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CPR & Electrical Therapies
CPR & Electrical Therapies
CARDIAC ARREST
The cessation of cardiac mechanical activity, as confirmed by the absence of signs of circulation.
Settings
Out of hospital In hospital A single approach to resuscitation is not practical, but a core set of actions provides a universal strategy for achieving successful resuscitation. Chain of Survival
SURVIVAL RATES
Survival rates from witnessed VF SCA decrease 7% to 10% if no CPR is provided. When these links are implemented in an effective way, survival rates can aprroach 50% following witnessed out of hospital VF arrest.
8. Precordial Thump
Precordial thump may be considered for termination of witnessed monitored unstable ventricular tachyarrythmias when a defibrillator is not immediately ready for use, but should not delay CPR and shock delivery. In 3 case series : VF / pulseless VT was converted to a perfusing rhthm by a PT. There is insufficient evidence to recommend for againts the witnessed onset of asystole.
CHEST COMPRESSION
1. Care should be taken to minimize interruptions in chest compressions when placing, or ventilating with an advanced airway. 2. Because delay in chest compressions should be minimized, the HP should take no more than 10 seconds to check for a pulse, and if the rescuer does not definitely feel a pulse within that time period the rescuer should start chest compressions.
CHEST COMPRESSION
3. Incomplete recoil during BLS CPR is associated with intrathoracic pressure significantly hemodynamics ( coronary perfusion, cardiax index, myocardial blood flow & cerebral perfussion). 4. It is reasonable to switch chest compressors approximately every 2 minutes to prevent decreases in the quality of compressions.
COMPRESSION : VENTILATION
When an advanced airway (ET, combitube or LMA) is in palce during 2 person CPR, continuous chest compressions (there should be no pause in chest compressions for delivery of ventilations). Performed at a rate of at least 100/min without pauses and give 1 breath every 6 8 seconds without attempting to synchronize breaths between compressions (this will result in delivery of 8 to 10 breaths/minute).
VENTILATION
Studies in anesthetized adults (normal perfusion) suggest that a tidal volume of 8 10 ml/kg maintains normal oxygenation and elimination of CO2. During CPR, cardiac output is 25 33% of N oxygen uptake from the lungs and CO2 delivery to the lungs are also reduced. As a result, a low minute ventilation (lower than normal TV and respiratory rate) can maintain effective oxygenation and ventilation.
VENTILATION
For that reason during adult CPR tidal volumes of approximately 500 600 mL (6 7 ml/kg) should suffice. This is consistent with a tidal volume that produces visible chest rise.
VENTILATION
Excessive ventilation is unnecessary & can cause gastric inflation and its resultant complications, such as regurgitation and aspiration. Excessive ventilation can be harmful increase intrathoracic pressure decrease venous return to the heart diminishes cardiac output and survival.
VENTILATION
Bag mask ventilation : the rescue should use an adult (1 to 2 L) bag to deliver approximately 600 mL TV for adult victims. Deliver by squeezing a 1 L adult bag about two thirds of its volume. The HP should use supplementary oxygen (O2 concentration >40%, at minimum flow rate of 10 12 L/min) when available.
DROWNING
The duration and severity of hypoxia sustained as a result of drowning. There is no evidence that water acts as an obstructive foreign body. Manuevers to relieve FBAO are not recommended for drowning victims because such manuevers arent necessary and they can cause injury, vomiting, aspiration & delay CPR.
DROWNING
When rescuing a drowning victim of any age, it is reasonable for the lone HP to give 5 cycles of CPR before leaving the victim to activate the EMS system.
DROWNING
As soon as the unresponsive victim is removed from the water open the airway check for breathing if theres no breathing give 2 rescue breaths that make the chest rise check the pulse if theres no pulse begin chest compressions. Dry the chest area before applying the defibrillation pads and using the AED.
HYPOTHERMIA
Body temperature : mild (> 34oC), moderate (30-34oC), severe hypothermia (< 30oC). If the victim is unresponsive with no normal breathing, lay rescuer should begin chest compressions (CPR) immediately. Do not wait to check the victims temperature and do not wait until the victim is rewarmed to start CPR.
HYPOTHERMIA
To prevent further heat loss, remove wet clothes from the victim; insulate from wind, heat or cold; and if possible, ventilate the victim with warm, humidified oxygen. If VF is detected, emergency personnel should deliver shocks using the same protocols of CPR.
FBAO
If the adult victim with FBAO becomes unresponsive, the recuer should carefully support the patient to the ground, immediately activate (or send someone to activate) EMS, and then begin CPR (without a pulse check). Each time the airway is opened during CPR, the rescuer should look for an object in the victims mouth and if found, remove it.
FBAO
Simply looking into the mouth should not significantly increase the time needed to attempt the ventilations and proceed to the 30 chest compressions. No studies have evaluated the routine use of the finger sweep to clear an airway in the absence of visible airway osbtruction case report documented harm to the victim or rescuer.
PREGNANCY
Patient positioning has emerged as an important strategy to improve the quality of CPR and resultant compression force and output. Left lateral tilt is used to improve maternal hemodynamics during cardiac arrest.
PREGNANCY
Chest compressions should be performed slightly higher on the sternum than normally recommended. Defibrillation : use of an AED on a pregnant victim has not been studied but is reasonable.
VASOPRESSOR
A vasopressor can be given as soon as feasible with the primary goal of increasing myocardial and cerebral blood flow during CPR and achieving ROSC. Epinephrine iv/io dose : 1 mg every 3 5 minutes. Vasopressin iv / io dose : 40 units can replace epinephrine.
VASOPRESSOR
Three RCTs and a meta-analysis of the trials demonstrated no differences in outcomes (ROSC, survival to discharge or neurologic outcome) with vasopression 40U iv VS epinephrine 1mg as a first-line vasopressor in cardiac arrest. Because the effects of vasopressin havent been shown to differ from those of epinephrine in cardiac arrest, 1 dose of V 40 units may replace either the first/second dose of E in cardiac arrest.
ANTIARRHYTMIC AGENT
Amiodarone is the first-line AAA given during cardiac arrest because it has been clinically demonstrated to improve the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT. Amiodarone iv/io : first dose : 300 mg bolus, second dose : 150 mg bolus. If it is unavailable, lidocaine may be considered, dose : 1 1,5 mg/kg iv bolus.
SULFAS ATROPINE
Atropine sulfate reverses cholinergicmediated decrease heart rate and atrioventricular nodal conduction. No prospective controlled clinical trials have examined the use of atropine in cardiac arrest. For this reason atropine is no longer recommended for routine use in the management of PEA / asystole & has been removed from the cardiac arrest algorithm..
OVERVIEW
Early defibrillation is critical to survival from sudden cardiac arrest (SCA). The most frequent initial rhythm in out of hospital witnessed SCA is ventricular fibrillation (VF) all BLS providers should be trained to provide. If bystanders provide immediate CPR, many adults in VF can survive with intact neurologic function, especially if defibrillation is performed within 5 10 minutes after SCA.
OVERVIEW
Rapid defibrillation is the treatment of choice for VF (witnessed out of hospital cardiac arrest or for hospitalized patients whose heart rhythm is monitored). Performing chest compressions while another rescuer retrieves and charges a defibrillator improves the probability of survival.
OVERVIEW
Electrical therapies (AHA 2010) are manual defibrillator, AED, synchronized cardioversion and pacing. AED may be used by lay rescuers and HP as part of basic life support. Manual defibrillation, cardioversion and pacing are advanced life support therapies.
MANUAL DEFIBRILLATOR
The recommended energy dose of biphasic defibrillator is 200 J for terminating VF. The recommended energy dose of monophasic defibrillator is 360 J for terminating VF. In pediatrics : initial monophasic doses of 2 J/kg are effective in terminating 18% - 50% of VF.
MONOPHASIC VS BIPHASIC
Biphasic waveform shock has been reported to be safer and more effective than a monophasic waveform shock. A biphasic defibrillator has lower energy requirements and is smaller and lighter in weight than a monophasic defibrillator. Almost all defibrillators currently available commercially are biphasic defibrillator.
MONOPHASIC VS BIPHASIC
A study in Japan 2005 2007 hypotesis : the survival of patients at 1 month with minimal neurological impairment who recieved defibrillation shock with the BD is better than the survival of patients who received defibrillation shock with the MD. Minimal neurological impairment was defined as Glasgow-Pittsburgh cerebral performance category 1 (good) or 2 (moderate disability).
MONOPHASIC VS BIPHASIC
Results : no significant difference was observed between the patients who were shocked with a biphasic defibrillator or with a monophasic defibrillator. Discussion : BD have several advantages compared with MD, including a lower burden for EMS personnel because of their lower weight and greater portability.
ROSC
When a rhythm check using a manual defibrillator or cardiac monitor reveals an organized rhythm, a pulse check is performed. If a pulse is detected ROSC it is important to begin post-cardiac arrest care immediately to avoid re-arrest and optimize the patients chance of long term-survival with good neurologic function.
ROSC
The treatable causes of cardiac arrest : The H5 and T5
Hypoxia Hypovolemia Hydrogen ion (acidosis) Hypo/hyperkalemia Hypotermia - Toxins - Tamponade (cardiac) - Tension pneumothorax - Thrombosis (pulmonary) - Thrombosis (coronary)
TREAT H5 & T5
1. Hypoxemia placement of an advanced airway to achieve adequate oxygenation or ventilation. 2. Hypovolemia administer iv/io crystalloid or blood transfusion. 3. Pulmonary embolism fibrinolitic therapy. 4. Tension pneumothorax needle decompression. 5. Etc
RECOVERY POSITION
Applied for out of hospital cardiac arrest. Used for unresponsive adult victims who clearly have normal breathing and effective circulation. RP is designed to maintain a patent airway and reduce the risk of airway obstruction and aspiration. The victim is placed on his or her side with the lower arm in front of the body.
RECOVERY POSITION
No single position is perfect of for all victims. The position should be stable, near a true lateral position, with the head dependent and with no pressure on the chest to impair breathing.
H I S A K
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