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CURRENT CONCEPTS  ON CARDIO-PULMONARY RESUCITATION
DR. NITIN M KULKARNI
MD DNB DM(CARDIOLOGY)
CARDIOLOGY  FELLOW (LONDON)
CONSULTING CARDIOLOGIST
KEM  HOSPITAL   PUNE
MOBILE : 9890001567
Email :    nm2k@mailexcite.com
My Web : members.tripod.com/~IndiaHeart

CARDIAC ARREST

Many thanks to Sir William Harvey(1578 – 1657)described the different theories of circulation of blood and heart.

PILOT WHO FINDS HIS ENGINE HAS SUDDENLY FAILED.

WHAT IS CPR  ???

HISTORICAL PERSPECTIVES
First publication on Guidelines on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC) was in 1974.
There is strong scientific evidence behind each subsequent recommendation.
1980 and more definitively in 1986, guidelines were developed for resuscitation of infants, children, and neonates in the delivery room.
The resuscitation councils that developed the International Guidelines 2000 used a “class of recommendations” scheme to indicate the evidence supporting each recommendation .
The new Resuscitation Guidelines are now Internationally developed, Science-Based, and Evidence-Based.
This document was pilot-tested multiple times with appropriate revisions and modifications after each of 3 evaluation meetings: the Mini Evidence Evaluation Conference, March 1999; the Evidence Evaluation Conference, September 1999; and the Guidelines 2000 Conference, February 2000.

STAGES OF MANAGEMENT
Initial response & basic Life support (doctors, nurses, paramedics)
Advanced Life support.
Post Resuscitation Care
Long term care.
Preventive aspects are important.

AIM OF BASIC LIFE SUPPORT

ESTABLISH RESPONSIVENESS

PATIENT POSTION DURING CPR

Cleaning the mouth

HEIMLICH MANEUVER

Cleaning of the airway

Mouth –to mouth respiration

Locating the Pulse

 BASIC STEPS OF CPR

CARDIAC MASSAGE
Cardiac compression allows the heart to maintain pump function  by sequential filling and emptying of its chambers with competant valves maintaining the forward direction of flow.Palm of one hand placed over lower sternum; heel of the other rests on dorsum of the lower hand.
 To get the right speed and rhythm, count out loud as you do the compressions, saying "1 and 2 and 3 and 4 and 5!" Rest on each "and," then compress on each number. Each series of 5 should take about 3 seconds. Force sufficient to depress sternum by 3-5cms;relaxation is abrupt.

Cardiac massage-position of the hand

Cardiac massage

CARDIAC   MASSAGE

CARDIAC MASSAGE


New CPR modalities

Interposed Abdominal Compression CPR-   IAC-CPR

 Success of resuscitation depends on availability of proper functioning equipments at proper time. Equipment should be tested periodically according to prescribed regulations and each periodic test documented.

CPR- BASIC EQUIPMENTS

BASIC EQUIPMENT

RX ASPECTS OF PERI-ARREST ARRHYTHMIAS
Arrhythmias in the peri-arrest period may need treatment to prevent  deterioration to cardiac arrest or to regain haemodynamic stability after  successful resuscitation.
The choice of treatment depends on the nature of the arrhythmia and the condition of the patient (adverse signs) .
Conscious patients must be  anaesthetised or well sedated before  subjecting the pt to Synchronised cardioversion .
Strong vagal manoeuvres that cause sudden bradycardia may trigger  ventricular fibrillation in the context of acute ischaemia or digitalis toxicity.
 Expert help must be sought early.

RX ASPECTS OF PERI-ARREST ARRHYTHMIAS
W/f Clinical evidence of low cardiac output : pallor, sweating, cold, clammy extremities  (increased  sympathic activity), impaired consciousness (reduced cerebral blood flow), and hypotension.
Excessive tachycardia :Very high  heart rates reduce diastole critically, resulting in poor coronary blood     flow and myocardial ischaemia.
Excessive bradycardia :may not be tolerated by patients with poor cardiac reserve.
All antiarrhythmic treatments - physical manoeuvres, drugs, or electrical   treatment - can also be proarrhythmic, so that clinical deterioration may  occur as a result of treatment.
use of multiple antiarrhythmic drugs or high doses   of a single drug can cause myocardial depression and hypotension.
External pacing most  reliable method for treating symptomatic        bradycardias resistant to atropine.

RX ASPECTS OF PERI-ARREST ARRHYTHMIAS
European Resuscitation Council recommends low dose epinephrine as an alternative treatment for symptomatic bradycardias resistant to atropine.
Amiodarone is the preferred drug for treating broad complex tachycardias, although lidocaine (lignocaine) remains an alternative.
The narrow complex tachycardia algorithm now includes the recommendation of a synchronised direct current shock if the heart rate exceeds 250 beats a minute and the patient has no pulse .
The algorithm for the management of atrial fibrillation is complex.
Patients are classed as having high, intermediate, or low risk, and the treatment options depend partly on the duration of the A.fibrillation.

LONG QT INTERVAL

Torsade-de Pontes- Malignant polymorhic ventricular tachycardia ;manifested  By R on T phenomenon; commenest cause of death in pts with long QT syndromes.

ECG  IN HYPO & HYPERERKALAEMIA

ADVANCED LIFE SUPPORT
AIM: To achieve adequate ventillation; control of arrythmias;stabilize BP & CO.
ACTIVITIES : Intubation with ETT; defibrillation/cardioversion; pacing; I/v access
INVESTIGATE: BSL,ABG; electrolytes; cardiac injury profile; RFTs

ADVANCED LIFE SUPPORT-DRUGS
I/V SODABICARB :  Only if evidence of Metabolic acidosis;1 meq/kg initially followed by 50% dose repeated every 5 minutes. Routinely not recommended.
I/V Amiodarone  150 mg over 10 minutes followed by 1mg/min for 6 hrs followed by 0.5mg/min for 24 hrs.
I/V Procainamide : loading dose 100mg in 5 minutes to total 500 to 800 mg followed by 2-5mg/min infusion for persistant arrythmias.
I/V Ca-gluconate – no longer considered safe/necessary for the routine use.(to be used only in pts.  With hyperkalaemia, hypocalcaemia/ pts. With overdose of Ca-channel blockers)

ADVANCED LIFE SUPPORT-DRUGS
I/V adrenaline 2mg I/V bolus
I/V nor adrenaline 25- 40ug/min I/V drip
I/V dopamine  5-15ug/kg/min I/V drip
I/V dobutamine 5-10 ug/kg/min I/V drip
I/V atropine 0.6-1.8mg/min bolus
I/V Efcorlin 200mg I/V bolus only if indicated.
I/V  amiodarone 150-300mg bolus over 10 minutes followed by 1mg/min for 6 hrs followed by 0.5mg/min for 24hrs.
I/V lignocaine  1.0mg/kg I/V bolus over 5 minutes followed by 1-2mg/min for next 24 hrs.

ADVANCED LIFE SUPPORT-DRUGS
I/V Procainamide : Loading dose  : 100 mg in 5 minutes to total 500 to 800 mg followed by 2-5 mg/min infusion for persistant arrythmias.
I/V Calcium Gluconate – no longer considered safe/necessary for routine use( useful only in hyperkaleamia, hypocalcaemia, overdose of calcium channel blockers;

Advanced Cardiovascular Life Support – AHA Guidelines –2000
 PHARMACOLOGICAL GUIDELINES
Amiodarone (Class IIb) and procainamide (Class IIb) are    recommended ahead of lidocaine and adenosine for the    initial treatment of hemodynamically stable wide-complex    tachycardia, especially in patients with Compromised   cardiac function.
 Amiodarone and sotalol (a drug that awaits Food and  Drug Administration approval for US use) are new agents  recommended as Class IIa agents for the treatment of stable  monomorphic and polymorphic ventricular tachycardia   (VT).
Magnesium has shown effectiveness only in the treatment of known hypomagnesemic states    and torsades de pointes, for which it still has a Class IIb recommendation.

Advanced Cardiovascular Life Support – AHA Guidelines –2000
PHARMACOLOGICAL GUIDELINES
Vasopressin (arginine vasopressin) may be a more effective pressor agent than    epinephrine for promoting the return of spontaneous circulation in cardiac arrest. The  evidence from prospective clinical trials in humans is limited but consistently positive    (Class IIb). Vasopressin (40 U IV, not repeated) may be substituted for epinephrine as an    alternative Class IIb agent. The lower adverse effects profile may be the major indication    for vasopressin.
Research on high-dose epinephrine has not yet shown that routine use of initial and    repeated or escalating doses of epinephrine can improve survival in cardiac arrest Nor has high-dose epinephrine (0.1 mg/kg) in adults been shown to  improve survival or neurological outcomes.
Cardiac arrest survivors who received high-dose epinephrine have more postresuscitation    complications than survivors who received the standard dose.
Because of the potential for  harm, high-dose epinephrine (0.1 mg/kg) is not recommended

Advanced Cardiovascular Life Support – AHA Guidelines –2000

VENTILLATORY GUIDELINES
Reduction in the ventilation tidal volume for patients not in  cardiovascular collapse to approximately one half of that  recommended previously.
Volume should approximate 6 to  7 mL/kg over 1.5 to 2 seconds Higher volumes  increase risk of gastric inflation without improving blood oxygenation.
For clinical guidance, resuscitation  professionals can use the "chest rise" sign as a rough  indication of ventilation tidal volumes that are in the range    of 6 to 7 mL/kg.
Smaller tidal volumes, however, raise the risk of inducing both hypoxia    and hypercarbia.
Provide supplemental   oxygen, adjusted on the basis of oxygen saturation readings.

Advanced Cardiovascular Life Support – AHA Guidelines –2000

VENTILLATORY GUIDELINES
Tracheal intubation in unconscious patients should be attempted only by healthcare    providers experienced in performing this skill.
Emergency responders must confirm tracheal tube  position by using nonphysical examination techniques. These include esophageal detector  devices, qualitative end-tidal CO2 indicators, and capnographic and capnometric devices.
Growing evidence suggests that tracheal tube dislodgments after a successful tracheal    tube insertion may be occurring at much higher rates than previously suspected.
 Emphasis   should be placed on securing the tube carefully with a tie or tape.Monitors for oxygen    saturation and end-tidal CO2 levels can detect tube dislodgments.
The best technique,  however, to prevent, detect, and correct tube dislodgment is the constant vigilance of care    providers.


'Chain of Survival' Concept



 Automated External-defibrillation -Guidelines

Automated External-defibrillation -Guidelines

Automated External-defibrillation -Guidelines

ELECTROMECHANICAL DISSOCIATION
Cardiac activity noted on the monitor but no pulse is felt.
Causes : hypovolumia, pneumothorax,Cardiac tamponade,pulmonary embolism, drug overdose,hypothermia,Metabolic abnormality

Prognosis of pts with EMD is generally very poor

European resuscitation council guidelines

European resuscitation council guidelines

OUTCOME OF SURVIVAL AFTER CPR.

Important Changes in the CPR Guidelines 2000
Once the trachea has been intubated, chest compressions, at a rate of 100 a minute, should continue uninterrupted (except for defibrillation or pulse checks when indicated), and ventilation should be continued at roughly 12 breaths/min..
chest compressions without interruption for ventilation result in a substantially higher mean coronary perfusion pressure.
 new guidelines include the option to use biphasic shocks. In defibrillation, success rates of repeated biphasic shocks at £ 200J are the same as or higher than success rates of monophasic waveforms of escalating energy (200 J, 200 J, 360 J).

Important Changes in the CPR-Pharmacological Guidelines 2000
An intravenous bolus of amiodarone 300 mg should be considered when the patient has ventricular fibrillation or when pulseless ventricular tachycardia does not respond to three shocks (2300 J, 200 J, 360 J).
Atropine 3 mg is now indicated for pulseless electrical activity (electromechanical dissociation) with a ventricular rate of less than 60 a minute, as well as for asystole.
The international guidelines recommend a single intravenous dose of 40 units of vasopressin as an alternative to adrenaline in cases of ventricular fibrillation or pulseless ventricular tachycardia refractory to three initial shocks.
The European Resuscitation Council and the Resuscitation Council (UK) continue to recommend epinephrine (adrenaline) 1 mg every three minutes during cardiopulmonary resuscitation.
A recent study of cardiac arrests occurring in hospital failed to detect any advantage for survival of vasopressin over epinephrine.
The administration of "high dose” epinephrine (5 mg) and bretylium is no longer recommended.



Important Changes in the International ECC and CPR Guidelines 2000

Important Changes in the International ECC and CPR Guidelines 2000
Changes in the Foundations of Education, Training, and Evaluation: Skills-Based, Video-Mediated Instruction for Lay Rescuers
Teaching ACLS: The Primary and Secondary ABCD Surveys as a Unifying Approach to Assessment and Management.
Acute Coronary Syndromes and Acute Ischemic Stroke: Increased Efforts to Achieve Rapid Identification, Rapid Transport, Prearrival Treatment, and Prearrival Notification of the Emergency Department .
Devices for Secondary Confirmation of Proper Tracheal Tube Placement: Techniques to Prevent Dislodgment of Tracheal Tubes .
Support for Family Presence at Resuscitation Attempts .
Death Pronouncement in the Field, Survivor Support Plans, the Futility of Transport of Patients Needing Continued CPR

Honouring the principles of  Hippocrates…

TRAINING ON DUMMY

CPR Group Training in Indianapolis

POST RESUSCITATION CARE
Outcome of patients after in hospital CA  associated with non cardiac diseases is poor.
Course is dominated by the underlying cause & nature of the disease.
Pts. With advanced malignancy, renal failure, uncontrolled infection have poor outcome.
Good outcome in pts with transient airway obstruction, electrolyte  disturbance, pro arrythmic effects of drugs, drug overdose. Primary VF  in AMI very responsive to Rx.
Secondary VF in AMI : in pts. With poor LVEF
poor outcome; high reccurance rate
bradyarrythmias/asystole > common.
pointless being too aggressive.

PREVENTION IS BETTER THAN CURE

Early detection of airway obstruction (mucous plugging,etc.)can prevent hypoxia related events in seriously ill pts

LONG TERM RX- pt must be benefitted by the advances in the technological developments.

LONG TERM RX

THANK YOU