RESUSCITATION

EMERGENCY MEDICINE TRAINING

Presented By:

Dr. Murad Karajah

Thursday,1st of Dec,2011

Adult Cardiopulmonary Resuscitation

• Survival from in-hospital cardiac arrest has been reported to be 17%

• The survival is dependent on the actions of many people, acting as a team

The most important new recommendation chest compressions.

And change A-B-C to C-A-B

Adult Cardiopulmonary Resuscitation

patients with a witnessed VF arrest, or time is< 5 minutes, early def ibr i l lat ion is the preferred

However, in patients un witnessed VF arrest, or an arrest of unclear length of time Ini t ia l CPR has been shown to improve outcomes

The New Guidelines Recommend

It is now recommended that rescuers should make chest compressions , at a rate at least 100 compressions per minute

Another recent change to the guidelines for CPR has been the recommendation of a ratio of 30 compressions to 2 ventilations

The only exception is for rescuer CPR delivered to newborn and pt with respiratory arrest .

The chest compressions should depress the adult sternum at least 2 inches, rather than the previous recommendation of 1 ½ to 2 inches

The New Guidelines Recommend

• If an advanced airway is in place delivery of respirations should occur without pauses in compressions at a rate of 8–10 per minute

The New Guidelines Recommend

Airway Management And Ventilation• Rescue breathing and airway management are

of less importance than uninterrupted chest compressions

• Insertion of (ETT) may not be the critical airway/ventilation management intervention

• All breaths, whether delivered by (BVM) or advanced airway device should be done over 1 second and at a rate of approximately 12BPM. Hyperventilation should be avoided

Approach To Cardiac Arrest AndLife-Threatening Arrhythmias

• Cardiac arrest is characterized by an abrupt LOC because of absence of blood flow

• The most common electrical mechanisms of cardiac arrest are the ventricular tachyarrhythmia's

Adult BLS Healthcare Providers

• Patient unresponsive or gasping

First: call help or send some one to do this

Second: check pulse if present give 1 breath q 5 sec check P q 2 min

no pulse start Compression 30 then 2 breath

3d check rhythm- if shockable give one shock then CPR 2 min

not shockable start CPR 2 min then check again rhythm until patient start to move or ALS provider take over

Un Shockable rhythm – a systole – pulseless electrical activity

Adult Cardiac Arrest Shout for help/active EMS

START CPRGIVE O2

ATTACH MONITOR

ASYSTOLEPEA

VF/VT

SHOCK

CPR 2 min EPINEPHRINE every 3-5 min

Consider advanced AW

Give shock then CPR for 2 min Iv access

YES

YES

NO

NO

CPR 2 min Iv epinephrine every 3-5

minConsider advanced AW

CHECK RHYTHMTREAT

REVERSIBLE CAUSE

If rhythm shockable give 3d shock

Then start amiodarone Treat reversible cause

RHYTHMSHOCHABLE

RhythmSHOCKABLE

CPR

Post Cardiac Arrest Care

After return to spontaneous circulation optimize ventilation and oxygenation by O2 sat < 94% Don’t hyperventilate Considered intubation Treat hypotension give IV fluids bolus If no response give vasopressore infusion Do ECG 12 leads Patient not follow commands consider induced

hypothermia Signs of AMI cardiac reperfusion is indicated

CPR Quality• Push hard (>=2inches [5cm]) and fast (>=100/min) and allow complete chest recoil• Minimize interruptions in compressions• Avoid excessive ventilation• Rotate compressor every 2 minutes• If no advanced airway, 30:2 compression-ventilation ratio• Quantitative waveform capnography

-If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality

Return of spontaneous Circulation (ROSC)• Pulse and blood pressure• Abrupt sustained increase in PETCO2 (typically>40 mm Hg)• Spontaneous arterial pressure waves with intra-arterial monitoring

Shock Energy• Biphasic: Manufacturer recommendation (120-200 J);if unknown, use maximum available. Second and subsequent

doses should be equivalent, and higher doses may be considered.

• Drug Therapy• Monophasic:360 J• Epinephrine IV/IO Dose:1 mg every 3-5 minutes• Vasopressin IV/IO Dose:40 units can replace first or second dose of epinephrine• Amiodarone IV/IO Dose: First dose:300 mg bolus. Second dose: 150 mg.

Advanced Airway• Supraglottic advanced airway or endotracheal intubation• Waveform capnography to confirm and monitor ET tube placement• 8-10 breaths per minute with continuous chest compressions

Reversible causes• Hypovolemia -Tension pneumothorax• Hypoxia -Tamponade, cardiac• Hydrogen Ion (acidosis) - Toxins• Hypo-/hyperkalemia -Thrombosis,pulmonary• Hypothermia -Thrombosis,coronary

Adult Bradycardia

symptomatic

yes

NO

No symptoms Just observation Under monitor

symptoms:Hypotension

Mental changes Shock

Chest pain Acute heart failure

HR> 50 bpmIdentify the cause

Started ABCs IV access Give O2 Monitor ECG

12 Leads

Give atropine If not effective transfer for pacing Or adrenalin Or dopamine

Adult Tachycardia With Pulse

Wide QRS < 0.12

Synchronized cardioversion

yesNO

NO

YES

IDENTIFY AND TREAT UNDERLYING CAUSE

ABCSO2 therapyIv access

BP monitoring

Symptoms :Hypotension Chest pain

Mental status changesShock

IHD Acute heart failure

Considered adenosine

Antiarrhythmic

IV accessVagal

maneuverB blocker

Ca blocker

HR<150

Synchronized CardioversionInitial recommended doses:

• Narrow regular: 50-100 J

• Narow irregular: 120-200 J biphasic or 200 J monophasic

• Wide regular: 100J

• Wide irregular: defibrillation close (NOT synchronized)

Adenosine IV DoseFirst dose: 6 mg rapid IV push: follow with NS flush.

Second dose:12 mg if required.

______________________________________

Antiarrhythmic Infusions for Stable Wide=QRS TachycardiaProcainamide IV Dose:20-50 mg/min until arrhythmia suppressed. hypotension ensues.

QRS duration increases>50%.or maximum dose 17 mg/kg given. Maintenance infusion:1-4 mg/min. Avoid if prolonged QT or CHF.

Amiodarone IV Dose:First dose: 150 mg over 10 minutes.

Repeat as needed if VT recurs.

Follow by maintenance infusion of 1 mg/min for first 6 hours.

Sotalol IV Dose:100 mg (1.5 mg/kg) over 5 minutes. Avoid if prolonged QT.

Doses/Details

Approach to patient with arrhythmia

Identify and treat underlying cause Maintain patent airway: assist breathing as

necessary Oxygen if hypoxic Cardiac monitor Monitor blood pressure Iv access 12 leads ECG don't delay therapy

Persistent tachyarrhythmia causing

• Hypotension• • Acute altered mental status• • Acute heart failure

• Ischemic heart disease

• Signs of shock

Sinus Bradycardia

First degree AV Block

• Causes

Medication

Ischemic heart disease

Hypothyroidism

• Sinus bradycardia • P wave before QRS • PR interval < 0.2 sec

P

Second Degree AV Block:

Type 1 – Wenkenbach

Causes

Inferior MI

Digoxin toxocity

• consists of progressive prolongation of the PR interval until

a nonconducted P wave occurs

P

PR

Second-Degree AV Block, Type II

• Most patients will require permanent pacemaker

• the PR interval remains constant with intermittent conduction

of atrial impulses

Conduction block below the AV node.

Third Degree AV Block:

Complete AV Block

• These patients require transvenous pacer placement for stabilization

• occurs when there is no AV conduction. P waves

• and QRS complexes exist independently of each other

• ventricular escape beats typically occur at a rate of about 40 beats/min.

Sinus Tachycardia

Causes include• pain, fear, anxiety, • fever, hypovolemia,• pulmonary embolism,

hyperthyroidism, • CHF, ischemia,• sepsis, • alcohol, nicotine, caffeine,

catecholamine's, atropine, anticholinergic toxicity, and herbal weight

• accelerated sinus node discharge at a rate

Higher than 100 beats/min.

Normal • P wave• PR interval, and• QRS complex

SVT – Supraventricular Tachycardia

CAUSES• IHD • catecholamine's, • COPD, digoxin toxicity,

rheumatic heart disease,• (MVP), alcohol,

electrolyte abnormalities, • accessory pathways such

as (WPW).

• ectopic pacemaker or reentry

Most SVTs are AV nodal reentrant tachycardia's

• narrow QRS complexes • P waves are often

absent

Management of SVT

• Carotid massage• A denosine, • Beta blockers,• Calcium-channel blockers,• Amiodarone,• Procainamide, • Synchronized cardioversion. If the

patient’s condition is unstable

Atrial Fibrillation

Causes• hypertension,• rheumatic heart disease, • coronary artery disease

hyperthyroidism, • COPD,• CHF, and• alcohol intoxication

• multiple areas of atrial myocardium continuously

Discharging and contracting

The atrial rate is between 400 and 600

• ventricular contraction rate <100 beats/min, it is

• termed atrial fibrillation with rapid ventricular response

Management of atrial fibrillation If the duration of atrial fibrillation is less than 48 hours or no

thrombus is present on TEE - Treatment • chemical (pharmacological)• or electrical cardioversion. If the patient’s condition is unstable, immediate sedation and

synchronized cardioversion is indicated(100–200 J is usually effective).

If the duration of AF more than 48 hrs the treatment focused

to rate control • Calcium-channel blockers and beta blockers are first-line

agents • Then plan for cardioversion after 3-4 wk of anticoagulation

Atrial Flutter

Causes• CAD• AMI. • CHF,• pulmonary embolus• myocarditis,• digoxin toxicity

• a localized area of ectopy in the atrium

• regular atrial rate between 250 and 350 beats/min

• The degree of AV block

is usually 2:1 but may be greater

Management of flutter

• Treatment is directed at controlling the

ventricular rate.

Calcium-channel blockers and beta blocker are first-line

• Chemical and electrical cardioversion may also be considered. If

• the patient’s condition is unstable, immediate sedation and synchronized

• cardioversion is indicated (0.5–1 J/kg is usually effective).

Ventricular Tachycardia (Monomorphic)

• VT occurs when more than three depolarization's occur from a ventricular focus.

• VT less than 30 seconds duration is termed nonsustained ventricular tachycardia.

• QRS complex is generally wide and regular• rate higher than 100 beats/min (usually 150–200)

•Polymorphic Ventricular Tachycardia – Torsade de Pointes

Management of VT

• The most common causes of VT are ischemic heart disease . Other common causes include

• MVP, HOCM, hypoxia, electrolyte abnormalities,

• Treatment is administered according to ACLS guidelines. • Amiodarone and lidocaine are first-line agents for stable VT. • Magnesium, procainamide, and bicarbonate can also be

considered• for refractory VT. If the patient’s condition is unstable,

immediate sedation and synchronized cardioversion are indicated.

VENTRICULAR FIBRILLATION

• Treatment is administered

according to

ACLS guidelines.

• there are no organized depolarization or contractions of the ventricles.

ACUTE CORONARY SYNDROMSymptoms suggest IHD

Emergency assessment :out clinic

Monitor-IV access- bed rest

Aspirine-O2 therapy – nitroglycerin – morphine

Obtain ECG –

If ST elevation transfer urgent to hospital

If considering fibrinolysis give prehospital

Time should be recorded

ED assessment- <10 min

review rapid history ,physical exam , ECG, Monitor, cardiac enzyme,O2

Portable x ray , coagulation study

Review complete fibrinolytic checklist

Treatment in the emergency department :

O2 therapy >94% , morphine , NTG , ASA

ECG finding

Normal or non specific

changes

ST or new LBBBStrongly suggest acute

myocardial injury

ST or T wave inversion High risk for unstable

angina or NSTEMI

Start therapy Don’t delay reperfusion Trop or high risk patient

consider early invasive strategy if :

Recurrent chest pain Recurrent st depression Ventricular tachycardia Hemodynamic instability

Signs of heart failure

ObservationSerial ECGEnzymes

Non invasive cardiac test Time of

symptoms

<12hr

<12 hr

ReperfusionDoor to Pallone

PCI 90 minDoor to

fibrinolysis 30 min

Start treatment by -NTG - -Heparin

-ASA - B blocker - Clopidogrel - ACEI/ARB

Statin therapy

Any changes consider

invasive test

ADULT SUSPECTED STROK

Candidate forFibrinolytic

Consult neurologist&Neurosurgery

Need admission

SIGNS&SYMPTOMS Active EMS

ASSESSMENT AND ACTIONABCs and give o2Obtain iv access

Check glucoseObtain 12 leads ECG

Order if possible urgent brain CT Alert hospital

Hemorrhagic Ischemia Yes NoCT showed bleeding

Give RtpaAnd give ASAHeparin after

24 h

Yes No

ASA

Thank You