CARDIORESPIRATORY ARREST

Sri Nimatullah Husain

111 2016 2029
 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.
 CPCR

MATI KLINIK MATI BIOLOGIK

(REVERSIBEL) (IRREVERSIBEL)
4 - 6 menit

PRINSIP CPCR
MENGALIRKAN DARAH YG MENGANDUNG
OKSIGEN KE ORGAN VITAL TERUTAMA
JANTUNG DAN OTAK

4
 RESUSITASI JANTUNG PARU
DAN OTAK (RJPO)

ADALAH USAHA UNTUK MENGEMBALIKAN FUNGSI

PERNAPASAN, SIRKULASI DAN ATAU SEREBRAL
SERTA PENANGANAN AKIBAT TERHENTINYA FUNGSI
PERNAPASAN, DENYUT JANTUNG DAN ATAU
AKTIFITAS SEREBRAL PADA :
ORANG YANG MENGALAMI KEGAGALAN ORGAN
TERSEBUT SECARA TIBA-TIBA
MASIH MEMUNGKINKAN HIDUP NORMAL

5
 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
 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 patients.
2. Patients with a history of
arrhythmias, 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
E: Electrocardiography.
F: Fibrillation treatment.
3. Bantuan Hidup Jangka Panjang
G: Gauging
H: Human Mentation
I: Intensive Care R: Rehabilitation
External Cardiac Compression

1. vertically downward 4-5 cm

2. Push hard push fast
3. 100 -120x/min.
4. Ratio Comp : Vent 30 : 2
5. Allow recoil
Cardiac Compression 100 -120
x/menit
 Assess Rhythm

CPR
Defibrillate mono or
Ventricular fibrillation 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.
 CPCR 2015 Guidelines

TINJAUAN BUKTI ILMIAH

KONSENSUS ILMIAH

PEDOMAN PENGOBATAN
Organisasi Resusitasi Dunia
Rantai Kehidupan
2015
2015
 Selama RJP
Pastikan pelaksanaan RJP kualitas tinggi : Kecepatan,
kedalaman, recoil
Rencanakan aksi selanjutnya sebelum melakukan perhentian
RJP
Berikan Oksigen
Pertimbangkan pembebasan jalan napas tahap lanjutan dan
pengukuran kapnograf
Lanjutkan kompresi dada ketika penempatan alat jalan napas
lanjutan telah terpasang
Akses vaskular (iv, io)
Berikan adrenalin setiap 3-5 menit
Koreksi Penyebab reversibel
 Latihan kelompok
Perjelas peranan dalam tim
Memantau RJP dan yang melakukan kompressi untuk
mencegah terputusnya kompresi
Penolong harus melakukan perhitungan untuk
pemberian ventilasi
Ganti penolong setiap 2 menit
Lakukan pengisian sebelum status clear
Semakin singkat waktu untuk melakukannnya, maka
prognosanya baik
Lakukan latihan Tiap 2 menit lakukan pergantian
 Tiap 2 menit
Untuk VF
Status pengisian ketika melakukan pengisian
listrik
Status Daerah bersih dan lihat irama (harus
irama shockable) dan lihat sekeliling semua
harus bersih. Lakukan cepat
Berikan kejut listrik, ketika itu penolong
berpindah posisi
Ulang RJP (< 10 detik)
 Tiap 2 menit
Asistol atau PEA
Setiap 2 menit , lokalisasi nadi dengan RJP
Status RJP tetap lanjut dan cek ritme dan
pulsasi
Penolong baru berganti posisi
Ulang RJP
Waktu kurang dari 10 detik
 ACLS
5 H dan 5 T ada di setiap algoritma
Tidak lagi memakai hipoglikemia atau Trauma
Memakai data klinis pasien, pendekatan dan
kemampuan untuk berpikir kritis
precordial thumb direkomendasikan hanya untuk
pasien yang termonitor dengan VF yang terlihat
Penguasaan Alat dan Obat
Lucas : Masih kontroversi sehingga memerlukan
penelitian lenih lanjut
Auto pulse : Out come neurologis yang jelek
Obat-obatan : Masih kelas indeterminate
 Kurangnya penekanan pada intubasi
tracheal sejak awal kecuali dilakukan
oleh tenaga terlatih dengan interupsi
kompresi yang minimal
 Penekanan yang lebih terhadap pemakaian
kapnograf untuk confirmasi dan secara
berkesinambungan memantau letak tube,
kualitas RJP, dan memantau indikasi awal
tanda-tanda ROSC
 ACLS : Gelombang Kapnograf
Perubahan :
Gelombang kapnograf kuantitatif adalah metode
yang lebih reliable untuk mengkonfirmasi letak ET
tube
Kenapa :
Banyaknya insidens yang tidak diinginkan akibat
letak ET tube yang tidak betul
Kapnograf memiliki sensitivitas dan spesifitas
yang tinggi untuk mengidentifikasi kebenaran
letak ETT pada pasien gagal jantung
 ACLS : Gelombang Kapnogtaf
Setelah intubasi, karbondioksida yang di
ekshalasi akan terdeteksi, sehingga dapat
dipakai sebagai pengkonfirmasi letak selang
ETT
Nilai yang paling tinggi pada saat akhir
ekspirasi
 Perubahan ACLS : Jalan Napas
Alat jalan napas supra glottis dapat dipakai
tanpa pemberhentian CPR
Insersi selang ETT > 10 detik sebaiknya
dihindari kecuali jalan nafas beresiko
Memerlukan banyak latihan dan kekompakan
tim
 TERAPI ELEKTRIK

KOMPRESI DADA YANG BERKUALITAS

Sejak awal , kompresi dada jangan

terputus
Meminimalkan fase jeda sebelum dan
setelah kejut
Melanjutkan kompresi selama pengisian
defibrilasi
 Assisting Sirkulasi
Alat mekanik
Autopulse
LUCAS

Sementara hasil hasil penelitian ditunggu, mungkin dapat

diterima untuk memakai alat mekanikal ketika kompresi dada
tidak adekuat atau memerlukan CPR jangka lama
 Gelombang bifasik
Rekomendasi Pengobatan :
Idealnya : energi bifasik awal tidak kurang dari 150 J untuk
semua bentuk gelombang
Sementara hasil hasil penelitian ditunggu, mungkin dapat
diterima untuk memakai alat mekanikal ketika kompresi dada
tidak adekuat atau memerlukan CPR jangka lama
 Tingkatan energi yang tetap atau
eskalasi
G2010 : 2015
Keduanya dapat diterima, bagaimanapun Jika kejut pertama
tidak berhasil dan defibrilasi masih dapat memungkinkan
untuk meningkatkan energi yang lebih tinggi, maka masih
dapat diterima untuk ditingkatkan
Jika VT/VF masih berlangsung
Berikan kejut kedua

CPR selama 2 menit

Berikan kejut ketiga

CPR 2 menit

Selama CPR,
berikan adrenalin 1 mg iv
Amiodarone 300 mg iv
Thank you
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 -120x/min.
4. Ratio Comp : Vent 30 : 2
5. Allow recoil
Cardiac Compression 100 -120
x/menit
 : Gauging.
: Human mentation.
: Intensive care.
 Assess Rhythm

CPR
Defibrillate mono or
Ventricular fibrillation 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
patients 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 120150 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
35 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 23 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 (11.5
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