MASURI DE

PRIM AJUTOR
CURS 1/2010
Sef lucrari dr.Ioana Ghitescu
UMF Tg.Mures, Disciplina A.T.I.
S.C.J.U. Mures, Clinica A.T.I.

PLAN
Definitie, Obiective, Principii
EVIDENCE BASED MEDICINE-medicina
bazata pe dovezi
Aspecte etico-medico-legale si
epidemiologice ale CPR si primului ajutor
Notiuni elementare de anatomie si
fiziologie
CPR: definitie
Lantul supravietuirii
BLS la adult

INTRODUCERE
Proceduri de ingrijire medicala simple, de
urgenta aplicabile de catre neprofesionisti
pana la sosirea personalului medical de
specialitate.
Se face referinta atat la laici, cat si la
personalul de pe ambulante sau alti first
responders.
NU INLOCUIESTE UN TRATAMENT
MEDICAL COMPETENT

PRIM AJUTOR
Masuri de ingrijire si tratament de urgenta
aplicate unui bolnav sau unei persoane
traumatizate INAINTEA sosirii/defeririii
catre servicii medicale.
MASURILE DE PRIM AJUTOR NU SUNT
APLICATE CU SCOPUL DE A INLOCUI
DIAGNOSTICAREA SI TERAPIA CORECTA
MEDICALA
ofera asistenta temporara pana la sosirea
personalului medical calificat

PRIM AJUTOR
Scop:
Salvarea vietii
Prevenirea producerii in continuare a leziunilor
Reducerea la minimum/prevenirea infectiilor
Cei trei P P - Preserve Life.
P - Prevent the condition worsening.
P - Promote Recovery
Face diferenta dintre:
Leziune temporara/permanenta
Vindecare rapida/ infirmitate permanenta
Viata/moarte

Medicina bazata pe dovezi

(EBM)

EBM are ca scop utilizarea celor mai bune dovezi

disponibile provenite din metode stiintifice pentru a
conduce la decizii medicale
urmareste sa stabileasca calitatea dovezilor ce
stabilesc riscurile si beneficiile tratamentelor
(inclusiv absenta acestora).
EBM recunoaste ca multe aspecte ale medicinii
depind de factori individuali cum ar fi calitatea si
rationament al valorii vietii ce sunt doar partial
supuse cercetarilor stiintifice.
sa aplice aceste metode in practica medicala cu
scopul de a asigura cea mai buna predictie asupra
prognosticului ad vitam, chiar daca persista inca
controversele legate de tipul prognosticului de
urmarit.

Masuratori statistice

Evidence-based medicine incearca sa

exprime beneficiile clinice ale testelor si
tratamentelor utilizand metode statistice

EBM- stadializarea nivelurilor

de evidenta

Evidence-based medicine categorizes different

types of clinical evidence and ranks them
according to the strength of their freedom from
the various biases that beset medical research.
The strongest evidence for therapeutic
interventions is provided by systematic review
of randomized, double-blind, placebo-controlled
trials involving a homogeneous patient population
and medical condition.
Little value as proof: patient testimonials, case
reports, and even expert opinion

the placebo effect,

the biases inherent in observation and reporting of
cases,
difficulties in ascertaining who is an expert, etc.

Nivel de evidenta
Systems to stratify evidence by quality have been developed,
such as this one by the U.S. Preventive Services Task Force for
ranking evidence about the effectiveness of treatments or
screening:
Level I: Evidence obtained from at least one properly designed
randomized controlled trial.
Level II-1: Evidence obtained from well-designed controlled
trials without randomization.
Level II-2: Evidence obtained from well-designed cohort or
case-control analytic studies, preferably from more than one
center or research group.
Level II-3: Evidence obtained from multiple time series with or
without the intervention. Dramatic results in uncontrolled trials
might also be regarded as this type of evidence.
Level III: Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees

Categorii de recomandari
In guidelines and other publications, recommendation for a clinical service is
classified by the balance of risk versus benefit of the service and the
level of evidence on which this information is based. The U.S. Preventive
Services Task Force uses:
Level A: Good scientific evidence suggests that the benefits of the clinical
service substantially outweighs the potential risks. Clinicians should discuss
the service with eligible patients.
Level B: At least fair scientific evidence suggests that the benefits of the
clinical service outweighs the potential risks. Clinicians should discuss the
service with eligible patients.
Level C: At least fair scientific evidence suggests that there are benefits
provided by the clinical service, but the balance between benefits and risks
are too close for making general recommendations. Clinicians need not
offer it unless there are individual considerations.
Level D: At least fair scientific evidence suggests that the risks of the
clinical service outweighs potential benefits. Clinicians should not routinely
offer the service to asymptomatic patients.
Level I: Scientific evidence is lacking, of poor quality, or conflicting, such
that the risk versus benefit balance cannot be assessed. Clinicians should
help patients understand the uncertainty surrounding the clinical service.

Ghiduri
Un ghid medical (denumit si ghid clinic,
protocol clinic, ghid de practica
medicala) este un document destinat
orientarii deciziilor si criteriilor de:
diagnostic
conduita
tratament intr-un domeniu specific medical

De ce ghiduri?

PRIM AJUTOR- Obiective

A. Airway: Mentinerea permeabilitatii
cailor aeriene
B. Breathing: Mentinerea respiratiilor
C. Circulation: Mentinerea circulatiei

+
Oprirea hemoragiilor
Prevenirea/ reducerea socului

PRIM AJUTOR
Evaluare initiala
Inspectia rapida a zonei

Pericole (curent electric, foc, apa, haz mats, obiecte

instabile, ascutite, animale)
Trafic
Violenta
Conditii de relief si clima
Situatii speciale

Preluarea controlului

calm,
rapid si
eficient

PRIM AJUTOR
Se vor evalua:
1. SIGURANTA proprie si a pacientului
2. MECANISMUL DE PRODUCERE A LEZIUNII
Constient
Inconstient
3. INFORMATII TRANSMISE PE CAI
SPECIALE
- Medalion, bratara cu simboluri
- card cu informatii

PRIM AJUTOR
4. NUMARUL VICTIMELOR
Cand sunt mai multe- evaluarea
A,B,sangerare si C
5. MARTORI
Pot furniza informatii, ajutor chiar daca
sunt nepregatiti prin: apel de urgenta,
suport moral victimei, impiedicarea
imixtiunii altor persoane
6. PREZENTATI-VA ca persoane calificate
in prim ajutor; consimtamant cerut celor
constienti, prezumat pentru cei
inconstienti

Aspecte etico-legale

Datoria de a interveni(desemnata, serviciu sau

responsabilitate preexistaenta fata de victima)
Standard: cat si pentru ce aveti calificare
Consimtamant= acord, permisiune

Pacient constient/inconstient
Minor/major
Bolnavi cu afectiuni psihiatrice
Exprimat/prezumat

Confidentialitatea
Legea Bunului Samaritean (urgenta, cu bune intentii, fara
compensatii, fara a produce daune/leziuni)
Abandon
Neglijenta (datorie, nerespectarea datoriei sau
substandard, producere de leziun/daune, nerespectarea
limitelor)

Aspecte etico-legale
Secventalogica:
Obtineti consimtamantul victimei INAINTE de A O
ATINGE
Urmati ghidurile si protocoalele pentru care ati
fost instruiti, fara a va depasi nivelul de
competenta
Explicati victimei fiecare lucru pe care urmeaza
sa-l faceti
Odata ce ati demarat asistarea victimei, nu o
parasiti pana nu o deferiti unei persoane cel putin
la fel de calificata ca dumneavoastra!

Aspecte etice

OUT OF HOSPITAL SETTINGS

To initiate resuscitation
Not to initiate resuscitation
To terminate resuscitation

IN HOSPITAL RESUSCITATION

To initiate resuscitation
Not to initiate resuscitation
To terminate resuscitation
To withdraw life support

PRIM AJUTOR-REGULI DE
BAZA
1. Mentineti pacientul in decubit dorsal, capul la
acelasi nivel cu corpul, pana la evaluarea
gravitatii situatiei.
Identificati exceptiile la aceasta regula:
Varsaturi sau hemoragii in zona cavitatii bucalepozitie laterala de siguranta ! la leziunile
suspectate de coloana cervico-dorsala (2%
explozii, 6% traumatism facial sau GCS<8)
Dispnee- pozitie sezanda sau semi
Socul- membrele superioare ridicate (!?) doar
daca nu se suspecteaza leziuni de coloana
2. Nu mobilizati pacientul mai mult decat necesar.
Indepartati hainele cu efect restrictiv, asigurati
comfortul termic

PRIM AJUTOR-REGULI DE
BAZA
3. Asigurati confort psihic pacientului
4. Nu atingeti rani, arsuri decat daca e absolut
necesar. Folositi obiecte sterile. Folositi bariere.
Spalati maini!
5. Nu oferiti apa sau alimente din primul moment
6. Imobilizati orice zona suspectata a fi fracturata.
Nu incercati sa reduceti fractura. Nu mobilizati
decat daca e strict necesar
7. Mentineti temperatura normala a corpului

PRIM AJUTOR-aspecte
epidemiologice
Transmitere de boli infectioase
HIV
Virusul hepatitei B, C
Tuberculoza
Masuri de protectie universala- orice pacient trebuie
considerat potential purtator de agenti cu transmitere
sanguina
Purtati manusi sau folositi alta bariera
Spalati-va mainile cu apa calda si sapun:

La venire/plecare
Inainte/dupa examinare, procedura
Dupa scoaterea manusii, mastii
Dupa folosirea batistei, toaletei, trecere prin par, activitati
administrative/gospodaresti

Bariera pentru respiratii artificiale, protectie oculara

NOTIUNI ELEMENTARE DE
ANATOMIE SI FIZIOLOGIE

Notiuni elementare
OXIGEN

CELULE

PLAMANI

SANGE

GLUCIDE
LIPIDE
PROTEINE

Ce se intampla daca
Se opreste respiratia.
Se opresc bataile cardiace?

Sudden Cardiac Arrest

300,000 victims of out-of-hospital cardiac arrest
each year in the U.S.
Less than 8% of people who suffer cardiac
arrest outside the hospital survive.
Sudden cardiac arrest can happen to anyone at
any time. Many victims appear healthy with no
known heart disease or other risk factors.
Sudden cardiac arrest a heart attack.
Sudden cardiac arrest: electrical impulses in
the heart become rapid or chaotic, which causes
the heart to suddenly stop beating.
A heart attack: when the blood supply to part of
the heart muscle is blocked. A heart attack may
cause cardiac arrest

SUDDEN CARDIAC
Approximativ 700,000 stopuri cardiace pe an in
ARREST
Europa

Supravietuirea la externare de aprox 5-10%

CPR efectuat de martori: interventie vitala

inaintea sosirii echipajelor de urgenta dubleaza
sau tripleaza supravietuirea dupa SCR

Resuscitarea precoce si defibrilarea prompta (in

decurs de 1-2 minute) poate duce la supravietuiri
de >60%.

CPR: Ghiduri

The International Liaison Committee on

Resuscitation (ILCOR)
American Heart Association (AHA)
International Guidelines 2000 for
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care
International Consensus Conference on
Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment
Recommendations (2005 Consensus Conference).

CPR

Cardiopulmonary resuscitation (CPR) is an emergency

medical procedure for a victim of cardiac arrest or, in some
circumstances, respiratory arrest. CPR is performed in
hospitals, or in the community by laypersons or by
emergency response professionals.
CPR involves physical interventions to create artificial
circulation through rhythmic pressing on the patient's chest
to manually pump blood through the heart, called chest
compressions, and usually also involves the rescuer
exhaling into the patient (or using a device to simulate this)
to inflate the lungs and pass oxygen in to the blood, called
artificial respiration,
CPR is unlikely to restart the heart; its main purpose is to
maintain a flow of oxygenated blood to the brain and the
heart, thereby delaying tissue death and extending the
brief window of opportunity for a successful resuscitation
without permanent brain damage

Istoric

1740 The Paris Academy of Sciences officially recommended mouth-to-mouth

resuscitation for drowning victims.
1767 The Society for the Recovery of Drowned Persons became the first organized effort
to deal with sudden and unexpected death.
1891 Dr. Friedrich Maass performed the first equivocally documented chest compression
in humans.
1903 Dr. George Crile reported the first successful use of external chest compressions in
human resuscitation.
1904 The first American case of closed-chest cardiac massage was performed by Dr.
George Crile.
1954 James Elam was the first to prove that expired air was sufficient to maintain
adequate oxygenation.
1956 Peter Safar and James Elam invented mouth-to-mouth resuscitation.
1957 The United States military adopted the mouth-to-mouth resuscitation method to
revive unresponsive victims.
1960 Cardiopulmonary resuscitation (CPR) was developed. The American Heart
Association started a program to acquaint physicians with close-chest cardiac resuscitation
and became the forerunner of CPR training for the general public.
1963 Cardiologist Leonard Scherlis started the American Heart Association's CPR
Committee, and the same year, the American Heart Association formally endorsed CPR.
1966 The National Research Council of the National Academy of Sciences convened an
ad hoc conference on cardiopulmonary resuscitation. The conference was the direct result
of requests from the American National Red Cross and other agencies to establish
standardized training and performance standards for CPR.
1972 Leonard Cobb held the world's first mass citizen training in CPR in Seattle,
Washington called Medic 2. He helped train over 100,000 people the first two years of the
programs.
1981 A program to provide telephone instructions in CPR began in King County,
Washington. The program used emergency dispatchers to give instant directions while the
fire department and EMT personnel were en route to the scene. Dispatcher-assisted CPR
is now standard care for dispatcher centers throughout the United States.

SCA

40% din victimele SCA: FV

Deteriorare in asistoliesanse reduse de
resuscitare
Tratament optim pentru
SCR cu FV este:

CPR de catre martori+

defibrilare

Tratamentul optim pentru

SCR cauzat de asfixie
(inec, trauma, droguri,
copii):

rescue breaths vitale

Lantul supravietuirii

CHAIN OF SURVIVAL

LANTUL SUPRAVIETUIRII
Recunoastera precoce si activarea
sistemului de urgenta: poate preveni SCR
Early CPR:dubleaza/tripleaza
supravietuirea din fv

Fiecare minut fara CPR scade supravietuirea cu

7-10%

Defibrilarea precoce:CPR + defib in 3-5

min: supravietuire de 49-75%

Fiecare minut intarziere- reduce sansele de

externare cu 10-15%

BASIC LIFE SUPPORT

secventa de proceduri efectuate pentru a
restabili circulatia sangelui oxigenat dupa
un SC/R
Compresii sternale si ventilatie pulmonara
efectuate de oricine care stie cum sa o
faca, oriunde, imediat, fara alt
echipament.

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

APPROACH SAFELY!
Scene
Rescuer
Victim
Bystanders

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

Factori de risc legati de

scena actiunii

Mediu

Victima

Boli infectioase
Intoxicatii

Tehnici

Trafic
cladiri
Electricitate
Apa, foc
Toxice

Defibrilatoare
Instrumente taioase sau ascutite

Training- manechin

Risk factors

Infection tramsmissions
Accidents with needles
Rescuers having wound on their mouth, hands
Case reports of tuberculosis, SARS, but no case
report of HIV transmission
Mannequins: of the estimated 40 mil. in the USA
and perhaps 150 mil worldwide that have been
taught mouth to mouth rescue breathing on
mannequins in the last 25 years, there has never
been a documented case of transmission of
bacterial, fungal or viral disease by a CPR training
mannequin

CHECK RESPONSE
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

CHECK RESPONSE

Shake shoulders gently

Ask Are you all right?
If he responds
Leave as you find him.
Find out what is wrong.
Reassess regularly.

SHOUT FOR HELP

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

OPEN AIRWAY
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

OPEN AIRWAY

Head tilt and chin lift

- lay rescuers
- non-healthcare rescuers

No need for finger sweep

unless solid material can be seen
in the airway

OPEN AIRWAY

Head tilt, chin lift + jaw thrust

- healthcare professionals

Campbell

AIRWAY OPENING BY
NECK EXTENSION

CHECK BREATHING
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

CHECK BREATHING

Look, listen and feel

for NORMAL breathing

Do not confuse agonal

breathing with
NORMAL breathing

Respiratii agonice

Apar la scurt timp dupa oprirea cordului in

aproximativ 40% din stopurile cardiace

Descrise ca respiratii grele, dificile.

Zgomotoase, gasping

Recunoscute ca semn de stop cardiac

Erroneous information can result in withholding CPR from cardiac arrest victim

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

Obstructia cailor aeriene

cu
corp starin (FBAO)
Approximativ 16 000 adulti si copii sunt tratati annual in UK
pentru obstruictie de cai aeriene cu corpi straini

SEMNE

OBSTRUCIE
MODERATA

OBSTRUCIE SEVERA

Te ineci?

Da

Incapabil sa vorbeasca,
poate incuviinta

Alte semne

Poate tusi, respira,

vorbeste

Nu poate respira/
respiratie cu
Wheezing/silentiu/ince
arca sa tuseasca/
inconstienta

ADULT FBAO TREATMENT

ABDOMINAL THRUSTS

30 CHEST
COMPRESSIONS
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

CHEST COMPRESSIONS

Place the heel of one hand in

the centre of the chest

Place other hand on top

Interlock fingers

Compress the chest

Rate 100 min-1

Depth 4-5 cm

Equal compression : relaxation

When possible change CPR

operator every 2 min

The most effective rate for chest

compressions is 100 compressions per
minute the same rhythm as the beat of
the BeeGees song, Stayin Alive.
http://www.dailymotion.com/video/x1afd7
_bee-gees-staying-alive_music

RESCUE BREATHS
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

RESCUE BREATHS

Pinch the nose

Take a normal breath
Place lips over mouth
Blow until the chest
rises
Take about 1 second
Allow chest to fall
Repeat

RESCUE BREATHS
RECOMMENDATIONS:
- Tidal volume
500 600 ml
- Respiratory rate
give each breaths over about 1s with enough
volume to make the victims chest rise
- Chest-compression-only
continuously at a rate of 100 min

CONTINUE CPR

30

Video Demons tration of CPR for Adults .flv

Hands-only CPR

DEFIBRILLATION

Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
Attach AED
Follow voice prompts

AUTOMATED EXTERNAL
DEFIBRILLATOR (AED)

Some AEDs will

automatically switch
themselves on when
the lid is opened

ATTACH PADS TO
CASUALTYS BARE
CHEST

ANALYSING RHYTHM
DO NOT TOUCH VICTIM

SHOCK
INDICATED

Stand clear
Deliver shock

SHOCK DELIVERED
FOLLOW AED
INSTRUCTIONS

30

NO SHOCK ADVISED
FOLLOW AED
INSTRUCTIONS

30

http://
www.youtube.com/watch?v
=O9T25SMyz3A

IF VICTIM STARTS TO
BREATHE NORMALLY
PLACE IN RECOVERY
POSITION

Approach safely

Approach safely

Check response

Check response

Shout for help

Shout for help

Open airway

Open airway

Check breathing

Check breathing

Call 112

Call 112

30 chest compressions

Attach AED

2 rescue breaths

Follow voice prompts

CONTINUE RESUSCITATION
UNTIL

Qualified help arrives and takes over

The victim starts breathing normally

Rescuer becomes exhausted