Cpr

CARDIO PULMONARY RESUSCITATION

1. CARDIO PULMONARY RESUSCITATION(CPR) K.KRISHNA LOHITHA 1 ST PG STUDENT

2. CONTENTS RESUSCITATION CARDIOULMONARY RESUSCITATION BACKGROUND PATHOPHYSIOLOGY OF CPR STEPS IN CPR BASIC LIFE SUPPORT CRITICAL CONCEPTS ADULT CHAIN OF SURVIVAL RESCUE BREATHING CHOKING CPR WITH ADVANCED AIRWAY CPR IN MAXILLOFACIAL TRAUMA

3. RESUSCITATION: Resuscitation is the process of correcting physiological disorders( such as lack of breathing or heart beat) in an acutely unwell patient.

4. cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and / or whose heart has stopped( cardiac arrest) CPR is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in a cardiac arrest

5. BACKGROUND: The American Heart Association(AHA) estimates that about 3,50,000 people die of cardyiac arrest each year Approximately 4280 out of evary1 lakh people die every year from sudden cardiac arrest (SCA) in India alone About 74-80% of all sudden cardiac arrests happen at home; so being trained in CPR can mean the difference between life and death for a member of a family Approximately 10% of SCA events occur among people less than 40 years of age Effective btstander CPR, provided immediately after sudden cardiac arrest, can double the victims chance of survival The survival rates for performing basic life support alone are reported between 0% and 6% CPR cannot ‘restart’ the heart, but it can keep blood and oxygen moving through the victim’s body until medical help arrives

6. PATHOPHYSIOLOGY OF CPR: The goal of CPR was to compress and release the ventricles between the sternum and thoracic spine CARDIAC PUMP MECHANISM/ TRADITIONAL THEORY: Depress the sternum 1.5 to 2 inches - Squeezes the heart b/w sternum and spine - Increase in ventricular pressure - Mitral and tricuspid valve closure

7. Opening of semilunar valves Blood expelled into arteries Anterograde left and right heart emptying (artificial systole) During decompression Reduces the ventricular volume Diastole/relaxation Mitral, tricuspid valve opening Ventricular filling from lungs and body

8. THORACIC PUMP MECHANISM: discovered in 1980’s by Criley’s clinical observation of cough CPR mechanism: when thoracic pump is operative, during chest compressions large antero posterior diameter of chest generalised increase in intrathoracic pressure both mitral valve and aortic valve open simultaneously causes increase in pressure gradient in all heart chambers left heart acts as a conduit(collective pulmonary vasculature constitutes main pumping chamber)

9. NEW STUDIES SHOW THAT: Both mechanisms function simultaneously during CPR( hybrid pump) In adults, hybrid pump is thoracic pump In children, hybrid pump is cardiac pump differences in compression force, location, force, chest wall characteristics, and volume status account for operating ,mechanisms of CPR

10. STEPS IN CPR BASIC LIFE SUPPORT(BLS) ADVANCED LIFE SUPPORT( ALS) PROLONGED LIFE SUPPORT(PLS)

11. BASIC LIFE SUPPORT( BLS) Basic life support is the provision and maintainence of an airway , and the support of ventilation and circulation without the use of any equipment other than simple airway devices or protective shields. STEP A – AIRWAY CONTROL STEP B – BREATHING SUPPORT STEP C – CIRCULATION SUPPORT

12. CHANGE IN SEQUENCE: C-A-B, not A-B-C the 2010 AHA guidelines for CPR and ECC recommend a change in BLS sequence of steps from A- B- C to C- A- B for adults, infants and children. This change is likely to improve survival in the A- B- C ( Airway- Breathing- Chest compressions sequence), chest compressions were often delayed while the rescuer opened the airway to give mouth to mouth breathes, retrieved a barrier device or gathered and assembles ventilation equipment by changing the sequence to C-A-B ( Chest compressions- Airway- Breathing),rescuers can start chest compressions sooner, and the delay in giving breaths should be minimal

13. ADVANCED LIFE SUPPORT ( ALS) - STEP D – DRUGS AND FLUIDS EPINEPHRINE BLOOD VOL REPLACEMENT - STEP E – ELECTROCARDIOGRAPHY - STEP F – FIBRILLATION TREATMENT - open chest - closed chest defibrillation

14. Reason for basic life support Speed of initiation may be more important than the absolute quality BLS should be started unresponsive not breathing ( apnoeic ) or have an absent major pulse, or both.

15. ON FINDING A COLLAPSED PATIENT S hout for help A pproach with care F ree from danger E valuate ABC

16. Causesof airway obstruction Hypopharyngeal obstruction Presence of foreign matter – vomitus /blood Laryngospasm Lower airway obstruction - spasm - bronchial secretions - mucosal edema - inhaled gastric contents - foreign matter

17. AIRWAY OBSTRUCTION Complete partial Complete Asphyxia, apnea Cardiac arrest (within 5-10 min

18. Partial: Hypoxic brain damage Cerebral, pulmonary edema Exhaustion Secondary apnea Cardiac arrest

19. Recognition of airway obstruction Hear or feel’ air flow Complete – nil Partial – Noisy (Crowing, Gurgling, Wheezing)

20. CHAIN OF SURVIVAL: The term chain of survival provides a useful metaphor for the elements of the ECC systems concept. The 5 links in the Adult Chain of Survival are Immediate recognition of cardiac arrest and activation of the emergency response system Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions Rapid defibrillation effective advanced life support Integrated post cardiac arrest care

21. MAJOR GUIDELINE CHANGES The following changes have recently been made in the 2010 BLS guidelines Refinements have been made to recommondations for immediate recognition and activation of emergency response system based on signs of unresponsiveness, as well as initiation with no breathing or normal breathing(gasping) Rescuers must place their hands in the center of the chest, in the lower half of sternum, rather than to spend more time using ‘rib margin’ method “ look,listen , feel” for breathing has been removed from the algorithm Use of cricoid pressure in cardiac arrest is not recommended Emphasis on high quality CPR Change in sequence to C- A- B, circulation is more important than airway

22. Critical concepts: high quality cpr improves persons chance of survival: Start compressions within 10 seconds of recognition of cardiacarrest Push hard, push fast: compressions at a rate of 100-120 minute - atleast 5cm / 2 inches for adults - at least 1/3 rd depth of the chest, about 5cm for children - atleast 1/3 rdthe depth of the chest, about 4 cm for infants Allow complete chest recoil after each compression Minimise interruptions in compressions(interruptions should be limitedfor < 10 secs ) Give effective breaths that make the chest rise Avoid excessive ventilation

23. INITIAL BLS STEPS FOR ADULTS: STEP ACTION 1 Assess the victim for a response and look for a normal or abnormal breathing. If there is no response and no breathing or no normal breathing ( i.e , only gasping), shout for help 2 if you are alone, activate the emergency response system and get an AED (or defibrillation) if available and return to the victim 3 check the victim’s pulse ( take atleast 5 but no more than 10 seconds) 4 If you definitely do not feel a pulse within 10 seconds, perform 5 cycles pf compressions and breaths ( 30: 2 ratio), starting with compressions( C-A-B) sequences

24. STEP 1: ASSESSMENT AND SCENE SAFETY the first rescuer who arrives at the side of the victim must quickly be sure that the scene is safe. The rescuer should then check the victim foe a response: STEP ACTION 1 Make sure the scene is safe for you and the victim. You do not want to become a victim for yourself 2 Tap the victim’s shoulder and shout, “ are you alright?” 3 Check to see if the victim is breathing. If a victim is not breathing or not breathing normally( ie , only gasping), you must activate the emergency response system.

25. CAUTION: agonal gasps are not normal breathing. They may be present in the first minutes after sudden cardiac arrest A person who gasps usually looks like he is drawing air in very quickly . The mouth may be open and the jaw, head or neck may move with gasps. Gasps may appear forceful or weak, and some time may pass between gasps because they usually happen at a slow rate The gasp may sound like a snort, snore, or groan. Gasping is a sign of cardiac arrest in someone who doesn’t respond

26. STEP 2: ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND GET AN AED if you are alone and find an unresponsive victim not breathing, shout for help. If no one responds, activate the emergency response system , get an AED(or defibrillator) if available, and then return to the victim to check the pulse and begin CPR(C-A-B) sequence

27. STEP 3: PULSE CHECK Healthcare providers should take no more than 10 second to check for a pulse Locating the carotid artery pulse Follow these steps to locate , carotid artery pulse: STEP ACTION 1 Locate the trachea, using 2 or 3 fingers 2 Slide these 2 or 3 fingers into the groove between the trachea and muscles at the side of the neck, where you can feel the carotid pulse 3 Feel for a pulse for atleast 5 but no more than 10 secs . If u do not definitely feel a pulse, begin CPR, starting with chest compressions( C-A-B sequence)

28. STEP 4: BEGIN CYCLES OF 30 CHEST COMPRESSIONS AND 2 BREATHS(CPR) The lone rescuer should use the compression- ventilation ratio of 30 compressions to 2 breaths when giving CPR to victims of any age

29. STEP ACTION 1 Position yourself at the victim’s side 2 Make sure victim is lying faceup on a firm, flat surface.if the victim is lying facedown, carefully roll him face up. 3 Put the heel of one hand on the center of the victim’s chest on the lower half of the breast bone 4 Put the heel of the other hand on top of the first hand 5 Straighten your arms and position your shoulders directly over your hands 6 Push hard and fast press down at least 5cm(2 inches) with each compression. For each chest compression, make sure you push straight down on the victim’s breastbone deliver compressions in a smooth fashion at a rate of atleast 100/min 7 at the end of each compression, make sure you allow the chest to recoil completely. Chest recoil allows blood to flow into the heart and is necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces blood flow created by chest compressions. Chest compressions and relaxation times should be approximately equal 8 Minimize interruptions

30. ALTERNATIVE TECHNIQUE FOR CHEST COMPRESSIONS: If one has difficulty pushing deeply during compressions, put one hand on the breastbone to push on the chest. Grasp the wrist of that hand to support the first hand as it pushes the chest. This technique is helpful for rescuers with arthritis

31. OPENING THE AIRWAY FOR BREATHS Two methods: head tilt- chin lift jaw thrust Use a jaw thrust only if head or neck injury is suspected Switch to head tilt – chin lift if the jaw thrust doesnot open the airway STEP ACTION 1 Place one hand on victims forehead and push with your palm to tilt the head back 2 Place the fingers of the other hand under the bony part of lower jaw near the chin 3 Lift the jaw to bring chin forward

32. Jaw thrust: if the victim has neck or spine injury, jaw thrust should be performed by 2 rescuers. STEP ACTION 1 place one hand on each side of the victim’s head,resting your elbows on the surface on which victim’s lying 2 place your fingers under the angles of the victims lower jaw and lift with both hands, displacing the jaw forward 3 If the lips close, push the lower lip with your thumb to open the lips

33. Adult mouth –to-barrier- device breathing: standard precautions include use of barrier devices, such as face mask or a bag mask device,when giving breaths in 1- rescuer CPR , the person performing CPR uses the mouth to mask breaths at a compression ventilation ratio of 30:2 i.e , after giving 15 compressions, ventilation is given by the lone rescuer from the victim’s side In 2- rescuer CPR, rescuer at the victim’s side, gives the compressions in the same ratio, and the rescuer at the head side gives ventilation Switch duties with the second rescuer every 5 cycles or about 2 minutes, taking less than 5 seconds to switch

34. DIRECT MOUTH TO MOUTH / BAG VLVE MASK MOUTH TO NOSE BREATHING

35. Once the AED team arrives, place it at victims side who will operate it When ventricular fibrillation is present, heart muscle quiver and donot contract together to pump blood A defibrillator delivers an electric shock to stop quivering of heart fibres This allows the muscle fibres of the heart to reset so that they begin to contract at the same time Once the organised rythm occurs, the heart muscle begins to contract effectively and begin to generate a pulse(Return of spontaneous circulation)

36. 4 universal steps for operating AED first 2 steps should be performed within 30 seconds after AED arrives

37. Modification of cpr in children Use the heel of one hand for chest compressions Press the sternum down 1 to 1.5 inches Give 1 full breath followed by 5 chest compressions If you are alone with the child give one minute of CPR before calling for help

38. THE PEDIATRIC BLS ALGORITHM

39. CHOKING foreign bodies may cause range of mild to severe airway obstruction Mild airway obstruction Severe airway obstruction Signs: good air exchange Can cough forcefully May wheeze between coughs Signs: Poor or no air exchange Weak,ineffective cough High pitched noise while inhaling or no noise at all Increased respiratory difficulty Cyanosis Unable to seak Clutching the neck with thumb and fingers Rescuer actions Rescuer actions Good air exchange- encourage spontaneoys coughing and breathing efforts If mild airway obstruction ersists , activate Emergenc response system ask victim if he/ she is choking. If the victimnods yes and cannot talk, you must try to telieve the obstruction

40. choking Heimlich maneuver : abdominal thrusts should be given make a fist with one hand place the thumb of your fist against thevictims abdomen. In the midline, slightly above the patients navel and below the breastbone grasp your fist with the other hand and press your fist in to abdomen with a quick, foreceful upward thrust Complications : - Gastric rupture - Injury to the liver - Danger of provoking regurgitation

41. Choking in infants< 1 year

42. CHOKING IN CONSCIOUS ADULT AND CHILDREN( 1- 8 YRS OF AGE

43. HEMILICH MANEUR IN PREGNANT PATIENTS

44. Rescue breathing When the adult ,child or infant has a pulse but is not breathing effectively, rescuers should give breaths without chest comprssions It is done in respiratory arrest,to prevent hypoxic injury tobrain and other organs give each breath 1 sec each breath should result in visible chest rise check the pulse for every 2 minutes Rescue breathing for adults Rescue breathing for infants and children Give 1 breath every 5-6 seconds(about 10-12 breaths per minute Give 1 breath every 3- 5 seconds( about 12- 20 breaths per minute)

45. CPR WITH AN ADVANCED AIRWAY Ventilation technique Compression to breaths ( adult) Compression to breaths(child and infant) No advanced airway (mouth to mouth, mouth to mask, bag mask) 30 compressions to 2 breaths Compression rateof atleast 100/min 15 comressions to 2 breaths Compression rate of atleast 100min Advanced airway ( endotracheal intubation, laryngeal mask airway, supraglottic ) Compression rate of atleast 100/min without pauses for breaths 1 breath every 6—8 secs (8-10 breaths per minute Compression rate of atleast 100/min without pauses for breaths 1 breath every 6—8 secs (8-10 breaths per minute

46. CPR INMAXILLOFACIAL TRAUMA Severe injuries to the maxillofacial region can complicate early management of atrauma patient owing to its proximity to brain , cervical spine and airway The usual A-B- C are often supplemental with other methods in maxilla facial injuries Situation is complicated by presence of broken teeth, dentures, foreign bodies, avulsed tissues, multiple mandibular fractures, massive edema of glottis which cause direct threat to airway Alcohal , drugs and pooled blood also trigger nausea and vomiting If patient has multiple fractures, the displacement of maxilla or mandible decreases airway patency

47. MANAGEMENT OF AIRWAY Airway should be tailored according to a particular situation in trauma depending on the typr of injury and magnitude of injury Look listen feel helps to figure out airway obstruction and anticipated airway complications High velocity trauma involving mandible, swallowing mechanism is altered due to pain and ineffective protective reflex modulation results in difficulty to keep airway clear Most common cause of airway obstruction is falling back of tongue To prevent airway blockage and to initiate CPR , tongue should be pulled out with a safety pin , blood should be finger sweeped , check for any obstructions like foreign body, vomitus, bleeding should be checked and airway adjuncts to be used to provide airway

48. Other devices can be used are: Indications for Suctioning A patient needs to be suctioned immediately when a gurgling sound is heard with artificial ventilation Remove blood, other liquids, and food particles from the airway

49. Types of suction devices : Mounted suction devices: fixed on board the ambulance portable suction device: electric battery powered oxygen powered hand powered

50. Special considerations Secretions that cannot be removed, log roll and finger sweep Patient producing frothy secretions as rapidly as suctioning can remove them Suction 15 seconds Positive pressure with supplemental oxygen for 2 minutes then suction again and repeat the process Residual air removed from lungs, monitor pulse and heart rate

51. Advanced airway maintenance Oropharyngeal airways Nasopharyngeal airways Esophageal tracheal combitube Laryngeal mask airway Endotracheal intubation Laryngoscoe Needle cricothyrotomy Retrograde intubation tracheostomy

52. OROPHARYNGEAL AIRWAY Used to maintain a patent airway only on deeply unresponsive patients No gag reflex Designed to allow suctioning while in place Must have the proper size If patient becomes responsive and starts to fight the OPA, remove it ...

53. Select the proper size (corner of the mouth to tip of the ear) Open the patient’s mouth Insert the OPA with the tip facing the roof of the mouth Advance while rotating 180° Continue until flange rests on the teeth Infants and children insertion

54. NASOPHARYNGEAL AIRWAY Used on patients who are unable to tolerate an OPA or is not fully responsive Do not use on suspected basilar skull fracture Still need to maintain head-tilt chin lift or jaw thrust when inserted Must select the proper size Made to go into right nare or nostril

55. INSERTING NASOPHARYNGEAL AIRWAY Select the proper size in length and diameter Lubricate Insert into right nostril with bevel always toward the septum Continue inserting until flange rests against the nostril Insertion into left nostril

56. CRICOID PRESSURE

57. ESOPHAGEAL TRACHEAL COMBITUBE

58. COMBITUBE IN THE TRACHEAL POSITION

59. LARYNGEAL MASK AIRWAY wide bore tube, -connector at its proximal end, elliptical cuff at its distal end. When inflated, the elliptical cuff forms a low pressure seal around the entrance into the larynx. variety of pediatric and adult sizes and successful insertion requires appropriate size selection.  Used When endotracheal intubation is not desired During emergency situations in which mask ventilation is not possible or intubation and/or ventilation fails

60. LARYNGOSCOPE Consists of a handle containing batteries and interchangeable blades of various shapes and sizes containing a bulb or fiberoptic light. The laryngoscope is used to lift the tongue, mandible, and epiglottis and visualize the glottis opening, both for removing foreign bodies and inserting endotracheal tubes. Blades commonly are available in 5 sizes, from 0 for infants to 4 for large adults

61. ENDOTRACHEAL TUBE Made from poly vinyl chloride, with a radiopaque line from top to bottom, standard size connectors Tubes come in a number of sizes, usually designated in millimeters of internal diameter.  The choice of ETT size is always a compromise between choosing the largest size to maximize flow and the smallest size to minimize airway trauma Once a view of the larynx is obtained via laryngoscopy, the ETT is introduced with the dominant hand through the right side of the mouth.  Directly observe the tip of the tube passing into the larynx, between the abducted cords.  Pass the tube 1 cm through the cords.

62. COMPLICATIONS OF INTUBATION Trauma- tooth damage - lip/tongue/mucosal laceration - sore throat - dislocated mandible - Mucosal inflammation and ulceration. Tube malfunction.  Malpositioning of the endotracheal tube can result in esophageal intubation and unintentional extubation .

63. RETROGRADE TRANSCRICOID INTUBATION INDICATIONS: VISUALISATION OF VOCAL CORDS DIFFICULT STABLE,CO-OPERATIVE COMATOSE PATIENTS IN WHOM ACCESS TO POST.OROPHARYNX IS EASY. SEVERE MAXILOFACIAL TRAUMA . CONTRAINDICATIONS PATIENTS REQUIRING IMMEDIATE INTUBATION AS THE PROCEDURE MAY LAST 3-5 MINUTES.

64. 1 . PLASTIC CATHETER IS FED THROUGH THE NEEDLE AND INTO THE PHARYNX . ENDOTRACHEAL TUBE IS BEING PASSED DOWN THE CATHETER GUIDE

65. “ TO DO NO HARM “ SURGICAL AIRWAY TECHNIQUES: cricothyrotomy : needle surgical Tracheostomy: it is an elective procedure once patient is stabilised by cricothyrotomy

66. BREATHING SUPPORT Emergency artificial ventilation Exhaled air Air oxygen

67. Mouth to Mask Direct mouth to mouth /mouth to nose ventilation

68. Automatic oxygen powered ventilators For prolonged artificial ventilation of the intubated/ tracheomatized patient

69. conclusion The development of modern CPR has given every person the ability to challenge death anywhere. Resuscitation medicine and its science, reanimatology , if pursued with historic perspective, wisdom and compassion, can become a positive force in human evolution.

70. THANK YOU