Cardiopulmonary resuscitation (cpr)

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1. C ardio p ulmonary R esuscitation (CPR) BALQEES MAJALI

2. Definition Cardiopulmonary Resuscitation – is an emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest

3. Purpose Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest. Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation—involving early defibrillation—and appropriate implementation of post–cardiac arrest care lead to improved survival and neurologic outcomes

4. Indications CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options . Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following: - Ventricular fibrillation (VF) - Pulseless ventricular tachycardia (VT) - Pulseless electrical activity (PEA) - Asystole - Pulseless bradycardia

5. Contraindications The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest . A relative contraindication to performing CPR is if a clinician justifiably feels that the intervention would be medically futile .

6. The American College of Surgeons, the American College of Emergency Physicians, the National Association of EMS Physicians, and the American Academy of Pediatrics have issued guidelines on the withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. 1. Withholding resuscitation should be considered in cases of penetrating or blunt trauma victims who will obviously not survive. 2. Standard resuscitation should be initiated in arrested patients who have not experienced a traumatic injury. 3. Victims of lighting strike or drowning with significant hypothermia should be resuscitated. 4. Children who showed signs of life before traumatic CPR should be taken immediately to the emergency room; CPR should be performed, the airway should be managed, and intravenous or intraosseous lines should be placed en route. 5. In cases in which the trauma was not witnessed, it may be assumed that a longer period of hypoxia might have occurred and limiting CPR to 30 minutes or less may be considered. 6. When the circumstances or timing of the traumatic event are in doubt, resuscitation can be initiated and continued until arrival at the hospital. 7. Terminating resuscitation in children should be included in state protocols.

7. Cardiac arrest

8. Phases of CPR Phase Definition Steps Phase I BLS Basic Life Support : without the use of special equipment. A : Airway B: Breathing C: Circulation Phase II ALS Advanced Life Support : with use of special equipment . - Drug - ECG Defibrillation Invasive airway procedures Phase III Prolonged support Post resuscitation care

9. Early recognition * Unresponsiveness : -Check the victim for a response. - Shake shoulders gently. -Ask “Are you all right ?” * No breathing or no normal breathing ( i.e , only gasping) * No pulse felt within 10 seconds.

10. Basic life support

11. BLS – CPR In its full, standard form, cardiopulmonary resuscitation (CPR) comprises 3 steps: chest compressions, airway, and breathing (CAB), to be performed in that order in accordance with the 2010 American Heart Association (AHA) guidelines. For an unconscious adult, CPR is initiated using 30 chest compressions . Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing. Before beginning ventilations, rule out airway obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s airway. CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia .

12. Chest compressions The heel of one hand is placed on the patient’s sternum , and the other hand is placed on top of the first, fingers interlaced. The elbows are extended and the provider leans directly over the patient (see the image below). The provider presses down, compressing the chest at least 2 in . The chest is released and allowed to recoil completely (see the video below).

13. Airway basic techniques for airway patency

14. Head tilt chin lift

15. Ventilation If the patient is not breathing, 2 ventilations are given via the provider’s mouth or a bag-valve-mask (BVM ). The mouth-to-mouth technique is performed as follows (see the video below ) : - The nostrils of the patient are pinched closed to assist with an airtight seal - The provider puts his mouth completely over the patient’s mouth - The provider gives a breath for approximately 1 second with enough force to make the patient’s chest rise

16. Effective mouth-to-mouth ventilation is determined by : * O bservation of chest rise during each exhalation . Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. 2 such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of CPR ). When breaths are completed, compressions are restarted. If available, a barrier device (pocket mask or face shield) should be used .

17. More commonly, health care providers use a BVM, which forces air into the lungs when the bag is squeezed. Several adjunct devices may be used with a BVM, including oropharyngeal and nasopharyngeal airways . The BVM or invasive airway technique is performed as follows: - The provider ensures a tight seal between the mask and the patient’s face. - The bag is squeezed with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs.

18. Assessment of restoration of breathing and circulation * Contraction of pupil * Improved color of the skin * Free movement of the chest wall * Swallowing attempts * Struggling movements S igns of restored ventilation and circulation include: • Struggling movements • Improved color • Return of or strong pulse • Return of systemic blood pressure

19. Complications Performing chest compressions may result in the fracturing of ribs or the sternum , though the incidence of such fractures is widely considered to be low. Artificial respiration using noninvasive ventilation methods ( eg , mouth-to-mouth, bag-valve-mask [BVM]) can often result in gastric insufflation . This can lead to vomiting , which can further lead to airway compromise or aspiration. The problem is eliminated by inserting an invasive airway, which prevents air from entering the esophagus .

20. When to terminate ‘ bls ’ • Pulse and respiration returns • Emergency medical help arrives • Physician declared patient is deceased • In a non health setting ,another indication to stop BLS would be that the rescuer was exhausted and physically unable to continue to perform BLS

21. Advanced life support

22. Recognition of arrhythmia

23. Shockable Unshockable VT Monophormic or biphormic VF Fine or coarse Asystole PEA : Pulseless electrical activity Electromechanical disociation

24. Defibrillation Defibrillation consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called a defibrillator. Biphasic : 120 – 200 J Monophasic : 360 J Failure of a single adequate shock to restore the pulse should be followed by continued CPR and 2 nd shock after 5 cycles of CPR If cardiac arrest still persist : intubation and IV access

25. Shockable -If nonshockable , see Nonshockable Rhythm (below). -If shockable , see Shockable Rhythm (above) and administer amiodarone after second defibrillation attempt. -Rotate chest compressors. -Identify and treat reversible causes.

26. Nonshockable

27. Advanced airway - Endotracheal tube (ETT) or supraglottic airway (SGA) - Waveform capnography to confirm and monitor ET tube placement - Ventilation every 6 seconds asynchronous with compressions - Stop CPR for no longer than 10 seconds for the placement of an advanced airway

28. Medications

29. Epinephrine - Given as a vasopressor α-1 effect (not as an inotrope). - Dose: 1 mg (0.01 mg/kg) IV every 4 minutes (alternating cycles) while continuing CPR . - Given: 1) Immediately in non- shockable rhythm (non-VT/VF). 2) In VF or VT given after the 2 nd shock . -Repeated: in alternate cycles (every 4 minutes).

30. amoidarone - Dose : 300 mg IV bolus (5 mg/kg). - Given: in shockable rhythm after the 3rd shock. - If unavailable give lidocaine 100 mg IV (1-1.5 mg/kg).

31. Thrombolytics - Fibrinolytic therapy is considered when cardiac arrest is caused by proven or suspected acute pulmonary embolism. • If a fibrinolytic drug is used in these circumstances consider performing CPR for at least 60-90 minutes before termination of resuscitation attempts. • Eg : Alteplase , tenecteplase (old generation: steptokinase )

32. The 2015 AHA guidelines offer the following recommendations for the administration of drugs during cardiac arrest Amiodarone may be considered for or pVT that is unresponsive to CPR, defibrillation, and a vasopressor; lidocaine may be considered as an alternative (class IIb ) Routine use of magnesium for VF/ pVT is not recommended in adult patients (class III) Inadequate evidence exists to support routine use of lidocaine ; however, the initiation or continuation of lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/ pVT (class IIb ) Inadequate evidence exists to support the routine use of a beta-blocker after cardiac arrest; however, the initiation or continuation of a beta-blocker may be considered after hospitalization from cardiac arrest due to VF/ pVT (class IIb ) Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic benefit (class IIb ) There is insufficient evidence for or against the routine initiation or continuation of other antiarrhythmic medications after ROSC from cardiac arrest Standard-dose epinephrine (1 mg every 3-5 min) may be reasonable for patients in cardiac arrest (class IIb ); high-dose epinephrine is not recommended for routine use in cardiac arrest (class III) Vasopressin has been removed from the Adult Cardiac Arrest Algorithm and offers no advantage in combination with epinephrine or as a substitute for standard-dose epinephrine (class IIb ) It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due to an initial nonshockable rhythm (class IIb )

33. Summary

34. Untrained Lay Responders Trained Lay Responders Healthcare Professionals Step 1 Ensure scene safety Step 2 Check for response Step 3 Responder should shout for nearby help and phone or have another bystander phone 9-1-1; the phone should remain on speaker for receiving further instructions from the dispatcher. Responder should shout for nearby help and activate the emergency response system (9-1-1, emergency response). Ensure that the phone remains on speaker, if at all possible. Responder should shout for nearby help. The resuscitation team can be activated before or after checking breathing and pulse. Step 4 Follow dispatcher’s instructions. Check for no breathing or only gasping; if there is none, begin CPR with chest compressions. A check for no breathing or only gasping and a check of pulse ideally should be done simultaneously. Activation and retrieval of the AED/emergency equipment by either the lone healthcare provider or by a second person must occur immediately after the check of breathing and pulse identifies cardiac arrest. Step 5 As instructed by dispatcher to check for no breathing or only gasping. Answer dispatcher’s questions and follow subsequent instructions. CPR begins immediately, and the AED/defibrillator is used if available. Step 6 Dispatcher’s instructions are followed. Send another person for an AED, if one is available. With arrival of a second responder, two-person CPR is provided and AED/defibrillator is used.

35. Post–Cardiac Arrest Care - T herapeutic hypothermia - Optimization of hemodynamics and gas exchange - Immediate coronary reperfusion, when indicated for restoration of coronary blood flow, with percutaneous coronary intervention (PCI) -Glycemic control -Neurological diagnosis, management, and prognostication

36. Organ donation Guidelines recommend that all patients who are resuscitated from cardiac arrest but subsequently progress to death or brain death be evaluated for organ donation . In addition, the AHA guidelines recommend considering kidney or liver donation in patients who do not have ROSC after resuscitation efforts and would otherwise have termination of efforts.

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