Cardiopulmonary

Arrest
Case Report

all cases accompanied

with hypoxia

extracardiac

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

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
3

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
4

In case of unconsciousness
it is necessary to estimate
quickly

The open
airway
Respiration

Hemodynamics

Main stages of resuscitation

C (Circulation) restore the circulation by
external cardiac massage
A (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
7
fibrillation

A (Airway)
ensure open
airway

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
9

Advanced Airway Management

LEMON

SOAP ME

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

BURP MANUEVER

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

14

Algorithm
for artificial ventilation
mouth to mouth or mouth
to nose respiration

ventilation by a face mask and a

self-inflating bag with oxygen

2 initial subsequent breaths

wait 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

15

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

16

ALGORITHM of Cardiopulmonary resuscitation

17

Rekomendasi
Komponen

Dewasa

Anak

Pengenalan awal

Bayi
Tidak sadarkan diri

Tidak ada napas atau bernapas

Tidak bernapas atau gasping.

tidak normal (misalnya gasping)

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

Urutan BHD

CAB

Frekuensi Kompresi
Kedalaman kompresi

Recoil dinding dada

CAB

CAB

Minimal 100 kali per menit

Minimal 5 cm (2 inch)

Minimal 1/3 diameter

Minimal 1/3 diameter

anteroposterior dinding dada

anteroposterior dinding dada

(sekitar 5 cm/2 inch)

(sekitar 4 cm/ 1.5 inch)

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

Ventilasi

30 : 2

30 : 2 (1 penolong)

30 : 2 (1 penolong)

(1 atau 2 penolong)

15 : 2 (2 penolong)

15 : 2 (2 penolong)

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.

18

ALGORITHM of Cardiopulmonary resuscitation

19

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

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
21

Operations in case of Bradycardiacardia

22

Operations in case of Tachycardia

23

Operations in case of asystole

24

Operations in case of PEA

25

ROSC

26

CASE REPORT

27

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

Evaluation:
1mg IV
- Asystol

1.12 WIB

CPR 2 min

Evaluation:
- Asystol

1.15 WIB

CPR 2 min + Injection of epinephrine

Evaluation:
1mg IV
- Asystol

1.19 WIB

CPR 2 min

Evaluation:
- PEA

1.23 WIB

CPR 2 min + Injection of epinephrine

Evaluation:
1mg IV
- 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 Asystol
CPR effort is stopped
1.45 WIB
Maximal mydriasis and absence of light reflex on both pupil
Patient was declared dead
32

Discussion

33

ALGORITHM of Cardiopulmonary resuscitation

35

Rekomendasi
Komponen

Dewasa

Anak

Pengenalan awal

Bayi
Tidak sadarkan diri

Tidak ada napas atau bernapas

Tidak bernapas atau gasping.

tidak normal (misalnya gasping)

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

Urutan BHD

CAB

Frekuensi Kompresi
Kedalaman kompresi

Recoil dinding dada

CAB

CAB

Minimal 100 kali per menit

Minimal 5 cm (2 inch)

Minimal 1/3 diameter

Minimal 1/3 diameter

anteroposterior dinding dada

anteroposterior dinding dada

(sekitar 5 cm/2 inch)

(sekitar 4 cm/ 1.5 inch)

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

Ventilasi

30 : 2

30 : 2 (1 penolong)

30 : 2 (1 penolong)

(1 atau 2 penolong)

15 : 2 (2 penolong)

15 : 2 (2 penolong)

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.

36

2 mechanisms explaining the

restoration of circulation by
external cardiac massage

Cardiac
pump

Thoracic
pump
37

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
38
is filled with blood

Thoracic pump at the cardiac massage

Blood circulation is
restored due to the change
in intra thoracic pressure
and jugular and subclavian
vein valves
During the chest
compression blood is
directed from the
pulmonary circulation to
the systemic circulation.
Cardiac valves function as
in normal cardiac cycle.
39

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:
Dont use atropine, calcium, bicarbonate, vasopressin,
magnesium
The benefit of using amiodarone is very small and
probably isnt 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)

46

ROSC

47

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
cant be saved.
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