Cardiopulmonary Resuscitation

PEMBIMBING Dr. Mahendratama P. A. Sp. An

Bagian/ SMF Anestesi Fakultas Kedokteran Universitas Lambung Mangkurat

CPR
Cardiopulmonary resuscitation (CPR) is a series of life saving actions that improve the chance of survival following cardiac arrest

Background Cardiac arrest continues to be an all-too-common cause of premature death, and small incremental improvements in survival can translate into thousands of lives saved every year.

Cardiopulmonary Resuscitation (CPR)

Successful CPR depends on Early Basic Life Support (BLS), prompt recognition and treatment of ventricular fibrillation (VF) if present and, Advanced airway and rhythm control (ACLS) as necessary.

Adult Basic Life Support

Key principles of BLS

Immediate recognition of cardiac arrest and activation of the emergency response system Early CPR with an emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post cardiac arrest care

Adult simplified BLS Algorithm

Adult BLS algorithm for healthcare provider

Pulse check
The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally. The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should start chest compressions.

Chest Compressions
Victim on a firm surface, supine position Rescuer kneeling beside the victims chest Rescuer place the heel of one hand on the center (middle) of the victims chest (which is the lower half of the sternum) and the heel of the other hand on top of the first so that the hands are overlapped and parallel

High Quality CPR

Providing chest compressions of adequate rate (at least 100/minute). Providing chest compressions of adequate depth.
Adults: a compression depth of at least 2 inches (5 cm) Infants and children: a depth of least one third the anterior-posterior (AP) diameter of the chest or about 1 inches (4 cm) in infants and about 2 inches (5 cm) in children
1 2

High Quality CPR

Allowing complete chest recoil after each compression Minimizing interruptions in compressions Avoiding excessive ventilation If 2 rescuers available switch in <5 seconds
Stop AED arrives, the victim wakes up, or EMS personnel take over CPR

Airway
CAB rather than ABC airway maneuvers should be performed quickly and efficiently so that interruptions in chest compressions are minimized and chest compressions should take priority in the resuscitation of an adult. head tiltchin lift maneuver jaw thrust without head extension

Airway and Ventilations

Opening the airway (with a head tilt chin lift or jaw thrust) followed by rescue breaths can improve oxygenation and ventilation. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim).

Rescue Breath
Deliver each rescue breath over 1 second Give a sufficient tidal volume to produce visible chest rise Use a compression to ventilation ratio of 30 chest compressions to 2 ventilations When an advanced airway is in place during 2-person CPR, give 1 breath every 6 to 8 seconds without attempting to synchronize breaths between compressions.

AED
The victims chance of survival decreases with an increasing interval between the arrest and defibrillation. cardioversion defibrillation

Adult Advanced Cardiovascular Life Support

Advanced cardiovascular life support (ACLS)

Prevent cardiac arrest, treat cardiac arrest, Improve outcomes of patients who achieve return of spontaneous circulation (ROSC) after cardiac arrest.

Passive Oxygen Delivery During CPR

PostCardiac Arrest Care

The initial objectives of postcardiac arrest care

Optimize cardiopulmonary function and vital organ perfusion. Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest

Subsequent objectives of post cardiac arrest care

Control body temperature to optimize survival and neurological recovery Identify and treat acute coronary syndromes (ACS) Optimize mechanical ventilation to minimize lung injury Reduce the risk of multiorgan injury and support organ function if required Objectively assess prognosis for recovery Assist survivors with rehabilitation services when required

Targeted Temperature Management

Induced hypothermia

Hypethermia

Organ-Specific Evaluation and Support

Pulmonary System
PaO 2 /FIO 2 ratio of 300 mm Hg usually defines acute lung injury Adjust mechanical ventilatory support based on the measured oxyhemoglobin saturation, blood gas values, minute ventilation (respiratory rate and tidal volume), and patient-ventilator synchrony oxyhemoglobin saturation can be maintained 94%

Pulmonary System cont.

Routine hyperventilation with hypocapnia should be avoided after ROSC because it may worsen global brain ischemia by excessive cerebral vasoconstriction Hyperventilation or excessive tidal volumes resulting in increased intrathoracic pressure may also contribute to hemodynamic instability in certain patients. Ventilation rate and volume may be titrated to maintain high-normal PaCO2 (40 to 45 mm Hg) or PETCO2 (35 to 40 mm Hg) while avoiding hemodynamic compromise

Treatment of Pulmonary Embolism After CPR

The use of fibrinolytics during CPR has been studied, and CPR itself does not appear to pose an unacceptable risk of bleeding. Alternatively, surgical embolectomy has also used successfully in some patients after PE-induced cardiac arrest In postcardiac arrest patients with arrest due to presumed or known pulmonary embolism, fibrinolytics may be considered

Sedation After Cardiac Arrest

The titrated use of sedation and analgesia in critically ill patients who require mechanical ventilation or shivering suppression during induced hypothermia after cardiac arrest Opioids, anxiolytics, and sedative-hypnotic agents can be used in various combinations to improve patientventilator interaction and blunt the stress-related surge of endogenous catecholamines 2 -adrenergic agonists and butyrophenones are also used based on individual clinical circumstances.

Organ-Specific Evaluation and Support

Cardiovascular System
ACS (Acute Coronaty Stndrome) is a common cause of cardiac arrest Evaluate the patients 12-lead ECG and cardiac markers after ROSC Determine whether acute ST elevation is present Patients with cardiac arrest may receive antiarrhythmic drugs such as lidocaine or amiodarone during initial resuscitation

Vasoactive Drugs for Use in PostCardiac Arrest Patients

Use of Vasoactive Drugs After Cardiac Arrest

Vasodilation may occur from loss of sympathetic tone and from metabolic acidosis Fluid administration as well as vasoactive (eg, norepinephrine), inotropic (eg, dobutamine), and inodilator (eg, milri-none) agents should be titrated as needed to optimize blood pressure, cardiac output, and systemic perfusion Mean arterial pressure 65 mm Hg and an ScvO2 70% are generally considered reasonable goals.

Modifying Outcomes From Critical Illness

Glucose Control
Hypoglycemia and hyperglycemia associated with worse outcomes in critically ill patients Target moderate glycemic control (144 to 180 mg/dL [8 to 10 mmol/L]) Glucose concentration within a lower range (80 to 110 mg/dL [4.4 to 6.1 mmol/L]) should not be implemented after cardiac arrest due to the increased risk of hypoglycemia

Steroids
Corticosteroids have an essential role in the physiological response to severe stress, including maintenance of vascular tone and capillary permeability No human randomized trials investigating corticosteroid use after ROSC

Central Nervous System

Clinical manifestations of post cardiac arrest brain injury include
Coma Seizures Myoclonus Various degrees of neurocognitive dysfunction (ranging from memory deficits to persistent vegetative state) Brain death

Seizure Management
An EEG for the diagnosis of seizure should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after ROSC Thiopental and single-dose diazepam or magnesium or both given after ROSC have not improved neurological outcome in survivors The same anticonvulsant regimens for the treatment of seizures used for status epilepticus caused by other etiologies may be considered after cardiac arrest

Prognostication of Neurological Outcome in Comatose Cardiac Arrest Survivors

Neurological Assessment Absence of both pupillary light and corneal reflexes at <72 hours after cardiac arrest predicted poor outcome with high reliability. The absence of vestibuloocular reflexes at 24 hours or Glasgow Coma Scale (GCS) score <5 at 72 hours are less reliable for predicting poor outcome Myoclonus not recommended for predicting poor outcome

EEG
EEG interpretation observed 24 hours after ROSC to assist with the prediction of a poor outcome in comatose survivors of cardiac arrest not treated with hypothermia

Evoked Potentials
Abnormalities in evoked potentials are associated with poor outcomes

Neuroimaging
Modalities are magnetic resonance imaging (MRI) and computed tomography (CT) of the brain detect if there any brain injury and predict functional outcome

Organ Donation After Cardiac Arrest

Adult patients who progress to brain death after resuscitation from cardiac arrest should be considered for organ donation

Outcome.
Return patients to their pre arrest functional level Remain permanently unresponsive Remain permanently unable to perform independent activities

TERIMA KASIH