CARDIOPULMONARY

RESUSCITATION

Associated Professor PhD MD Nica Adriana Elena

Assistant Professor MD Tudorica Stefan Dragos Octavian
SUDDEN CARDIAC ARREST
• Sudden cardiac arrest is one of the leading causes of death in Europe
• On initial heart rate rhythm analysis 25 to 50 % of SCA victims have
ventricular fibrillation (VF) or rapid ventricular tachycardia
• By the time ECG is recorded by emergency medical personnel the
rhythm has deteriorated to asystole.
• More victims of SCA survive if bystanders act immediately while VF is
still present. Success-ful resuscitation is less likely once the rhythm
has deteriorated to asystole.
Basic Life Support
Patients who are unresponsive and not breathing
normally should be presumed to be in cardiac arrest.
Opening the airway and checking
for breathing
• The trained provider should assess the collapsed victim rapidlyto
determine if they are responsive and breathing normally.Open the
airway using the head tilt and chin lift technique whilstassessing
whether the person is breathing normally. Do not delayassessment by
checking for obstructions in the airway.
Chest compressions
 Chest compressions
• Deliver compressions ‘in the centre of the chest
• Compress to a depth of at least 5 cm but not more than 6 cm.3.
Compress the chest at a rate of 100–120 /min with as few
interruptions as possible
• Allow the chest to recoil completely after each compression; donot
lean on the chest.
• Hand position - Experimental studies show better haemodynamic
responseswhen chest compressions are performed on the lower half
of thesternum.
• In adults needing CPR, there is a high probability of a primary cardiac
cause. When blood flow stops after cardiac arrest, the blood in the
lungs and arterial system remains oxygenated for some minutes. To
emphasise the priority of chest compressions, it is recommended that
CPR should start with chest compressions rather than initial
ventilations
• Deliver compressions ‘in the centre of the chest. Compress to a depth
of at least 5 cm but not more than 6 cm. Compress the chest at a rate
of 100–120 min−1with as few interruptions as possible. Allow the
chest to recoil completely after each compression; do not lean on the
chest.
 Ventilation
• During CPR, systemic blood flow, and thus blood flow to the lungs, is
substantially reduced, so lower tidal volumes and respiratory rates
than normal can maintain effective oxygenation and ventilation
• From the available evidence we suggest that during adult CPRtidal
volumes of approximately 500–600 mL (6–7 mL kg−1) are delivered.
• The ERC continues to recommend a compression to ventilation ratio
of 30:2.
Use of an automated external
defibrillator
• AEDs are safe and effective when used by lay people with minimal or
no training. AEDs make it possible to defibrillate many minutes before
professional help arrives
• 1. Minimise pauses in chest compressions for rhythm analysis and
charging;
• 2. a single shock only, when a shockable rhythm is detected;
• 3. a voice prompt for immediate resumption of chest compressionafter
the shock delivery;
• 4. a period of 2 min of CPR before the next voice prompt to re-analyse
the rhythm.
Foreign body airway obstruction
(choking)
Adult advanced life support (ALS)
• Heart rhythms associated with cardiac arrest are divided into two
groups: shockable rhythms (ventricular fibrillation/pulseless ventricular
tachycardia (VF/pVT)) and non-shockable rhythms(asystole and pulseless
electrical activity (PEA)). The principal difference in the treatment of
these two groups of arrhythmias is the need for attempted defibrillation
in those patients with VF/pVT.
• Having confirmed cardiac arrest,summon help (including the request for
a defibrillator) and startCPR, beginning with chest compressions, with a
compression: ven-tilation (CV) ratio of 30:2.
• If IV access has been obtained, during the next 2 min of CPR give
adrenaline 1 mg
• Give adrenaline 1 mg as soon as venous or intraosseous accessis
achieved, and repeat every alternate CPR cycle (i.e. about every3–5 min).
• For biphasic waveforms (rectilinear biphasic or biphasic truncated
exponential), use an initial shock energy of at least 150 J.
• Minimise the delay between stopping chest compressions anddelivery
of the shock
• Without pausing to reassess the rhythm or feel for a pulse, resume
CPR (CV ratio 30:2) immediately after the shock
• Continue CPR for 2 min, then pause briefly to assess the rhythm;if still
VF/pVT, give a second shock (150–360 J biphasic). Withoutpausing to
reassess the rhythm or feel for a pulse, resume CPR(CV ratio 30:2)
immediately after the shock, starting with
chestcompressions.•Continue CPR for 2 min, then pause briefly to
assess the rhythm
•
• VF/pVT persists, consider changing the position of the pads/paddles.
Review all potentially reversible causes using the 4 H and 4 T approach
and treat any that are identified.

• Anti-arrhythmic drugs. We recommend that amiodarone should begiven

after three defibrillation attempts irrespective of whether they are
consecutive shocks, or interrupted by CPR, or for recurrentVF/pVT
during cardiac arrest. Give amiodarone 300 mg intravenously; a further
dose of 150 mg may be given after five defibrillation attempts. Lidocaine
1 mg kg−1 may be used as analternative if amiodarone is not available
but do not give lidocaine if amiodarone has been given already.
 Magnesium
• Hypomagnesaemia is often associated with hypokalaemia, and may
contribute to arrhythmias and cardiac arrest. Hypomagnesaemia
increases myocardial digoxin uptake and decreases cellular Na+/K+-ATP-
ase activity. In patients with hypomagnesaemia, hypokalaemia, or both
digitalis may become cardiotoxic even with therapeutic digitalis levels.
Magnesium deficiency is not uncommon in hospitalised patients and
frequently coexists with other electrolyte disturbances, particularly
hypokalaemia,hypophosphataemia, hyponatraemia and hypocalcaemia.
Give an initial intravenous dose of 2 g (4 ml (8 mmol)) of 50% magnesium
sulphate); it may be repeated after 10–15 min. Preparations of
magnesium sulphate solutions differ among European countries.
• PEA is often caused by reversible conditions, and canbe treated if
those conditions are identified and corrected. Survivalfollowing
cardiac arrest with asystole or PEA is unlikely unless areversible cause
can be found and treated effectively.
• Whenever a diagnosis of asystole is made, check the ECG care-fully for
the presence of P waves, because this may respond tocardiac pacing.
There is no benefit in attempting to pace true asys-tole.
REVERSIBLE CAUSES
 Airway and ventilation
• Tracheal intubation provides the most reliable airway, but should be
attempted only if the healthcare provider is properly trained and has
regular,ongoing experience with the technique. Tracheal intubation
must not delay defibrillation attempts.
• In the absence of personnel skilled in tracheal intubation, a
supraglottic airway (SGA) (e.g. laryngeal mask airway, laryngeal tube )
is an acceptable alternative. Once a SGA has been inserted, attempt
to deliver continuous chest compressions, uninterrupted by
ventilation.
Extracorporeal cardiopulmonary
resuscitation (eCPR)
• Extracorporeal CPR (eCPR) should be considered as a rescue therapy
for those patients in whom initial ALS measures are unsuccessful and,
or to facilitate specific interventions (e.g. coronary angiography and
percutaneous coronary intervention (PCI) or pulmonary
thrombectomy for massive pulmonary embolism OR thrombolysis).
• This has the potential to buy time for restoration of an adequate
spontaneous circulation, and treatment of reversible underlying
conditions. This is commonly called extracorporeal life support (ECLS)
 Hypothermia
• At 18◦C the brain can tolerate cardiac arrest for up to 10 times longer than at37◦C.
This results in hypothermia exerting a protective effect on the brain and heart,and
intact neurological recovery may be possibleeven after prolonged cardiac arrest if
deep hypothermia dev
• Neurologically intact survival has been reportedafter hypothermic cardiac arrest
with a core temperature as low as 13.7◦C and CPR for as long as six and a half
hourselops before asphyxia.
• The hypothermic heart may be unresponsive to cardioac-tive drugs, attempted
electrical pacing and defibrillation.
• Given that defibrillationand adrenaline may induce myocardial injury, it is
reasonableto withhold adrenaline, other CPR drugs and shocks until thepatient has
been warmed to a core temperature ≥30◦C.
Paediatric life support
• If breathing is not normal or absent:•Carefully remove any obvious
airway obstruction.•Give five initial rescue breaths.•While performing
the rescue breaths note any gag orcough response to your action.
These responses or theirabsence will form part of your assessment of
‘signs of life’,which will be described later.
• For all children, compress the lower half of the sternum. The
compression should be sufficient to depress the sternum by at least
one third of the anterior–posterior diameter of the chest. Release the
pressure completely and repeat at a rate 100–120 min−1. After 15
compressions, tilt the head, lift the chin, and give two effective
breaths. Continue compressions and breaths in a ratio of 15:2.
• For cardiopulmonary resuscitation, the recommended IV/IOdose of
adrenaline in children for the first and for subsequent dosesis 10
micrograms kg−1. The maximum single dose is 1 mg. If needed,give
further doses of adrenaline every 3–5 min, i.e. every 2 cycles.
• Amiodarone can be given aspart of the cardiac arrest algorithm in
managing refractory VF/pVT. It is given after the third shock as a 5 mg
kg−1bolus (and can be repeated following the fifth shock).
 Energy dose in children
• We continue to recommend 4 J kg−1for initial and subsequent
defibrillation. Doses higher than 4 J kg−1(as much as 9 J kg−1) have
defibrillated children effectively with negligible side effects. When
using a manual defibrillator, use 4 J kg−1(preferably biphasic but
monophasic waveform is also acceptable) for the first and sub-
sequent shocks.
Cardiac arrest associated with
pregnancy
• In an emergency, use a systematic ABCDE approach. Many car-
diovascular problems associated with pregnancy are caused by aorto-
caval compression.
• Place the patient in the left lateral position or manually and
gentlydisplace the uterus to the left
• The hand position for chest compressions may need to be
slightlyhigher on the sternum for patients with advanced pregnancy
e.g.third trimester