A.M.

TAKDIR MUSBA

EMERGENCY AND TRAUMATOLOGY , 2010

 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.
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.
A. Cardiac asystole.
B. Ventricular fibrillation or Pulseless VT
Electrical defibrillation is required to
reestablish spontaneous and effective
cardiac electrical activity.
C. Electromechanical dissociation
circulatory collapse that occurs despite
satisfactory electrical complexes on the ECG
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
 1. Airway obstruction by vomitus, foreign body,
blood, secretions, solid material, mucous plugs,
laryngeal or bronchial spasm, or tumor.
2. CNS depression: caused by stroke, head trauma,
hypercapnia, barbiturates,narcotics, tranquilizers,
or anesthetics.
3. Neuromuscular failure secondary to
poliomyelitis, muscular dystrophy, myasthenia, or
muscle relaxant drugs.
Flail chest
Pneumothorax
Massive atelectasis
Acute pulmonary embolism
Congestive heart failure
Overwhelming pneumonia
Gram-negative septicemia
Lung burns
Carbon monoxide poisoning
Massive blood loss.
 In geriatric or pediatric patients.
 In patients with a history of
arrhythmias, heart block, digitalis
toxicity, myocarditis , myocardial
infarction, congestive heart failure,
electrolyte imbalance , or dehydration.
 In massive hemorrhage.
 During or following heart surgery.
The initial goal of therapy is BRAIN oxygenation
The second goal is restoration of circulation.
Underlying condition must be corrected.

 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
Basic Life support (BLS):
Airway, Breathing, Circulation, Drug (Defibrillation )

Advanced life support (ALS):

Airway, Breathing, Circulation, Drug (Defibrillation),
ECG, Fluid, Gauge, ICU
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 per minute

Every minute 15:2 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
  Defibrillate up to 3 times
Ventricular fibrillation  Epinephrine – several
dose options
 Antiarrhythmic agents
 Lidocaine
 Bretylium
 Magnesium
 Procainamide
• Search for reversible causes and treat
• Epinephrine
• Atropine for absolute or relative bradicardia
 Epinephrine
 Atropine
 Consider transcutaneous pacing
 Search for reversible causes and
treat if possible
 Atropine
 Dopamine
 Epinephrine
 Transcutaneous pacing
 Transvenous pacing
 Immediate cardioversion

 Premedicate when possible

 Synchronized setting
 Narrow-complex
 Adenosine
 Verapamil
 Diltiazem
 -blockers
 Digoxin
 Synchronized cardioversion
• Wide-complex
– Lidocaine
– Procainamide
– Bretylium
– Consider adenosine
• Synchronized cardioversion
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.
 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.
 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
 Monophasic defibrillator : select a
dose of 360 J for all shocks.
 If VF is initially terminated by a
shock but then recurs later in the
arrest, deliver subsequent shocks at
the previously successful energy
level.
 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.
 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 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 (2005
Consensus Conference): vasopressors, anti-
arrhythmics and other drugs.
 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.
.
 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.
 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.
 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.
 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.
 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.
 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.
 CPR must be continued until
 Cardiopulmonary system is stabilized
 The patient is pronounced death
 Alone rescuer is physically unable to
continue