Effective Resuscitation

BY CHUA
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Introduction
The goal of resuscitation interventions for a patient in respiratory or cardiac arrest is to support and restore effective oxygenation, ventilation, and circulation with return of intact neurologic function.

An intermediate goal of resuscitation is the return of spontaneous circulation. (ROSC)

Effective Resuscitation Team Dynamics

1. 2. 3. 4. 5. 6. 7. 8. Closed-Loop Communication Clear Messages Clear Roles & Responsibilities Knowing One s Limitation Knowledge Sharing Constructive Intervention Reevaluation & Summarizing Mutual Respect

Teamwork divides the tasks multiplying the chances of a successful resuscitation

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The Systemic Approach

The BLS Primary Survey
Circulation Airway Breathing Defibrillation

The ACLS Secondary Survey

Circulation Airway Breathing Differential Diagnosis

The ACLS Secondary Survey

ASSESS
Circulation IV/IO access Rhythm monitoring Drugs to manage rhythm IV/IO fluids if needed head tilt-chin lift, OPA, NPA Advanced airway management (LMA, ETT) O2 Assess oxygenation (SPO2) Measure exhaled CO2 Secure devices 5H&5T Hypovolemia Hypoxia Hypo / hyperkalemia Hydrogen ion (acidosis) Hypothermia Toxins Tamponade (Cardiac) Tension Pneumothorax Thrombosis pulmonary Thrombosis coronary

ACTION

Airway

Breathing

Differential Diagnosis

Critical concepts
Early CPR and early defibrillation Minimizing Interruptions High quality CPR

Principle of Early CPR

In the 1st min after successful defibrillation, any spontaneous rhythm is typically slow and does not create pulses or perfusion CPR is needed for several mins until adequate heart function resumes This is the rationale for resuming immediate high quality chest compressions after a shock

Principle of Early Defibrillation

The interval from collapse to defibrillation is one of the most important determinants of survival from cardiac arrest The most common initial rhythms in witnessed sudden cardiac arrest are VF or rapid pulseless VT Only effective treatment is electrical defibrillation Probability of successful defibrillation decreases quickly over time ( declines by 7% - 10% / min) VF deteriorates to asystole if not treated

Minimizing Interruption
The benefit of advanced airway placement is weighed against the adverse effect of interrupting chest compressions.

If bag-mask ventilation is adequate, insertion of an advanced airway may be deferred until the patient fails to respond to initial CPR and defibrillation or until spontaneous circulation returns.

High Quality CPR

Chest compressions of adequate rate and depth (100/2 ) Allowing full chest recoil between compressions Minimizing interruptions in chest compressions and avoiding excessive ventilation

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High Quality CPR

No more than 10 seconds pulse check After shock delivery, the rescuer should not delay resumption of chest compressions to recheck the rhythm or pulse. After about 5 cycles of CPR (about 2 minutes, although this time is not firm), ideally ending with compressions analyze the cardiac rhythm and deliver another shock if indicated. If a non shockable rhythm is detected, the rescuer should resume CPR immediately, beginning with chest compressions.
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Defibrillation
Does not restart the heart

Stuns the heart and briefly terminates all electrical activity, including VF & rapid VT If the heart is still viable, its normal pacemaker may eventually resume electrical activity that ultimately results in a perfusing rhythm

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Electrical Therapies
Shortening the interval between the last compression and the shock by even a few seconds can improve shock success. (defibrillation and ROSC) Healthcare providers to practice efficient coordination between CPR and defibrillation to minimize the hands-off interval between stopping compression and administering shock. The rescuer operating the defibrillator should be prepared to deliver a shock as soon as the compressor removes his or her hands from the victim's chest and all rescuers are "clear" of contact with the victim.
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Electrical Therapies
Biphasic waveforms are safe and have equivalent or higher efficacy for termination of VF when compared with monophasic waveforms. For biphasic defibrillators, providers should use the manufacturer's recommended energy dose. (120 to 200 J) If the manufacturer's recommended dose is not known, defibrillation at the maximal dose may be considered.

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Electrical Therapies
Ten studies indicated that larger pad/paddle size (8 to 12 cm diameter) lowers transthoracic impedance. The precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrhythmias when a defibrillator is not immediately ready for use.

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Agonal Gasps
Agonal gasps are not adequate breathing Agonal gasps may happen in the first minutes after sudden cardiac arrest A patient who has agonal gasps, does not respond, and has no pulse is in cardiac arrest

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Airway Management
Bag-mask ventilation is particularly helpful when placement of an advanced airway is delayed or unsuccessful approximately 600 mLs of tidal volume sufficient to produce chest rise over 1 second. Oropharyngeal airways can be used in unconscious (unresponsive) patients with no cough or gag reflex Nasopharyngeal airway can be used in patients with an obstructed airway.

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Bag mask Ventilation

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Bag mask Ventilation

Give 1 breath every 5 6 sec (10 12bpm) without chest compression
Give 1 breath every 6 8 sec (8 10bpm) when advanced airway in place

Each breath 1 sec Achieve visible chest rise

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Advanced Airway Management

During the first few minutes of witnessed cardiac arrest a lone rescuer should not interrupt chest compressions for ventilation. Advanced airway placement in cardiac arrest should not delay initial CPR and defibrillation for VF cardiac arrest.

Empirical use of 100% inspired oxygen during CPR optimizes arterial oxyhemoglobin content and in turn oxygen delivery; therefore, use of 100% inspired oxygen (FIO2=1.0) as soon as it becomes available is reasonable during resuscitation from cardiac arrest.
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Confirmation of Placement
Even when the endotracheal tube is seen to pass through the vocal cords and tube position is verified by chest expansion and auscultation during positive-pressure ventilation, providers should obtain additional confirmation of placement using waveform capnography or an exhaled CO2 device.

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End -Tidal CO2

Persistently low PETCO2 values (<10 mm Hg) during CPR in intubated patients suggest that ROSC is unlikely. If PETCO2 is <10 mm Hg, it is reasonable to consider trying to improve CPR quality by optimizing chest compression parameters. If PETCO2 abruptly increases to a normal value (35 to 40 mm Hg), it is reasonable to consider that this is an indicator of ROSC .

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Advanced airway devices

Laryngeal Mask Airway

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Advanced airway devices

Endotracheal Tube

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Avoiding Hyperventilation
It increases intra thoracic pressure, decreases venous return to the heart, and diminishes cardiac output It increases gastric inflation and predispose the patient to vomiting and aspiration of gastric contents

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Increased Intrathorasic Pressure

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Cricoid Pressure
Routine use of cricoid pressure in adult cardiac arrest is not recommended

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Special situations require extra care in placing the electrode pads

Hairy chest (clip) Immersed in H2O/H2o covering pt s chest (wipe dry) Implanted pacemaker or defibrillator (1 away) - device block delivery of shock Transdermal medication patch or other object on surface of skin (remove) - patch block the energy transfer/may cause small burn to skin
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PEA
Pulseless Electrical Activity Rhythm that are organized or semi organized without a palpable pulse True pulseless electrical activity is a condition in which cardiac contractions are absent in the presence of coordinated electrical activity. Include :- Idioventricular rhythms, Ventricular escape rhythms, Post defibrillation Idioventricular rhythms & Bradyasystole rhythms Even a SR without pulse is called PEA.
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Alternative drugs route

Intraosseous (IO) Temporary Drugs & blood giving Via ETT "NAVEL" N arcan A tropine V alium E pinephrine L idocaine

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Vasopressor
IV Epinephrine 1mg (q 3 5 min) Vasopressin 40U Replace 1st/2nd dose of Epinephrine

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Antiarrhythmics
IV Amiodarone 300mg, then 150mg Or Lidocaine 1 - 1.5mg/kg(1st), then 0.5 0.75mg/kg Max 3 doses or 3mg/kg Magnesium Sulphate Routine administration of magnesium sulphate in cardiac arrest is not recommended unless torsades de pointes is present.
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Other drugs
Sodium Bicarbonate In some special resuscitation situations, such as preexisting metabolic acidosis, hyperkalemia, or tricyclic antidepressant overdose, bicarbonate can be beneficial. However, Routine use of sodium bicarbonate is not recommended for patients in cardiac arrest.

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VT/VF

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Bradycardia
If bradycardia produces signs and symptoms of instability (eg, acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing), the initial treatment is atropine. If bradycardia is unresponsive to atropine, intravenous (IV) infusion of B-adrenergic agonists with rate-accelerating effects (dopamine, epinephrine) or transcutaneous pacing (TCP) can be effective while the patient is prepared for emergent transvenous temporary pacing if required
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Bradycardia
IV Atropine 0.5mg Repeat to total dose of 3mg Epinephrine 2 10 g/min Dopamine 2 to 10 g/kg/min Infusion

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Tachycardias
If the tachycardic patient is unstable with severe signs and symptoms related to a suspected arrhythmia (eg, acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock), immediate cardioversion should be performed. (with prior sedation in the conscious patient)

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Narrow Complex Tachycardia

Adenosine If PSVT does not respond to Vagal maneuvers (PSVT) IV adenosine 6mg as a rapid IV push through a large (eg, antecubital) vein followed by a 20 mL saline flush. IV Adenosine 12mg rapid push If the rhythm does not convert within 1 to 2 minutes.

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Thank you

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