Cpr for medical undergraduates

Cardiopulmonary Resuscitation Lecture for Medical Undergraduate Students

1. BY Professor of Internal Medicine Zagazig University 2015 DR MONKEZ M YOUSIF CPR

2. OBJECTIVES Recognise cardiac arrest. How to perform chest compression and rescue breathing. Differentiate between shockable and non- shockable rhythm. Understand Principal Drugs (Atropine–Adrenaline- Amiodarone ). Case presentations.

3. CASE 1 You find a 72-year-old man lying unresponsive in a restroom of a local airport. He is alone, and you don't know how long he has been unconscious. You speak loudly, trying to wake him up, and you shake him; he continues to be unresponsive. What should be your sequential response in this situation?

4. CASE 2 A 56-year-old woman is found pulseless in her room at a local hospital. The nurse calls "code blue," and you are the first doctor responding. The nurse has started CPR, and the patient has a patent I.V. line. After 2 minutes, the patient is still pulseless. A defibrillator has now been brought to the room. What is the best intervention to take next in the care of this patient?

5. What is CPR Cardiopulmonary Resuscitation (CPR) consists of chest compression and mouth-to-mouth respiration . CPR allows oxygenated blood to circulate to vital organs such as the brain and heart. CPR can keep a person alive until more advanced procedures (such as defibrillation - an electric shock to the chest) can treat the cardiac arrest.

6. Cardio Pulmonary Resuscitation BLS – basic life support. ACLS – advanced cardiac life support .

7. Causes of Cardiac Arrest

8. 8 Causes of cardiac arrest Cardiac Extracardiac Primary lesion of cardiac muscle leading to the progressive decline of contractility, conductivity disorders, mechanical factors All cases accompanied with hypoxia

9. 9 Causes of circulation arrest Cardiac Ischemic heart disease Arrhythmias of different origin and character Electrolytic disorders Valvular disease Cardiac tamponade Pulmonary artery thromboembolism Ruptured aneurysm of aorta Hypertrophic obstructive CM Extracardiac Airway obstruction Acute respiratory failure Shock Embolisms of different origin Drug overdose Electrocution Poisoning

10. Cardiac Arrest Brain damage begins 4 - 6 minutes after cardiac arrest Brain damage becomes irreversible in 8 - 10 minutes

11. Chain of Survival for OHCA Andrew H. Travers et al. Circulation. 2010;122:S676-S684 Immediate recognition and activation Early CPR Rapid defibrillation Effective advanced life support Integrated post-cardiac arrest care

12. Basic life support (BLS) Implies that no equipment is employed other than a protective device. Consists of chest compression mouth-to-mouth respiration and

13. Steps of CPR (3 Cs) Check Scene Injuries Consciousness Call EMS Care C-A-B-D

14. CHECK Establish Unresponsiveness Tap victim on shoulder and ask “Are you OK?”

15. Check Pulse Check carotid pulse Check for 5-10 seconds If you are not sure if the victim has a pulse, start CPR Unnecessary CPR is less harmful than not performing CPR that is needed

16. Check for Breathing Look, Listen and Feel for Breathing (for at least 5 seconds and not more than 10)

17. CALL Activate EMS If victim is unresponsive, activate EMS immediately Instruct a bystander to call If you are alone, you must activate EMS before performing any other step If unresponsive & victim is breathing, place in recovery position Patient unresponsive with no breathing Start CPR

18. C-A-B-D C ARE

19. CARE Hand Placement for Chest C ompression Place the heel of one hand in the center of the victim’s bare chest between the nipples Put the heel of your other hand on the top of your first hand Straighten your arms and position your shoulders directly over your hands

20. Put hand(s) in correct position for chest compressions

21. Chest C ompressions Push hard and fast—rate of 100 per min Press down 1 ½- 2 inches with each compression For each compression press straight down At the end of the compression allow the chest to recoil or re-expand completely

22. Opening the A irway Head tilt – Chin lift Remove any visible objects from mouth If victim has possible spinal injury, use jaw thrus t without a head tilt

23. Jaw-thrust maneuver Used on patients with a suspected  spinal injury  and is used on a  supine  patient. Prevents the  tongue  from obstructing  the upper airways.

24. Give 2 B reaths Pinch the nose closed with your thumb and index finger Take a regular breath and seal your lips around the victim’s mouth, creating an airtight seal Slowly breath air into victim’s mouth until victim’s chest rises Remove your mouth to let the air come out Repeat one more breath

25. Recheck Circulation Cycle=30 compressions and 2 breaths Recheck pulse after 5 cycles

26. During CPR Push hard & fast (100-120/min ) Compressions to relaxation ration 50:50 Ensure full chest recoil

27. During CPR Avoid hyperventilation Secure airway & confirm placement Rotate compressors every 2min with rhythm checks After an advanced airway is placed, rescuers no longer deliver “cycles” of CPR. Give continuous chest compressions without pause for breaths. Give 6-8 breaths/min. check every 2min.

28. CPR Pushing on the Chest Sometimes you may hear a cracking sound . The sound is caused by cartilage or ribs cracking . Even if this occurs the damage is not serious. The risk of delaying CPR or not doing CPR is far greater than the risk of a broken rib.

29. BLS Dos and Don’ts of Adult High-Quality CPR Rescuers Should Not Rescuers Should Compress at a rate slower than 100/min or faster than 120/min Perform chest compressions at a rate of 100-120/min Compress to a depth of less than 2 inches (5 cm) or greater than 2.4 inches (6 cm Compress to a depth of at least 2 inches (5 cm) Lean on the chest between compressions Allow full recoil after each compression Interrupt compressions for greater than 10 seconds Minimize pauses in compressions Provide excessive ventilation ( ie , too many breaths or breaths with excessive force) Ventilate adequately (2 breaths after 30 compressions, each breath delivered over 1 second, each causing chest rise)

30. When to Stop CPR Victim is revived Replaced by another equally trained person or physician assumes responsibility Exhaustion Scene becomes unsafe Physician direction to stop

31. Simplified Adult BLS Algorithm. Andrew H. Travers et al. Circulation. 2010;122:S676-S684

32. In Hospital Resuscitation In hospital resuscitation differs in ; - location (monitored), - training of the first responder, - number of responders, - equipment available and - resuscitation team.

33. Physiology: Acute changes in: Threatened Airway All respiratory arrests Respiratory rate <5 / min Respiratory rate >36 / min Breathing Pulse rate <40 /min Pulse rate >140 /min Systolic BP <90 mmHg Circulation Sudden  in level of consciousness Decrease in GCS >2points Repeated or prolonged seizures Neurology Any patient - causing concern who does not fit the above criteria Other Predictors of cardiac arrest

34. Sequence for collapsed patient in a hospital Ensure personal safety: Your personal safety and that of resuscitation team members is the first priority. Check that the patient’s surroundings are safe. Put on gloves as soon as possible, eye protection and face mask may be necessary.

35. Check the patient for a response: If you see a patient collapse or apparently unconscious, -shout for help -assess response by gently shaking the victim and ask loudly, "Are you OK?“ If he has a pulse or signs of life : ABCDE If he has no pulse or signs of life: call the resuscitation team and start CPR immediately If he is not breathing and has a pulse ( respiratory arrest): keep ventilation and check for a circulation / 10 breath.

36. If the patient has a monitored and witnessed cardiac arrest: Confirm cardiac arrest and shout for help. Give precordial thump if the rhythm VF / VT or defibrillator is not to hand immediately , and start CPR. Success  if done  10 sec of VF

37. Deliver a sharp impact to the lower half of the sternum from a height 20 cm, using the ulnar edge of a tightly clenched fist.

38. ABCDE

39. Airway (A): Airway obstruction  hypoxia, and risk damage to brain, kidneys, heart, cardiac arrest and even death. Signs of obstruction : stridor, wheeze, gurgling, snoring.. TTT: Airway clearance Airway opening maneuvers, suction, Insertion of an oropharyngeal or nasopharyngeal airway Tracheal intubation. Use high concentration oxygen with sufficient flow (>10 L / min.).

40. Oropharyngeal  Laryngeal mask  Tracheal tubes Nasopharyngeal airway

41. Breathing (B): Diagnose and treat immediately life- threatening condition, - acute severe asthma, - pulmonary edema, - tension pneumothorax , - massive hemothorax . Look, listen and feel for general signs of respiratory distress; - sweating, central cyanosis, - use of accessory ms of resp , abd breathing. - resp rate, depth, JVP, record oxygen saturation %, TTT: give oxygen , use bag-mask or pocket mask ventilation if rate and depth of breathing is inadequate.

42. bag-mask pocket mask

43. Circulation (C) : Look for color and temperature of the hand Assess state of veins, peripheral and central pulse Measure BP, auscultate the heart. Look for signs of poor cardiac output (reduced conscious level and oliguria ) Treat urgently life threatening conditions, cardiac tamponade , massive or continued hge, septicemic shock. Insert IV cannula, give fluids, reassess HR and BP /5min. 12-lead ECG monitoring

44. Disability (D): Common causes of unconsciousness include profound hypoxia, hypercapnea , cerebral hypo perfusion or recent administration of sedatives or analgesics. Exclude or treat hypoxia and hypotension Check drug chart and give antagonist Measure bl gl and give glucose if<50mg /dl. Rapid initial assessment of conscious level using Glasgow coma scale Nurse unconscious patients in lateral position if their airway is not protected.

45. Glasgow Coma Scale Score 4 Spontaneous Eye Opening 3 To Speech 2 To Pain 1 Nil 5 Oriented Verbal Response 4 Confused 3 Inappropriate words 2 Incomprehensive sounds 1 Nil 6 Obeys commands Motor Response 5 Localizes 4 Normal flexion 3 Abnormal flexion 3 Abnormal extension 1 Nil

46. Exposure (E): To examine the patient properly full exposure of the body may be necessary. Respect the patient dignity and minimize heat loss . Additional information: -Take a full history -Review the patient notes and charts -Review the results of lab and radiology -Assess, treat and record response to treatment -Consider definitive treatment of underlying condition.

47. Problems with CPR Technique CPR often ineffective because of poor technique Compressions not delivered steadily and constantly during resuscitation efforts Often compressions are too shallow, resulting in ineffective blood flow Compressions may be given at too fast a rate

48. Advanced Life Support ALS

49. Advanced Life Support Interventions intended to achieve 1- Adequate ventilation, 2- Control cardiac arrhythmias, 3- Stabilize blood pressure and cardiac output 4- Restoration of spontaneous circulation 5- Protection of the central nervous system

50. Advanced Life Support The activities carried out to achieve these goals include Defibrillation / cardioversion and/or pacing, Anti-arrhythmic medications Intubation with an endotracheal tube, and Insertion of an intravenous line . Immediate defibrillation should precede intubation and insertion of an intravenous line; CPR should be carried out while the defibrillator is being charged.

51. Advanced life support algorithm: Heart rhythms associated with CA are either: Shockable rhythm VF pulseless VT Non-shockable rhythm Asystole pulseless electrical activity PEA

52. Asystole

53. Pulseless electrical activity (electromechanical dissociation)

54. Treatment of shockable rhythm: - If VF /VT is confirmed , follow the algorithm of European Resuscitation Council ERC Guidelines for Resuscitation, 2010. Attempt defib . Give one chock of 150-200 biphasic or 360 j monophasic . Immediately resume CPR 30-2 without assessing the rhythm or feeling the pulse for 2 min. If VF /VT persists give 2 nd shock of 150-360 biphasic or 360 j monophasic . and resume CPR for 2 min

55. If VF/VT persists give 3 rd shock of 150-360 biphasic or 360 j monophasic . resume CPR for 2 min. Pause briefly to check the monitor. If VF /VT persists give adrenaline 1 mg IV and amiodarone 300 mg IV followed by 4 th shock of 150-360 biphasic or 360 j monophasic . resume CPR for 2 min. Pause briefly to check the monitor. Give adrenaline 1mg IV immediately before alternate shocks ( every 3-5min).

56. Non- shockable rhythm survival following CA with asystole or PEA , is unlikely unless a reversible cause can be found and treated quickly and effectively. Treatment Start CPR 30-2 Give adrenaline 1 mg IV as soon as I.V access is achieved. Continue CPR 30-2 until airway is secured, then continue chest compression without pausing during ventilation. Recheck the rhythm after 2 min:

57. During CPR: consider potential causes or aggravating factors during CA. 6 H’s H ypovolemia H ypoxia H ydrogen ion (acidosis) H ypo-/ H yperkalemia H ypoglycemia H ypothermia 5 T’s T oxins T amponade T hrombosis (coronary or pulmonary) T ension PTx T rauma

58. Post–cardiac arrest care algorithm Mary Ann Peberdy et al. Circulation. 2010;122:S768-S786

59. CASE 1 You find a 72-year-old man lying unresponsive in a restroom of a local airport. He is alone, and you don't know how long he has been unconscious. You speak loudly, trying to wake him up, and you shake him; he continues to be unresponsive. what should be your sequential response in this situation?

60. The resuscitation of an adult victim of sudden cardiac arrest should follow an orderly sequence, no matter where the patient collapse occurs. This sequence is called the chain of survival.

61. CASE 2 A 56-year-old woman is found pulseless in her room at a local hospital. The nurse calls "code blue," and you are the first doctor responding. The nurse has started CPR, and the patient has a patent I.V. line. After 2 minutes, the patient is still pulseless. A defibrillator has now been brought to the room. What is the best intervention to take next in the care of this patient?

62. In the chain of survival, the importance of rapid access to defibrillation cannot be ignored. In a patient who is dying from a shockable rhythm, the chance of survival declines by 7% to 10% for every minute that defibrillation is delayed. Early defibrillation is so critical that if a defibrillator is immediately available, its use takes precedence over CPR in patients with pulseless VT or VF. If CPR is already in progress, it should be halted while defibrillation takes place.

63. Questions

64. Success of any resuscitation attempt is built on : high quality CPR defibrillation when required by the patients ECG rhythm neither 1 or 2 both 1 and 2

65. Success of any resuscitation attempt is built on : high quality CPR defibrillation when required by the patients ECG rhythm neither 1 or 2 both 1 and 2

66. 2) The most important algorithm to know for adult resuscitation is : Bradycardia PEA Tachycardia Cardiac Arrest

67. 2) The most important algorithm to know for adult resuscitation is : Bradycardia PEA Tachycardia Cardiac Arrest

68. The systematic approach with a person in cardiac arrest should include the BLS survey and the ACLS survey ? True False

69. The systematic approach with a person in cardiac arrest should include the BLS survey and the ACLS survey ? True False

70. While conducting the BLS Survey, you should do all of the following except : check patient responsiveness activate emergency response system open the airway get an AED

71. While conducting the BLS Survey, you should do all of the following except : check patient responsiveness activate emergency response system open the airway get an AED

72. According to new 2010 Guidelines for CPR , which of the following is in the correct order for the patient with sudden cardiac arrest ? open airway, provide ventilations, give 30 chest compressions, attach AED as soon as possible give 30 compressions, open airway, provide ventilation, attach AED as soon as possible open airway, check breathing, check pulse , attach AED as soon as possible none of the above

73. According to new 2010 Guidelines for CPR , which of the following is in the correct order for the patient with sudden cardiac arrest ? open airway, provide ventilations, give 30 chest compressions, attach AED as soon as possible give 30 compressions, open airway, provide ventilation, attach AED as soon as possible open airway, check breathing, check pulse , attach AED as soon as possible none of the above

74. After providing a shock with an AED you should : Start CPR, beginning with chest compressions check a pulse give a rescue breath let the AED reanalyze the rhythm

75. After providing a shock with an AED you should : Start CPR, beginning with chest compressions check a pulse give a rescue breath let the AED reanalyze the rhythm

76. During CPR with no advanced airway in place the compression-to-ventilation ratio is : 5:1 30:2 10:1 20:2

77. During CPR with no advanced airway in place the compression-to-ventilation ratio is : 5:1 30:2 10:1 20:2

78. During CPR after an advanced airway is in place, which of the following is true : Breaths should be synchronized with the chest compressions. The goal is 20 or greater breaths per minute Chest compressions should be stopped while giving breaths. One breath every 6 to 8 seconds should be given

79. During CPR after an advanced airway is in place, which of the following is true : Breaths should be synchronized with the chest compressions. The goal is 20 or greater breaths per minute Chest compressions should be stopped while giving breaths. One breath every 6 to 8 seconds should be given

80. The most important intervention with witnessed sudden cardiac arrest is : early defibrillation effective chest compressions early activation of EMS rapid use of resuscitation drugs

81. The most important intervention with witnessed sudden cardiac arrest is : early defibrillation effective chest compressions early activation of EMS rapid use of resuscitation drugs

82. Typically, suctioning attempts in ACLS situations should be : 10 seconds or less 20 seconds or less 5 seconds or less no more than 30 seconds

83. Typically, suctioning attempts in ACLS situations should be : 10 seconds or less 20 seconds or less 5 seconds or less no more than 30 seconds

84. Please rate the lecture on the following items Slightly disagree Strongly disagree Slightly agree Strongly agree Clear Interesting Easy to take notes from Well organized Relevant to the course

85. Please rate the lecture on the following items Slightly disagree Strongly disagree Slightly agree Strongly agree Was enthusiastic Was clearly audible Seemed confident Gave clear explanation Encouraged participation

86. BLS healthcare provider algorithm. Robert A. Berg et al. Circulation. 2010;122:S685-S705