Guidelines Rkp

8/8/2019 Guidelines Rkp

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RESUSCITATIONGUIDE LINES 2005

Aries Perdana

Department of AnesthesiologyFaculty of Medicine, University of Indonesia/

Cipto Mangunkusumo Hospital


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GUIDE LINES 2005

Prevention

Cardiac

Arrest /

MET

BASIC

LIFE

SUPPORT

Advanced

Life

Support

Pediatric

Life

Support

NEONATAL

RESUS.

SPECIAL

RESUS.

SITUATIONS

POST

RESUS.

CARE

CONTROVERSIAL

TOPICS

BRADY &

TACHYCARDIA

Acute

Coronary

Syndrome


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Jerry P Nolan,Mary F H, et allResuscitation,2005;67:175-179

Compression first vs shock first

Compression ventilation ratio 1 vs 3- shock sequence for

defibrillation Shock dose Role of Vasopressor in treatment of

cardiac arrest Post resuscitation care

CONTROVERSIAL TOPICS FROM THE 2005INTERNATIONAL CONFERENCE ON CoSTR


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Delaying Defibrillation to Give Basic CPR toPatients With Out-of-Hospital VF,Randomized

Trial Lars Wik, MD, PhD,Trond Boye Hansen, MD et all

Conclusions : Compared with standard care forventricular fibrillation, CPR first prior to defibrillationoffered no advantage in improving outcomes forpatients with ambulance response times shorterthan 5 minutes. However, the patients withventricular fibrillation and ambulanceresponse intervals longer than 5 minutes hadbetter outcomes with CPR first beforedefibrillation was at tempted.

JAMA.2003;289:1389-1395


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The Cobb Study : influence of CPR prior todefib. in patients with out-of-hospital VF

Result: All patients:

* Survival shock first 24%* Survival CPR first 30%

Patients with response interval 4 minutes:* Survival shock first 17%* Survival CPR first 27%

After adjusting patient & factor differences:* CPR first- improved survival

JAMA. 1999;281: 1182-1188



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Other Research Robinson et al. (European journal of

anesthesiology. 1998; 15:702-709) :

CPR first 2 minutes unwitnessed VFarrests ROSC = 16 %, survival = 4% Defibrillation first questioned

Yakaitis rw, Ewy GA ( Critical Care Medicine.1980;8:157-163) : CPR first increases defibrillation successrates if limited to 3 7.5 minutes

?


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Conclusions

Absolute delay before Shock is critical Survival better with shorter response

times Survival improve with CPR first if

response times > 5 minutes CPR may provide critical cardiac

perfusion & metabolic state ofmyocytes more favorable responseto defibrillation


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Recommendation: CPR is performed 1,5-3 minutes

before defibrillation on ventricularfibrillation or pulseless ventriculartachiccardi which occurred out ofhospital orif emergency responsetime is more than 4 minutes


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Compression ventilation ratio

Survival and Neurologic Outcome After

Cardiopulmonary Resuscitation With FourDifferent Chest Compression-VentilationRatios

Arthur B. Sanders, Karl B Kern et all

Conclusion: In this experimental model of

bystander CPR, the group receiving compressionsonly for 4 minutes followed by a compression-ventilation ratio of 100:2 achieved betterneurologic outcome than the group receivingstandard CPR and CC-CPR. Consideration ofalternative chest compression-ventilation ratiosmight be appropriate.

(Ann Emerg Med. 2002;40:553-562.)


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Quality of Cardiopulmonary Resuscitation

During in-hospital Cardiac Arrest Benjamin S. Abella, MD, PhilJason P. Alvarado, BA,et all

ResultResult Analysis of the first 5 minutes of eachAnalysis of the first 5 minutes of eachresuscitation by 30resuscitation by 30--second segments revealed thatsecond segments revealed thatchest compression rates were less than 90/min inchest compression rates were less than 90/min in

28.1% of segments. Compression depth was too28.1% of segments. Compression depth was tooshallow for 37.4% of compression. Ventilationshallow for 37.4% of compression. Ventilationrates were high, with 60.9% of segmentsrates were high, with 60.9% of segmentscontaining a rate of more than 20/min.containing a rate of more than 20/min.

(JAMA. 2005;293:305-310)


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Compression ventilation ratio .

Conclusions : In this study of in-hospital cardiac arrest, the quality ofmultiple parameters of CPR wasinconsistent and often did not meetpublished guideline recommendationseven when performed by well-trained

hospital staff.

(JAMA. 2005;293:305-310)


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Adverse Hemodynamic Effects of Interrupting ChestCompressions for Rescue Breathing During

Cardiopulmonary Resuscitation for VentricularFibrillation Cardiac Arrest

Robert A. Berg, MD; Arthur B. Sanders, MD; et all

Conclusion :

Interrupting chest compressions for rescue

breathing can adversely affect hemodynamicsduring CPR for VF.

(Circulation.2001;104:2465-2470.)


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Importance of Continuous Chest Compressions During

Cardiopulmonary Resuscitation Improved OutcomeDuring A Simulated Single Lay-Rescuer ScenarioKarl B. Kern, MD Ronald W. Hilwig, DVM, PhD et all

ConclusionsMouth-to-mouth ventilation performed by

single layperson rescuers produces substantialinterruptions in chests compressionsupportedcirculation. Continuous chest compression CPRproduces greater neurologically normal 24-hoursurvival than standard ABC CPR when performed in aclinically realistic fashion. Any technique that minimizes

lengthy interruptions of chest compressions during the first10 to 15 minutes of basic life support should be givenserious consideration in future efforts to improve outcomeresults from cardiac arrest.

(Circulation. 2002;105:645-649.)


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Recommendation: Universal ratio of 30:2 for lone

rescuers of victims from infancy(excluding newly born) through

adulthood. Ratio 15:2 for 2 rescuers CPR in

infants & children.

Make rotation every 5 cycles/2minutes


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1 vs 3- shock sequence for defibrillation

Interruption of Cardiopulmonary Resuscitation

With the Use of the Automated ExternalDefibrillator in Out-Of-Hospital Cardiac Arrest

Anouk P. van Alem, MD, Rudolph W. Koster, MD, PhD et all

Conclusion : First responders using automatedexternal defibrillator voice prompts provide CPR lessthan half the time that the automated externaldefibrillator is connected to the patient. Technicalimprovements in automated external defibrillatorrhythm analysis, more efficient resuscitation

algorithms, and first-responder education couldincrease CPR delivery and, perhaps, improveoutcome.

(Ann Emerg Med. 2003;42:449-457)


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1 vs 3- shock sequence for defibrillation.

Outcome of Interrupted Precordial Compression DuringAutomated Defibrillation

Ting Yu, MD; Max Harry Weil, MD, PhD; et all

Conclusion :

Interruptions of precordial compression for rhythm analyses thatexceed 15 second before each shock compromise the outcome of CPRand increase the severity of post-resuscitation myocardialdysfunction.

(Circulation 2002;106:368-372.)


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Automated eksternal defibrillator; to what

extend does the algorithm delay CPR Rea TD, Shah S,et all

Rhythm analysis for a 3-shock sequence

performed by commercially Available AEDresulted in delays of 29 to 37 secondsbetween delivery of 1st shock and thebeginning of 1st post shock compression.

Ann Emerg Med. 2005;46:132-141


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Recommendation :

One initial shock immediately followed

by CPR, beginning with chest

compression without initial evaluation

of cardiac rhythm orcheck circulation

based on pulse examination, until one

period of CPR (5 cycles or 2 minutes)

is completed.


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Shock dose

Recommendation: One shock

optimum shock dose needed

efficiency of first shock monophasic

< biphasic

Monophasic : 360 J for initial and

subsequent shocks

Biphasic : initially 150-200 J or 120 J


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Role of Vasopressor in teatment of cardiac arrest

Vasopresin for cardiac arrest A systematicreview & meta analysis

Aung K, Htay T

No statistically significant difference between vasopresinand epinephrine on ROSC , death within 24 hours or deathbefore discharge from Hospital.Arch Intern Med 2005:165;17-24

Recommendation:Individual resuscitationcouncils will need to determine the Roleof vasopresin in their guide lines.


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Post resuscitation careILCOR Recommendations

The Advanced Life Support Task Force of theInternational Liaison Committee on Resuscitation(ILCOR) made the following recommendations :

Unconscious adult patients with spontaneouscirculation after out-of-hospital cardiac arrestshould be cooled to 32o C to 34o C for 12 to24 hours when the initial rhythm wasventricular fibrillation (VF).

Such cooling may also be beneficial for otherrhythms or in-hospital arrest.


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GUIDE LINES FOR PREVENTION OF IN- HOSPITALCARDIAC ARREST

Provide care for patients who are critically ill or at risk ofclinical deterioration in appropriate areas, with the level of careprovided matched to the level of patient sickness

Regular observations for critically ill patients; match thefrequency & type of observations to the severity of illness or

the likelihood of clinical deterioration and cardiopulmonaryarrest. Often simple vital sign observations (pulse, BP, RR) areneeded.

Early Warning Score (EWS) to identify patients who arecritically ill and or at risk of clinical deterioration &cardiopulmonary arrest.

Charting system that enables the regular measurement &

recording of EWS Rules about clinical responses to EWS system, including rules

about medical treatment & detail responsible of the medicalstaff & nurse


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GUIDE LINES FOR PREVENTION OF IN- HOSPITALCARDIAC ARREST

Clear identified response to critical illnes

resuscitation team ready for 24 hours

Training for all staffs in nursing ward to recognice,

monitor & take care of patients with severe diseasewhile waiting for more experienced team arrived

Identification of patients on terminal state of cardiacarrest

certain rules in hospitals about DNAR

Adequate audit of every cardiac arrest incidences,unexpected death, patients with unexpected ICU care,& response time of emergency (code blue)


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ILCOR Universal

Cardiac Arrest Algorithm

Circulation 2005; III 1-4


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IN HOSPITAL RESUSCITATIONEUROPEAN RESUSCITATION COUNCIL

Collapsed/sick patient

Shout forHELP & assess patient

Signs of life?No Yes

Call Resuscitation Team Assess ABCDE

Recognize & treat

Oxygen, monitoring, iv accessCPR 30:2

With oxygen & airway adjuncts

Call Resuscitation TeamIf appropriate

Apply pads/monitor

Attempt defibrillation if appropriateHandover to Resuscitation

Team

Advanced Life Support

When Resuscitation Team arrives


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Circulation 2005;112: IV 18-34


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5


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ADULT ALS ALGORITHM, EUROPEAN RESUSCITATION COUNCIL

Unresponsive?

Open Airway

Look for signs of lifeCall

Resuscitation Team

CPR 30 : 2Until defibrillator/monitor attached

Assess rhythm

Shockable

(VF/Pulseless VT)

1 Shock150-360 J biphasic or

360 J monophasic

Immediately resume:

CPR 30:2For 2 min

Non-shockable

(PEA/Asystole)

Immediately resume:

CPR 30:2For 2 min


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LANJUTAN

During CPR :

Correct reversible causes *

Check electrode position & contact

Attempt/verify :

IV access

Airway & oxygen

Give uninterrupted compressions when airway secure

Give adrenaline every 3-5 mins

Consider : amiodarone, atropine, magnesium

*Reversible Causes

Hypoxia Tension Pneumothorax

Hypovolemia Tamponade cardiac

Hypo/hyperkalaemia/Metabolic Toxins

Hypothermia Thrombosis (coronary or pulmonary)


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Circulation 2005;112: IV 57-66


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Adult Child InfantLay rescuer: ? 8 year Lay rescuers: 1 to 8 years Under 1 year of age

Maneuver HCP: Adolescent and older HCP: 1 year to adolescent

Airway

Breathing Initial 2 breaths at 1 second/breathHCP: Rescue breathing without chest

compressions

10 to 12 breaths/min

(approximate)

HCP: Rescue breaths for CPR with

advanced airway

Foreign-body airway obstruction Back slaps and chest thrusts

Circulation HCP : Pulse check (?10 sec) Brachial or femoral

Compression landmarks Just below nipple line (lower half of sternum)

Compression method Heel of one hand, other hand Heel of one hand or as for adults 2 or 3 fingers

Push hard and fast on top HCP (2 rescuers):

Allow complete recoll 2 thumb-encircling hands

Compression depth 1 to 2 inches

Compression rate

Compression-ventilation ratio 30:2 (one or two rescuers)

Defibrillation AED Use adult pads Use AED after 5 cycles of CPR (out of No recommendation for

Do not use child pads hodpital). infants

Use pediatric system for child 1 to 2 years


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