CARDIORESPIRATORY

ARREST

FAISAL SOMMENG

Small Group Learning , FK-UMI 2016

 DEFINISI

Cardiorespiratory arrest is
The sudden, unexpected cessation of
respiration and functional circulation.
 CPCR Principle

4 – 6 minutes

CPCR
During respiratory and cardiac arrest, CPCR may be successful
if performed before biological death of vital tissue develops.
 SURVIVAL OF THE PATIENTS
DEPENDS ON :
1. Degree of preexisting hypoxia of the cells.

2. The brain depends totally on oxygen and is

the organ least able to withstand hypoxia.

3. The whether circulatory or respiratory arrest

occurs first.
 CARDIAC ARREST

1. Ventricular fibrillation or Pulseless VT

Electrical defibrillation is required to
reestablish spontaneous and effective
cardiac electrical activity.
2. Cardiac asystole.
3. Electromechanical dissociation
circulatory collapse that occurs despite
satisfactory electrical complexes on the ECG
CAUSES OF CARDIAC ARREST

1. Low cardiac output.

2. Hyparcapnia.
3. Hyperkalemia.
4. Hypoxia and vagal stimulation.
5. Stimulation of the heart.
6. Coronary occlusion.
7. Overdosage.
8. Hypothermia.
9. Hyperthermia
10. Acidosis
CAUSES OF RESPIRATORY FAILURE

1. Airway obstruction
Vomitus, foreign body, blood, secretions, solid material,
mucous plugs, laryngeal or bronchial spasm, or tumor.
2. CNS depression
Stroke, head trauma, hypercapnia, barbiturates,narcotics,
tranquilizers, or anesthetics.
3. Neuromuscular failure secondary to
Poliomyelitis, muscular dystrophy, myasthenia, or
muscle relaxant drugs.
• Mayor Traumatic potensial to
cardiacrespiratory arrest
PRIMARY CAUSES OF
CARDIAC OR RESPIRATORY ARREST.
Flail chest
Pneumothorax
Massive atelectasis
Acute pulmonary embolism
Congestive heart failure
Overwhelming pneumonia
Gram-negative septicemia
Lung burns
Carbon monoxide poisoning
Massive blood loss.
CARDIAC ARREST IS
More frequent in:
1. Geriatric or pediatric patients.
2. Patients with a history of
arrhythmias, heart block, digitalis
toxicity, myocarditis , myocardial
infarction, congestive heart failure,
electrolyte imbalance , or
dehydration.
3. Massive hemorrhage.
4. During or following heart surgery.
 MANAGEMENT

1. The initial goal of therapy is BRAIN oxygenation

2. The second goal is restoration of circulation.
3. Underlying condition must be corrected.

CPCR

CPCR is not indicated for all patients.

Natural death in the aged or in the terminal stages of a
chronic illness
CPCR should be performed in cases of reversible unexpected
death
CPCR.....
1. Basic Life support (BLS):
A: Airway,
B: Breathing,
C: Circulation,
+ (Defibrillation )

2. Advanced life support (ALS):

D: Drug and Fluid Therapy G: Gauging

E: Electrocardiography. H: Human Mentation

F: Fibrillation treatment. I: Intensive Care
EMERGENCY CPCR

ABCD steps
A, airway.
B, breathing.
C, circulation.
D, drugs and definitive therapy.

In a witnessed cardiac arrest (when treatment can be

initiated within 1 min of the onset of arrest), the ABCD
sequence should include use of a precordial thump.
Precordial Thumb
 Adult Basic Life Support

CHECK
RESPONSIVENESS Shake and shout

OPEN AIRWAY Head tilt / Chin lift

If breathing: CHECK BREATHING Look, listen and feel

recovery position

BREATHE 2 effective breaths

 ASSESS
10 secs only Signs of a circulation

CIRCULATION PRESENT NO CIRCULATION

Continue Rescue Breathing Compress Chest

Check circulation 100-120 per minute

Every minute 30:2 ratio

Send or go for help as soon as possible

according to guidelines
External Cardiac Compression

1. vertically downward 4-5 cm

2. Push hard push fast
3. 100 x/min.
4. Ratio Comp : Vent  30 : 2
Cardiac Compression 100 -120 x/menit
 : Gauging.
: Human mentation.
: Intensive care.
 ASSESS RHYTHM

• CPR
Ventricular fibrillation • Defibrillate mono or
biphasic
• Epinephrine – several dose
options
• Antiarrhythmic agents
• Lidocaine
• Bretylium
• Magnesium
• Procainamide
 PULSELESS ELECTRICAL
ACTIVITY

• CPR
• Search for reversible causes and treat
• Epinephrine
• Atropine for absolute or relative bradicardia
 ASYSTOLE

• CPR
• Epinephrine
• Consider transcutaneous pacing
• Search for reversible causes and
treat if possible
 BRADYCARDIA –
PATIENT NOT IN ARREST

 Oxygen
 Atropine
 Dopamine
 Epinephrine
 Transcutaneous pacing
 Transvenous pacing
TACHYCARDIA WITH SERIOUS
SIGNS/SYMPTOMS
 Oxygen

 Immediate cardioversion

 Premedicate when possible

 Synchronized setting
TACHYCARDIA WITHOUT
SERIOUS INSTABILITY
 Narrow-complex
 Adenosine
 Verapamil
 Diltiazem
 -blockers
 Digoxin
 Synchronized cardioversion
TACHYCARDIA WITHOUT SERIOUS
INSTABILITY

• Wide-complex
– Lidocaine
– Procainamide
– Bretylium
– Consider adenosine
• Synchronized cardioversion
EARLY DEFIBRILLATION
IT IS CRITICAL TO SURVIVAL FROM SUDDEN CARDIAC ARREST (SCA)
FOR SEVERAL REASONS:

(1) The most frequent initial rhythm

in witnessed is ventricular
fibrillation (VF),
(2) The treatment for VF is electrical
defibrillation,
(3) The probability of successful
defibrillation diminishes rapidly
over time, and
(4) VF tends to deteriorate to asystole
within a few minutes.
CHAIN OF SURVIVAL
 PADDLE POSITIONS
DEFIBRILLATION OR CARDIOVERSION
 DEFIBRILLATION WAVEFORMS
AND ENERGY LEVELS

 Defibrillation  delivery of current through the chest

and to the heart to depolarize myocardial cells and
eliminate VF.
 The energy settings for defibrillators are designed to
provide the lowest effective energy needed to terminate
VF.
 Electrophysiologic event that occurs in 300 to 500
milliseconds after shock delivery.
 Defibrillation (shock success) is typically defined as
termination of VF for at least 5 seconds following the
shock.
 SHOCK ENERGIES

• Biphasic defibrillator (initial shock) :

• selected energies of 150 J to 200 J
(biphasic truncated exponential
waveform) or
• 120 J (rectilinear biphasic waveform).
• For second and subsequent shocks, use the
same or higher energy
 SHOCK ENERGIES

• Monophasic defibrillator : select a dose

of 200-360 J for all shocks.
• If VF is initially terminated by a shock
but then recurs later in the arrest, No
need to deliver subsequent shocks BUT
continous CPR
 SYNCHRONIZED
CARDIOVERSION

• Shock delivery that is timed (synchronized)

with the QRS complex.
• The energy (shock dose) used is lower than
that used for unsynchronized shocks
(defibrillation).
• These low-energy shocks if delivered as
unsynchronized are likely to induce VF.
• If cardioversion is needed and it is impossible
to synchronize a shock (eg, the patient’s
rhythm is irregular), use high-energy
unsynchronized shocks.
 SYNCHRONIZED
CARDIOVERSION

• Ventricular tachycardia
• Ventricular tachycardia with a pulse responds
well to cardioversion using initial monophasic
energies of 200 J.
• Use biphasic energy levels of 120—150 J for
the initial shock.
• Give stepwise increases if the first shock fails
to achieve sinus rhythm.
Electrode Position
 DRUGS
• Drugs should be considered only after initial
shocks have been delivered (if indicated) and
chest compressions and ventilation have
been started.
• Three groups of drugs relevant to the
management of cardiac arrest (2015
Consensus Conference): vasopressors, anti-
arrhythmics and other drugs.
 INOTROPS and VASOPRESSORS

• Adrenaline - the primary sympathomimetic agent

for the management of cardiac arrest for 40 years.
• Alpha-adrenergic actions, vasoconstrictive effects 
systemic vasoconstriction, which increases coronary
and cerebral perfusion pressures.
• Beta-adrenergic actions, (inotropic, chronotropic)
may increase coronary and cerebral blood flow.
 ADRENALINE

 Indications
 Adrenaline is the first drug used in cardiac arrest of any
aetiology: it is included in the ALS algorithm for use every
3—5 min of CPR.
 Adrenaline is preferred in the treatment of anaphylaxis.
 Adrenaline is second-line treatment for cardiogenic shock.
 Dose. During cardiac arrest, the initial intravenous dose of
adrenaline is 1 mg.
 When intravascular (intravenous or intra-osseous) access is
delayed or cannot be achieved, give 2—3 mg, diluted to 10 ml
with sterile water, via the tracheal tube. Absorption via the
tracheal route is highly variable.
 ANTI-ARRHYTHMICS

• Amiodarone is a membranestabilising anti-arrhythmic

drug that increases the duration of the action
potential and refractory period in atrial and
ventricular myocardium.
• Atrioventricular conduction is slowed, and a similar
effect is seen with accessory pathways.
• Amiodarone has a mild negative inotropic action
and causes peripheral vasodilation through non-
competitive alpha-blocking effects.
 AMIODARONE

• Indications.
• refractory VF/VT
• haemodynamically stable ventricular tachycardia (VT) and other
resistant tachyarrhythmias

• Dose. Consider an initial intravenous dose of 300

mg amiodarone, diluted in 5% dextrose to a
volume of 20 ml (or from a pre-filled syringe), if
VF/VT persists after the third shock.
• Amiodarone can cause thrombophlebitis when
injected into a peripheral vein; use a central
venous catheter if one is in situ but,if not, use a
large peripheral vein and a generous flush.
 LIDOCAINE

 Indications. Lidocaine is indicated in refractory

VF/VT (when amiodarone is unavailable).
 Dose. an initial dose of 100 mg (1—1.5 mg/kg) for
VF/pulseless VT refractory to three shocks.
 Give an additional bolus of 50 mg if necessary.
 The total dose should not exceed 3 mg/kg during
the first hour.
 OTHER DRUG

• Atropine. antagonises the action of the

parasympathetic neurotransmitter
acetylcholine at muscarinic receptors.
• Blocks the effect of the vagus nerve on
both the sinoatrial (SA) node and the
atrioventricular (AV) node, increasing
sinus automaticity and facilitating AV
node conduction.
 ATROPINE
• is indicated in:
• Asystole
• pulseless electrical activity (PEA) with a rate
<60/min.
• sinus, atrial, or nodal bradycardia when the
haemodynamic condition of the patient is
unstable.
• The recommended adult dose of atropine for
Asystole or PEA with a rate <60 /min is 3 mg
i.v. in a single bolus.
 VF/ VT
Intubasi : as soon as possible, without stop CPR Pijat 100x/menit
Nafas 8x/menit

Cardiac 3’ 3’
adrenalin adrenalin adrenalin
arrest VF / VT

2 menit 2 menit 2 menit 2 menit

- AMIODARON - AMIODARON
a single shock -I a single shock -II a single shock-III - a single shock-IV a single shock-V
CPR -1 CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2
Amiodaron is the first choice
CALL Adrenaline: 1 mg, iv, 300 mg, bolus. Repeated 150 mg
FOR repeated every 3-5 for reccurrent VT/VF. Followed by
HELP minutes 900 mg infusion over 24 hours

PASANG Or LIDOCAIN 1mg/kg. Can be

MONITOR repeated. Do not exceed a total dose
Evaluasi CPR : tiap 2 menit of 3 mg/kg,during the first hour.
ASYSTOL/PEA/EMD
Intubasi : as soon as possible, without stop CPR Pijat 100x/menit
Nafas 8x/menit

Cardiac SA -1 SA - 2
arrest evaluasi evaluasi evaluasi evaluasi
ASYST

2 menit 2 menit 2 menit 2 menit

CPR -1
CPR-2 CPR-3 CPR-4 CPR-5 CPR-6
30 : 2
Adrenalin-1 Adrenalin-2 Adrenalin-3

CALL
FOR
HELP Adrenaline: 1 mg, iv,
repeated every 3-5
minutes
PASANG Evaluasi CPR : tiap 2 menit
MONITOR
 TERMINATION OF
RESUSCITATION

• CPR must be continued until

• Cardiopulmonary system is stabilized
• The patient is pronounced death
• Alone rescuer is physically unable to
continue