Cpr for adults

1. CPR FOR ADULTS
1

2. 2

4. Plan
4
 Definition/Aim of Cardiopulmonary Resuscitation (CPR)
 Treatment of VF / Pulseless VT
 Treatment of non-VF/VT rhythm
 Potential reversible causes of cardiac arrest
 Airway, IV Access, Drugs

5. Cardiopulmonary Resuscitation
(CPR) - Definition
5
Emergent medical applications that are performed for a living
whose respiratory and circulation functions have been stopped
in an immediate and unexpected status

6. 6
To provide adequate amount of oxygenated blood
for vital organs
Cardiopulmonary Resuscitation
(CPR) - Aim

7. 7

8. Cardiopulmonary Arrest (CPR)
8
Causes:
 Airway obstruction
 Respiratory distress
 Cardiac abnormalities
ACUTE MYOCARDIAL
INFARCTON

9. 9
CPR – ILCOR (International Liaison Committee On Resuscitation)
 American Heart Association (AHA)
 European Resuscitation Council (ERC)
 Heart and Stroke Foundation of Canada (HSFC)
 Australian Resuscitation Council (ARC)
 Resuscitation Councils of Southern Africa (RCSA)
 Council of Latin America for Resuscitation (CLAR)

10. 10
CPR
 Basic Life Support
 Advanced Life Support
 Prolonged Life Support

11. 11
CPR
 Basic Life Support
 Advanced Life Support
 Prolonged Life Support

12. 12
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
1 Shock
150-360 J biphasic
or 360 J monophasic
Open Airway
Look for signs of life
Immediately resume
CPR 30:2
for 2 min
Call
Resuscitation
Team
During CPR:
• Correct reversible causes
• Check electrode position and
contact
• Attempt / verify:
IV access
airway and oxygen
• Give uninterrupted
compressions when airway
secure
• Give adrenaline every 3-5 min
• Consider: amiodarone,
atropine,
magnesium
Immediately resume
CPR 30:2
for 2 min
Adult ALS
Algorithm

13. 13
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
1 Shock
150-360 J biphasic
or 360 J monophasic
Open Airway
Look for signs of life
Immediately resume
CPR 30:2
for 2 min
Call
Resuscitation
Team
During CPR:
• Correct reversible causes
• Check electrode position and
contact
• Attempt / verify:
IV access
airway and oxygen
• Give uninterrupted
compressions when airway
secure
• Give adrenaline every 3-5 min
• Consider: amiodarone,
magnesium
Immediately resume
CPR 30:2
for 2 min
Adult ALS
Algorithm

14. 14
Open Airway
Look for signs of life
…. to confirm cardiac arrest
 Patient response
 Open airway
 Check for normal breathing
(caution agonal breathing)
 Check circulation
 Monitoring

15. 15
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
1 Shock
150-360 J biphasic
or 360 J monophasic
Open Airway
Look for signs of life
Immediately resume
CPR 30:2
for 2 min
Call
Resuscitation
Team
During CPR:
• Correct reversible causes
• Check electrode position and
contact
• Attempt / verify:
IV access
airway and oxygen
• Give uninterrupted
compressions when airway
secure
• Give adrenaline every 3-5 min
• Consider: amiodarone,
magnesium
Immediately resume
CPR 30:2
for 2 min
Adult ALS
Algorithm

16. 16
Open Airway
Look for signs of life
Call
Resuscitation
Team
Cardiac arrest confirmed
CPR 30:2
Until defibrillator /
monitor attached

17. 17
Chest Compression
 30:2
 Compressions
 Centre of chest
 5-6 cm depth
 100-120 min-1
 Uninterrupted
compressions when
airway secured
 Avoid
 Provider fatigue
 Interruptions

18. 18
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
1 Shock
150-360 J biphasic
or 360 J monophasic
Open Airway
Look for signs of life
Immediately resume
CPR 30:2
for 2 min
Call
Resuscitation
Team
During CPR:
• Correct reversible causes
• Check electrode position and
contact
• Attempt / verify:
IV access
airway and oxygen
• Give uninterrupted
compressions when airway
secure
• Give adrenaline every 3-5 min
• Consider: amiodarone,
atropine,
magnesium
Immediately resume
CPR 30:2
for 2 min
Adult ALS
Algorithm

19. 19
Adult ALS
Algorithm
Open Airway
Look for signs of life
Call
Resuscitation
Team
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)

20. 20
Adult ALS
Algorithm
Open Airway
Look for signs of life
Call
Resuscitation
Team
CPR 30:2
Until defibrillator/monitor attached
Assess
Rhythm
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
CARDİAC ARREST RHYTHMS
1. Ventricular Fibrillation (VF)
2. Pulseless Ventricular Tachicardia (VF)
3. Asystole
4. Pulseless Electrical Activity (PEA)

21. 21
Shockable (VF)
 Irregular waveform
 No recognisable QRS
complexes
 Random frequency and
amplitude
 Uncoordinated electrical activity
 Coarse /fine
 Exclude artifact
 movement
 electrical interference

22. Monomorphic VT
 broad complex rhythm
 rapid rate
 constant QRS morphology
Polymorphic VT
 torsade de pointes
Shockable (VT)

23. Precordial Thump
 Rapid treatment of a
witnessed and monitored
VF/VT cardiac arrest
 Used if defibrillator not
immediately available
?

24. 1st shock
 150 - 200 J biphasic
 360 J monophasic
Assess
Rhythm
Shockable
(VF/Pulseless VT)
1 Shock
150-360 J biphasic
or 360 J monophasic
Immediately resume
CPR 30:2
for 2 min

25. Defibrillation Energies
 Vary with manufacturer
 Check local equipment
 If unsure, deliver 200 J (do not delay shock)

26. Deliver 2nd shock
Deliver 3rd shock
CPR for 2 min
If VF/VT persists
CPR for 2 min
Deliver 4th shock
Adrenalin, 1mg iV
Amiodaron, 300 mg
2nd and subsequent shocks
 Max. (270-360J) biphasic
 360 J monophasic
Minimise delays between CPR
and shocks (< 10 s)

27. After delivery of shock
Continue CPR for another 2 min
 stop CPR only if patient shows signs of life
After 2 min, assess rhythm:
If organised electrical activity, check for signs of life:
 if ROSC start post resuscitation care
 if no ROSC go to non VF/VT algorithm
If asystole, go to non VF/VT algorithm

28. Asystole
Pulseless Electrical
Activity (PEA)
Assess
Rhythm
Non-shockable
(PEA/Asystole)
Immediately resume
CPR 30:2
for 2 min

29.  Absent ventricular (QRS) activity
 Atrial activity (P waves) may persist
 Rarely a straight line trace
 Treat fine VF as asystole
Non-shockable
(Asystole)

30. Asystole
During CPR:
 check leads are attached
 adrenaline 1 mg IV every 3 – 5 min

31.  Clinical features of cardiac arrest
 ECG normally associated with an output
Non-shockable
(PEA)

32. Pulseless Electrical Activity
(PEA)
 Exclude/treat reversible causes
 Adrenaline 1 mg IV every 3-5 min

33. During CPR:
 Correct reversible causes
 Check electrode position and contact
 Attempt / verify:
- IV access
- Airway and oxygen
 Give uninterrupted compressions when airway
secure
 Give adrenaline every 3-5 min
 Consider: amiodarone, magnesium

34. Potential reversible causes:
 Hypoxia
 Hypovolaemia
 Hypo/hyperkalaemia & metabolic disorders
 Hypothermia
 Tension pneumothorax
 Tamponade, cardiac
 Toxins
 Thrombosis (coronary or pulmonary)
4H
4T

35. Airway and Ventilation
 Secure airway:
 tracheal tube
 supraglottic airway device
 e.g. LMA
 Once airway secured, if possible, do not
interrupt chest compressions for ventilation
 Avoid hyperventilation

36. Intravenous Access
 Peripheral versus central veins

37. Intraosseous Access
TRACHEAL ACCESS
x

38. Drugs
 Adrenaline
 Amiodarone
 Magnesium
 Thrombolytics
 Sodium bicarbonate
O2

39. Adrenaline
Actions:
 agonist arterial vasoconstriction
 systemic vascular resistance
 cerebral and coronary blood flow
 agonist  heart rate
 force of contraction
 myocardial O2 demand
(may increase ischaemia)

40. Adrenaline
Indications:
 During cardiac arrest
 VF/VT – give after 3rd shock
 Non VF/VT – give immediately
 Repeat every 3-5 min
 1 mg IV
 Cautious use after ROSC

41. Amiodarone
Actions:
 Lengthens duration of action potential
 Prolongs QT interval
 Mild negative inotrope - may cause
hypotension

42. Amiodarone
Indications:
 Shock refractory VF/VT
 300 mg IV
 Give after 3rd shock
 If unavailable give lidocaine 1.5mg/kg IV

43. Atropine
Actions:
 Blocks effects of vagus nerve
 Increases sinus node automaticity
 Increases atrioventricular conduction

44. Atropine
Indications:
 Peri-arrest
 Symptomatic sinus, atrial or nodal bradycardia
 500 mcg IV increments to 3 mg

45. Magnesium
 Hypomagnesaemia often co-exists with
hypokalaemia
Actions:
 Depresses neurological and myocardial
function
 A physiological calcium blocker

46. Magnesium
Indications:
 VF / VT with hypomagnesaemia
 Torsade de pointes
 Atrial fibrillation
 Digoxin toxicity
 Dose:
 cardiac arrest 2 g (8 mmol) IV bolus
 peri-arrest 2 g (8 mmol) IV over 10 min

47. Thrombolytic Drugs
Actions:
 Dissolves thrombus
 Improves cerebral blood flow
 Has a role in coronary thrombosis and
pulmonary embolism

48. Thrombolytic Drugs
Indications:
 Cardiac arrest caused by suspected pulmonary
embolus
 Can take up to 60 min to have effect
 Dose:
 Tenecteplase 500-600 mcg kg-1 IV over 10 sec
 Alteplase (rt-PA) 10 mg IV over 1-2 min followed
by IV infusion of 90 mg over 2 h

49. Sodium Bicarbonate
Actions:
 Alkalinising agent (increases pH)
 But can:
 increase carbon dioxide load
 inhibit release of oxygen to tissues
 impair myocardial contractility
 cause hypernatraemia

50. Sodium Bicarbonate
Indications:
 Life-threatening hyperkalaemia
 Tricyclic overdose
 Severe metabolic acidosis (pH < 7.1)
 Dose:
 50 ml 8.4% sodium bicarbonate IV

51. Summary
• ALS algorhythm provides a standardised approach to
cardiac arrest treatment
• Shockable rhythms (VF/pulseless VT)
• Non-shockable rhythms (Asystole, PEA)
• Reversible reasons of cardiac arrest (4H,4T)

52. LAST WORDS
Drugs role in cardiac arrest becomes after
effective chest compression, effective ventilation
with high oxygen concentration and defibrillation

53. 53
THANK
YOU…
Dr. Sule AKIN

54. 54
THANK
YOU…
Dr. Sule AKIN