Transcript Document

Cardio-Pulmonary and
Cerebral Resuscitation
Lecture 1
Department of Anesthesiology and
Intensive Care
The head of a department: I.Titov, DrPh.
The theme of lecture N 1
1. Cardiopulmonary
resuscitation.
Symptoms of clinical death. Safar’s triple
manoeuvre. Breathing.
2. Cardiopulmonary resuscitation. Chest
compression. Complications of the CPR.
Part II. Cardiopulmonary
resuscitation
Life
For normal functioning all cells of the body
require oxygen. If oxygen is not provided,
death of organism appears within 4..5
minutes.
Brain is the tissue most susceptible to
anoxia (absence of oxygen).
Part II. Cardiopulmonary
resuscitation
Process of the death
Is not a momentary but stepwise process, which can take certain
time.
Five steps of the death:
– Preagony
– Terminal pause
– Agony
– Clinical death
(reversible injury)
– Biological death (irreversible injury)
Part II. Cardiopulmonary
resuscitation
Agony is a stage which precede to the death.
Function of vital organs is severe disturbed, and
conditions required for survival of organism
cannot be met.
Unconsciousness
Blood pressure is undetectable
No pulse on arteries
Clinical death: circulation stops completely and
that leads to the cessation of breathing and
nervous system activity.
Part II. Cardiopulmonary
resuscitation
Symptoms of clinical death
No pulse on arteries (carotid or
femoral)
Change of skin colour
Unconsciousness
Gasping, cessation of breathing
Dilatation of eye pupils
Duration of clinical death is 3(5) minutes
Part II. Cardiopulmonary
resuscitation
Biological death is irreversible condition.
Metabolism and functioning of vital organs has
completely ceased. Organ damage is as
extensive that resuscitation of the body is
impossible.
Evident symptoms of the death:
Rigor mortis
Death spots on the body
Drop of body temperature to the level of the
surrounding
Part II. Cardiopulmonary
resuscitation
Adult BLS sequence
Basic life support consists of the following actions:
1. Make sure that the victim, any bystanders, and
you are safe.
2. Check the victim for a response (gently shake
his shoulders and ask loudly, “Sir. Or Ms., are
you all right?”)
3 A. If he responds:
 Leave him in the position in which you find him
provided there is no further danger.
 Try to find out what is wrong with him and get
help if needed.
 Reassess him regularly.
Part II. Cardiopulmonary
resuscitation
Adult BLS sequence
3 B. If he does not respond:
 Shout for help, call 911 (USA and Canada)
or 03 (Ukraine and Russian Fed)
 Turn the victim onto his back and then
open the airway using head tilt and chin
lift:
- place your hand on his forehead and
gently tilt head back.
- with your fingertips under the point of the
victim’s chin, lift the chin to open the
airway.
Part II. Cardiopulmonary
resuscitation
Adult BLS sequence
4. Keep the airway open, look, listen, and
feel for normal breathing.
 Look for chest movement
 Listen at the victim’s mouth for breath
sounds.
 Feel for air on your cheek
Look, listen and feel for no more than 10
sec to determine if the victim breathing
normally.
Shake and Shout
Opening the airway
Head tilt
Chin lift
If cervical spine
injury suspected:
– jaw thrust
Assess Breathing
Look for chest
movement
Listen for breath
sounds
Feel for expired air
Assess for 10
seconds before
deciding breathing is
absent
Rescue breathing
(Expired air ventilation)
If he is not breathing normally:
Ask someone to call for an
ambulance.
 Kneel by the side of the victim.
 Pinch the soft part of the victim’s
nose, using the index finger and
thumb of your hand on his
forehead.
 Allows his mouth to open, but
maintain chin tilt.
 Take a normal breath and place
your lips around his mouth,
making sure that you have a
Part II. Cardiopulmonary
resuscitation
 Blow into his mouth and look on his chest, chest
must rise; take about one second to make his
chest rise as in normal breathing; this is an
effective rescue breath.
 Maintaining head tilt and chin lift, take your
mouth away from the victim and watch for his
chest.
 Take another normal breath and blow into the
victim’s mouth once more to give a total of two
effective rescue breaths.
 Give each rescue breath over 1 sec rather than
2 sec.
Assess Circulation
Check the victim’s pulse.
A. If pulse on the carotid artery is not palpable –
begin chest compression.
 Place the heel of one hand in the centre of the
victim’s chest.
 Place the heel of your other hand on the top of
the first hand.
 Interlock the fingers of your hands and ensure
that pressure is not applied over the victim’s ribs.
Do not apply any pressure over the upper
abdomen or the bottom end of the bony sternum
(breastbone).
Part II. Cardiopulmonary
resuscitation
– 30 compressions
: 2 breaths for
1-person
CPR
2-person
CPR
Part II. Cardiopulmonary
resuscitation
Chest
compressions:
Depress sternum
4-5 cm
Rate: 100 per
minute
PRECORDIAL BLOW
Indications:
Confirmed of
blood circulation
stop
Continue resuscitation until:
Qualified help arrives and takes
over
The victim shows signs of life
You become exhausted
Airway management and
ventilation
Basic airway management and
ventilation
The laryngeal mask airway and
Combitube
Advanced techniques of airway
management
Basic mechanical ventilation
Safar’s triple manoeuvre
Open mouth
Head Tilt and
Chin Lift
Jaw Thrust
SUCTION
Ventilation by mouth through a
mask
Advantages:
Allows to avoid direct contact
Reduces probability of
infected
Allows to raise O2
Restrictions:
Tightness maintenance
Stomach inflating
Bag-valve-mask
Ventilation by means of bag Аmbu
Advantages
Direct contact allows to
avoid
Allows to increase
concentration О2 - to 85
%
Can be used with an
obverse mask, LМ,
Combitube,
endotracheal tube
Restrictions
At use with an obverse
mask:
Risk of inadequate
ventilation
Risk of inflating of a
stomach
4 hands are necessary
for optimum use
Installation LМ
Laryngeal mask
Advantages
Speed and simplicity of
installation
Presence of the
different sizes
More effective
ventilation in
comparison with an
obverse mask
Allows to avoid
laryngoscopy
Restrictions
Does not protect from
aspiration
Does not approach in
situations when high
pressure use on a breath
is required
It is impossible to
aspirate from bottom BP
Choice of an air line of the suitable
size
Simple adaptations for maintenance
of BP
Installation of pharyngo-oral an air
line
Installation of pharyngonasal an air line
Combitube
Advantages
Speed and simplicity of
installation
Allows to avoid
laryngoscopy
It is possible to use,
when pressure upon a
breath the high
Restrictions
It is accessible only 2 sizes
There is a risk of ventilation
through a gastric gleam
Damage of cuffs at installation
Trauma in an installation time
Only for disposable use
Ventilation by means of
Combitube
Intubation of tracheas
Attempt of intubation:
Preoxygenation of the patient
30 seconds on each attempt
Spend a tube through a vocal crack under the
control of direct sight
At any doubts or complexities, reoxygenation the
patient before the subsequent attempts
Patients are harmed by unsuccessful attempts
of oxygenation, instead of intubation!
Installation of endotracheal
tube
Intubation of trachea
Advantages
Allows to increase PO2
to 100 %
Isolates BP, preventing
of aspiration
Allows aspirated of BP
Alternative way for
introduction of medicine
Restrictions
Training and
experience are
absolutely necessary
Unfortunate attempt,
esophageal intubation
Risk of deterioration of
damage back and a
brain during
laryngoscope
Confirmation of correct position
of ETT in a trachea
Direct visualisation during laryngoscope
Auscultation:
– With two sides, on average axillary's lines
– Over epigastrium
Symmetric movements of thorax during
ventilation
Sellick”s manoeuvre
Pressure on cricoid
cartilage on purpose of
occlusion a gullet about
cervical department of a
backbone
Sellick”s manoeuvre
Advantages
Decrease of risk of
aspiration and
regurgitation
It can be applied at
intubation, and also
ventilation by means of
an obverse mask and
LM
Lacks
Can complicate
intubation
Can complicate
ventilation by means
of an obverse mask
or LM
Avoid at active
vomiting
Cricothireotomy
Indications
Impossibility of maintenance
passableness of BP in
another way
Complications
Displacement of cannula
– Emphysema
– Bleeding
– Gullet punching
Hypoventilation
DEFIBRILLATION
Rhythm of a stop of blood
circulation
Fibrillation of ventricles
Ventricle's tachycardia «without pulse»
Asystole
Electro-mechanical dissociation (EMD)
Asystole
There is no activity of ventricles
(complex QRS)
Activity of auricles (wave P) can be
Seldom straight line
Possibility of small waves of VF
The mechanism of
DEFIBRILLATION
Definition
– “The termination of fibrillation or absence
VF/VT in 5 seconds after the discharge”
Depolarized all weight of a myocardium
Natural pacemeker renew job
Automatic external
DEFIBRILLATOR
Analyze a heart rhythm
Make the discharge
Specificity in
recognition of the
rhythm in subject which
is defibrillation comes
nearer to 100 %
Automatic external DEFIBRILLATOR
Attach sticky electrodes
Follow the sound and
visual instruction
The automatic analysis of
an electrocardiogram - do
not touch the patient
The automatic discharge
at a corresponding
rhythm
+/-a manual overload
Manual DEFIBRILLATION
It is based on:
The rhythm is recognised
by the operator
The operator puts the
discharge
It can be used for
synchronised cardioversion
Safety of defibrillation
Never hold both electrodes in one hand
Charge only when electrodes on a breast
of the victim
Avoid direct or indirect contact
Wipe dry a breast of the patient
Remove oxygen from a zone of
defibrillation
Manual DEFIBRILLATION (1)
Diagnostics VF/VT and
signs of a stop of blood
circulation
Choice of suitable energy of
the discharge
To load condensers
(electrodes on the patient)
The command “all to depart”
Visual check of a zone of
defibrillation
To check up the monitor
The discharge
Manual DEFIBRILLATION (2)
Repeatedly to estimate a rhythm
To hold electrodes on a breast between
discharges
To increase energy
– The assistant makes, or
– To place an electrode on defibrillator and to
choose energy level independently
Not to spend BLS between discharges if
there is no long delay
The conclusion
Defibrillation it is unique effective at
restoration of circulation at patients with
VF or VT without pulse
Defibrillation should it is spent quickly,
effectively and safely
New technologies increase possibilities of
equipment and simplify use
Introduction of medicines in
time of СРR
The central venous access
Internal jugular vein
Subclavian vein
Complications of catheterization
the central veins
Artery puncture
Hematoma
Hemothorax
Pneumothorax
Air embolism
Damage of surrounding fabrics
Аrrhythmias
Intatracheal introductin of medicines
Preparations which
can it is entered into
a trachea:
Adrenaline
Lidocaine
Atropine
Naloxoni
Preparations which
cannot be entered into
a trachea:
Amiodaroni
Sodium bicarbonate
Calcium
Adrenaline
Indications:
Any rhythm at a blood circulation stop
Bradycardia
Special circumstances:
Anaphylactic shock
Adrenaline
Dose:
1 mg I\V in 10 1:10,000 (1 ml 1:1,000) every 2-3
min at resuscitation
2-3 mg throw EТТ
2–10 mkg min-1 at bradycardia resistant to
atropine
0.5 ml 1:1,000 i/m, 3-5 ml 1:10,000 i/v
at anaphylactic shock, in depending on weight
Adrenaline
Action:
a-agonist:
- arterial vasoconstriction
ОПСС
a cerebral and coronary blood-groove
b-agonist ↑ HC
↑ forces of heart reductions
requirements of a myocardium for oxygen (can
strengthen an ischemia)
Atropine
Indications:
Asystole
Bradycardia
EMD (F of HC < 60 in min)
Atropine
Action :
Blockade of effects of nervus vagus
Strengthening of automatism of sinoatrial
node
Increase А-В of conductivity
Atropine
Dose :
Asystole / EMD (F of HC < 60 in min)
– 3 mg i/v, unitary
– 6 mg throw EТТ
Bradycardia
– 0.5 mg i/v, to repeat at necessity, maximum 3 mg
Amiodaroni
Indications :
Refractory VF / VT without pulse
Hemodynamic stable VT
Other resistant tachyarrhythmia
Amiodaroni
Dose :
Refractory VF / VT without pulse
300 mg in 20 ml 5% dextrose, i/v
Tachyarrhythmia
– 150 mg in 20 ml 5% dextrose during 10 min
– Repeat 150 mg at necessity
– 300 mg in 100 ml 5% dextrose during 1 hour
Amiodaroni
Action:
Increases duration of potential of action
Extends interval Q-T
Weak negative inotropic action - can call a
hypotension
Lidocaine
Indications :
Refractory VF / VT without pulse
– at inaccessibility of amiodaroni
Hemodynamic stable VT
– as alternative for amiodaroni
Lidocaine
Dose :
Refractory VF / VT without pulse
– 100 mg i/v
– after boluses 50 mg, max 200 mg
Hemodynamic stable VT
– 50 mg i/v.
– after boluses 50 mg, max 200 mg
To lower a dose at elderly and at hepatic insufficiency
Sodium bicarbonate
Indications :
Heavy metabolic acidosis (pH <7.1)
↑ K in blood
Special circumstances
Poisoning by energizers
Sodium bicarbonate
Dose :
50 mmol (50 ml 8.4% solution) i/v
Sodium bicarbonate
Action:
Alkaline agent (increase pH)
But can call:
– Increase in loading СО2
– Reduction of liberation О2 in fabrics
– Decrease contractility of myocardium
– Increase Na in blood
Co-operates with adrenaline
Calcium
Action:
It is necessary for normal reduction of a
myocardium
Surplus can call arrhythmia
The trigger of destruction of cages ischemic
myocardium
Surplus can break brain restoration
Calcium
Indications :
EMD calling by :
– ↑ K in blood
– ↓ Ca in blood
– Overdose of calcium blocker
Dose :
10 ml 10% Ca Cl (6.8 mmol\l)
Not to enter at once before or after bicarbonate
sodium
Naloxoni
Indications :
Overdose of opiates
Oppression of breath after appointment of
opiates
Naloxoni
Dose :
0.2 - 2.0 mg i/v
It can be demanded repeatedly, possible to 10
mg
Infusion can be demanded
To
estimate
rhythm
+/- check up pulse
VF/VT
Defibrillation X 3
if necessary
СРR 1 min
Ventricle fibrillation
/ Ventricle tachycardia
without pulse
VF/VT
Discharge 200 J*
Discharge 200 J*
Discharge 360 J*
To make 3 discharges if it is
necessary, in a current of 1
minute
Not to interrupt defibrillation
for BLS
After the discharge, palpate
pulse on carotids, only if on
an electrocardiogram a
rhythm corresponding to job
of heart
During СРR
Correction of the reversible reasons
If it is not made:
To check up electrodes, an arrangement
and contact
To provide / to check up
- Passableness BP and O2
- Venous access
Adrenaline each 3 mines
To consider:
amidaroni, atropine / pacing buffers
Compression, respiratory ways
and ventilation
Passableness of respiratory ways:
– Endotracheal tube
– LM
– Combitube
After maintenance of passableness of
BP do not interrupt a compression for
ventilation
Venous access and preparations
FV/VT
The central or peripheral vein
Adrenaline of 1 mg i/v or 2-3 mg endotracheal
To consider amiodaroni 300 mg if FV/VT
present after 3rd category
Alternatively - lidocaine of 100 mg
To consider magnesium 8 mmol
False asystole
When monitoring with paddle-gel pads
More likely with increasing number of
shocks and high chest impedance
Displays apparent “asystole”
Confirm rhythm with monitoring leads