation) – restore the circulation by

external cardiac massageA (Airway) – ensure open airway by preventing

the falling back of tongue, tracheal intubation if possible

B (Breathing) – start artificial ventilation of lungs

D (Differentiation, Drugs, Defibrilation) – quickly perform differential diagnosis of cardiac arrest, use different medication and electric defibrillation in case of ventricular fibrillation

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A (Airway) ensure open

airway

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Open the airway using a head tilt lifting of chin. Do not tilt the head too far back

Check the pulse on carotid artery using fingers of the other hand

Advanced Airway Management

LEMONSOAP ME

Do not hyperventilate (1 breath every 6-8 second)

BURP MANUEVER

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B (Breathing) 

Tilt the head back and listen for. If not breathing normally, pinch nose and cover the mouth with yours and blow until you see the chest rise.

Ensure 100% O2 delivery

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mouth to mouth or mouth to nose respiration

ventilation by a face mask and a self-inflating bag with oxygen

2 initial subsequent breathswait for the end of expiration

10-12 breaths per minute with a volume of app. 800 ml, each breath should take 1,5-2 seconds

Control over the ventilation

check chest movements during ventilation

check the air return

Algorithm for artificial ventilation

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C (Circulation)Restore the circulation, that is start external cardiac massage

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ALGORITHM of Cardiopulmonary resuscitation

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Rekomendasi

Komponen Dewasa Anak Bayi

Pengenalan awal Tidak sadarkan diri

Tidak ada napas atau bernapas

tidak normal (misalnya gasping)

Tidak bernapas atau gasping.

Tidak teraba nadi dalam 10 detik (hanya dilakukan oleh tenaga kesehatan)

Urutan BHD CAB CAB CAB

Frekuensi Kompresi Minimal 100 kali per menit

Kedalaman kompresi Minimal 5 cm (2 inch) Minimal 1/3 diameter

anteroposterior dinding dada

(sekitar 5 cm/2 inch)

Minimal 1/3 diameter

anteroposterior dinding dada

(sekitar 4 cm/ 1.5 inch)

Recoil dinding dada Recoil sempurna dinding dada setelah setiap kompresi. Untuk penolong terlatih, pergantian posisi

kompresor setiap 2 menit.

Interupsi kompresi Interupsi kompresi seminimal mungkin.

Interupsi terhadap kompresi tidak lebih 10 detik.

Jalan napas Head tilt chin lift.

(jaw thrust pada kecurigaan trauma leher – hanya oleh tenaga kesehatan).

Kompresi 30 : 2

(1 atau 2 penolong)

30 : 2 (1 penolong)

15 : 2 (2 penolong)

30 : 2 (1 penolong)

15 : 2 (2 penolong)

Ventilasi Jika penolong tidak terlatih, kompresi saja.

Pada penolong terlatih tanpa alat bantu jalan napas lanjutan berikan 2 kali napas buatan setelah 30

kompresi. Bila terpasang alat bantu jalan napas lanjutan berikan napas setiap 6-8 detik (8-10 kali per

menit).

Penderita ROSC, napas diberikan setiap 5-6 detik (10-12 kali per menit)

Defibrilasi Pasang dan tempelkan AED sesegera mungkin.

Interupsi kompresi minimal, baik sebelum atau sesudah kejut listrik.

Lanjutkan RJP, diawali dengan kompresi segera setelah kejut listrik.

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ALGORITHM of Cardiopulmonary resuscitation

D (Defibrillation) • All moving away from stacked shocks to single shocks

– Reduces pauses in chest compressions • All recommend immediate CPR after defibrillation (without

rhythm or pulse check) • Different recommendations on joules (150-360J)

– Between guidelines – Between manufacturers – Between monophasic and biphasic

• There may be a role for CPR before defibrillation in some – Particularly if in VF for more than a few minutes – Right heart dilation an impediment to defibrillation

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Possible arrhythmias after cardiac defibrillation

• Ventricular tachycardia• Bradyarrythmia including

electromechanical dissociation and asystole

• Supraventricular arrhythmia accompanied with tachycardia

• Supraventricular arrhythmia with normal blood pressure and pulse rate

• Asystole or PEA

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Operations in case of Bradycardiacardia

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Operations in case of Tachycardia

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Operations in case of asystole

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Operations in case of PEA

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ROSCROSC

CASE REPORT

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Chief Complain

• Patient came to hospital with loss of counsciousness

Primary survey• C: Carotid pulse is absent• A: Clean, airway obstruction (-)• B: Breath is absent

Management:- Cardiopulmonary resuscitation- Airway management head tilt, chin lift manuver + Oropharyngeal tube

Level 1 priority patient

01.00 WIB

CPR 2 min + Monitor, defibrillator, and IV line establishment Evaluation:

- IV line established- Monitor and defibrillator plugged in- Asystol

1.10 WIB

CPR 2 min + Injection of epinephrine 1mg IV Evaluation:

- Asystol

1.12 WIB

CPR 2 min Evaluation:- Asystol

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1.15 WIB

CPR 2 min + Injection of epinephrine 1mg IV Evaluation:

- Asystol

1.19 WIB

CPR 2 min Evaluation:- PEA

1.23 WIB

CPR 2 min + Injection of epinephrine 1mg IV Evaluation:

- ROSC

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1.23 WIB

Advanced airway establishment Endotracheal intubation

1.40 WIB

Advanced airway established

1.42 WIB

SaO2 deminished carotid pulse become absent AsystolCPR effort is stopped

1.45 WIB

Maximal mydriasis and absence of light reflex on both pupil Patient was declared dead

Discussion

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ALGORITHM of Cardiopulmonary resuscitation

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Rekomendasi

Komponen Dewasa Anak Bayi

Pengenalan awal Tidak sadarkan diri

Tidak ada napas atau bernapas

tidak normal (misalnya gasping)

Tidak bernapas atau gasping.

Tidak teraba nadi dalam 10 detik (hanya dilakukan oleh tenaga kesehatan)

Urutan BHD CAB CAB CAB

Frekuensi Kompresi Minimal 100 kali per menit

Kedalaman kompresi Minimal 5 cm (2 inch) Minimal 1/3 diameter

anteroposterior dinding dada

(sekitar 5 cm/2 inch)

Minimal 1/3 diameter

anteroposterior dinding dada

(sekitar 4 cm/ 1.5 inch)

Recoil dinding dada Recoil sempurna dinding dada setelah setiap kompresi. Untuk penolong terlatih, pergantian posisi

kompresor setiap 2 menit.

Interupsi kompresi Interupsi kompresi seminimal mungkin.

Interupsi terhadap kompresi tidak lebih 10 detik.

Jalan napas Head tilt chin lift.

(jaw thrust pada kecurigaan trauma leher – hanya oleh tenaga kesehatan).

Kompresi 30 : 2

(1 atau 2 penolong)

30 : 2 (1 penolong)

15 : 2 (2 penolong)

30 : 2 (1 penolong)

15 : 2 (2 penolong)

Ventilasi Jika penolong tidak terlatih, kompresi saja.

Pada penolong terlatih tanpa alat bantu jalan napas lanjutan berikan 2 kali napas buatan setelah 30

kompresi. Bila terpasang alat bantu jalan napas lanjutan berikan napas setiap 6-8 detik (8-10 kali per

menit).

Penderita ROSC, napas diberikan setiap 5-6 detik (10-12 kali per menit)

Defibrilasi Pasang dan tempelkan AED sesegera mungkin.

Interupsi kompresi minimal, baik sebelum atau sesudah kejut listrik.

Lanjutkan RJP, diawali dengan kompresi segera setelah kejut listrik.

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2 mechanisms explaining the restoration of circulation by external cardiac massage

Cardiac pump

Thoracic pump

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Cardiac pump during the cardiac massage

Blood pumping is assured by the compression of heart between sternum and spine

Between compressions thoracic cage is expanding and heart is filled with blood

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Thoracic pump at the cardiac massageBlood circulation is restored due to the change in intra thoracic pressure and jugular and subclavian vein valvesDuring the chest compression blood is directed from the pulmonary circulation to the systemic circulation. Cardiac valves function as in normal cardiac cycle.

D (Drugs) • No evidence that drugs improve survival from cardiac arrest

– High dose adrenaline is no better than normal dose– Amiodarone improves ROSC rates in recurrent VF

• Keep it simple: – Don’t use atropine, calcium, bicarbonate, vasopressin,

magnesium – The benefit of using amiodarone is very small and

probably isn’t worthwhile in a clinic where cardiac arrest is rare

– Give 1 mg (adults) adrenaline every four minutes– Use a decent flush (the easiest is a running line)

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ROSCROSC

Starting and stopping • These decisions can be difficult• A resuscitation attempt should

begin in most patients– Except where the patient is

clearly dead (livedo, rigor mortis)

– Or where they are clearly dying and it would be inappropriate

• Some scenarios have >99% mortality rates – Unwitnessed cardiac arrest

with initial rhythm of asystole

Starting and stopping • The chances of survival fall

rapidly with time– Exponential falling curve

• There is no absolute cut off when mortality becomes zero

• Resuscitation attempts requiring longer than 20 minutes of CPR have a very high mortality rate– We recommend stopping at

around 20 minutes unless there is a clinical reason to continue for longer

• Transport to hospital with CPR enroute usually has no role

Conclusion• Ny S 45 yo is diagnosed with cardiac arrest in

time when she came to the hospital. The diagnosis was made through primary survey evaluation.

• This patient is level 1 priority patient on triage.• The cause of cardiac arrest is unknown due to

lack of information that we can get from the patient.

• CPR with ACLS intervention is performed at approximate 45 min resuscitation but the patient can’t be saved.

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