Advanced Life Support - Guidelines 2010 (ALS) MUDr. L. Dadák ARK, FN u sv. Anny Resuscitation journal homepage: www.elsevier.com/locate/resuscitation ^Cardiopulmonary Resuscitation (For pediatric resuscitation, see Ch. 263.) In unconscious or collapsed persons, the state of ventilation and circulation must be determined immediately. Speed, efficiency, and proper application of CPR directly relate to successful neurologic outcome. An urgent systematic approach should ensure that only seconds elapse between recognition of cardiac arrest and intervention. Tissue anoxia for > 4 to 6 min can result in irreversible brain damage or death, yet prognosis varies widely depending on age, cause of arrest, and clinical circumstances. Successful CPR depends on early basic life support (BLS), prompt recognition and treatment of VF if present, and advanced airway and rhythm control as necessary. CPR must be continued until the cardiopulmonary system is stabilized, the patient is pronounced dead, or resuscitation cannot be continued (rescuer exhaustion). After profound hypothermia or prolonged cold-water submersion, CPR should be continued until the total body core is rewarmed because patients needing CPR for as long as 3 h have recovered. Guidelines established by the American Heart Association divide CPR into a primary and secondary survey. PRIMARY SURVEY After establishing unresponsiveness of the victim (tap, shake, or shout), the rescuer calls for help, notes the exact time of arrest (if known), and positions the victim horizontally on a hard surface. Then BLS is rapidly carried out following the mnemonic ABC (see Table 206-1). Next, defibrillation (D) is used to correct VF or pulseless VT if appropriate equipment is immediately available (conventional or automated defibrillators). When the exact duration of cardiac arrest is uncertain, the victim, unless in a terminal stage of an incurable condition, should be given the benefit of the doubt. Once BLS is begun, the physician must decide when to end it. The physician stops treatment and pronounces the patient dead if deep unconsciousness or absence of spontaneous respiration, circulation, and brain stem reflexes indicates that resuscitation is impossible. This implies that the patient has been refractory to standard BLS and available advanced cardiac life support (ACLS) measures. Although evidence of neurologic function during resuscitation favors brain recovery, absence of this evidence is not a reliable indication that the brain will not recover. Airway Opened Opening the airway (A) is the first priority in BLS for respiratory insufficiency (labored, noisy breathing) and for cardiac or respiratory arrest. Sometimes an opened airway is all that is needed to restore spontaneous breathing (B) and circulation (C); in these instances, cardiac compression is not needed. Airway obstruction resulting from relaxed tongue and neck muscles in an unconscious person is accentuated with neck flexion. A head tilt backwards stretches the anterior neck structures, lifting and drawing the tongue away from the posterior pharyngeal wall. Because head tilt alone usually does not open the airway sufficiently, an additional measure is needed. The head tilt-chin lift is performed by tilting the head back and placing a finger of the second hand under the rim of the mandible, lifting the chin forward (vertically upwards) until the teeth are brought almost together, but using care to avoid closing the mouth (see Fig. 206-1A). If this approach is unsuccessful, the head tilt-neck lift should be used. This is performed by placing one hand on the victim's forehead, lifting the neck straight up while tilting the head back. Both techniques can open the airway quickly. A mandibular jaw thrust is added if neither the head tilt-chin lift nor the head tilt-neck lift is successful or if the patient is breathing spontaneously with noisy respirations from partial airway obstruction. This triple airway maneuver (head tilt-neck lift-mandibular jaw thrust) produces additional forward displacement of tongue and neck structures. The rescuer stands or kneels at the head of the patient, placing the hands at the sides of the patient's face and using the fingertips to lift the mandible forward. Usually, the most comfortable position involves resting the elbows on the flat surface on which the victim is lying. The mandibular jaw thrust without head tilt is the preferred method for establishing an airway in patients with suspected cervical spine injuries (eg, a trauma victim) and respiratory compromise. This technique maintains the cervical spine in a neutral position while establishing a patent airway. It can be combined with chin lift alone as needed. Unless initial attempts to open the airway are unsuccessful, dentures should be left in place because removing them may make a mouth-to-mouth seal more difficult during rescue breathing. After the airway is opened, evidence of spontaneous ventilation is sought by watching for the rise and fall of the victim's chest while listening for airflow at the mouth, feeling exhaled air on the rescuer's cheek. If spontaneous ventilation does not occur while the airway is held open, rescue breathing is immediately begun. Breathing Restored (See also Mechanical Resuscitation Devices, below.) Rescue breathing: Rescue breathing using mouth-to-mouth resuscitation is begun by placing the heel of one hand against the victim's forehead to keep the head tilted backward, using the thumb and index finger to gently pinch the nostrils shut to prevent escape of air (Fig. 206-1B). The rescuer opens his or her own mouth widely, deeply inhales, makes a tight seal with the mouth over the victim's mouth, and blows two full breaths (1 to 1.5 sec each), thereby beginning ventilation yet avoiding trapping air in the stomach. The adequacy of these ventilatory efforts is assessed by seeing the victim's chest rise and fall and by hearing and feeling passive exhalation. Adequate time (1 to 2 sec per ventilation) should be provided to allow for exhalation. Mouth-to-nose resuscitation is indicated when a tight seal around the victim's mouth is impossible or when the mouth cannot be opened because of muscular spasm, deformity, or severe inflammation. Backward tilt of the head in these instances is similar to that in mouth-to-mouth resuscitation, but the rescuer's other hand should push the lower jaw forward, closing the mouth. A tight seal is made around the victim's nose and a deep breath is delivered. The victim's mouth should be allowed to open during passive exhalation. Combined mouth-and-nose resuscitation is used for infants and small children when a tight mouth seal cannot be maintained. The rescuer places the mouth over the victim's mouth and nose, inflating the victim's lungs with varying amounts of air according to the victim's size (see Fig. 206-2C). In general, in children >= 8 yr of normal body size, adult CPR techniques can be used. Cricoid pressure, if experienced personnel are available, should be applied continuously until airway control is achieved with endotracheal intubation. This technique takes advantage of the rigid cartilaginous rings of the trachea to occlude the esophagus. Applying cricoid pressure minimizes gastric inflation from ventilations and minimizes the risk of aspiration if regurgitation of gastric contents occurs. The techniques used in one- and two-rescuer CPR are shown in Table 206-2. Whereas inhaled air contains about 21% O2 and trace amounts of CO2, exhaled air contains 16 to 18% O2 and 4 to 5% CO2, which is adequate to maintain the victim's blood O2 and CO2 values at close to normal levels if the correct rate and amplitude of ventilation are used. If the rescuer develops hyperventilation alkalosis (manifested by dizziness, numbness, ringing in the ears, and paresthesias), the respiratory rate should be slowed or the amplitude of each breath decreased. Also, excessive gastric distention with the associated risk of subsequent aspiration may occur if larger-than-necessary volumes of air are used. Heimlich maneuver: In adults, if the rescuer does not feel the lungs expand or see the chest rise after opening the airway and applying rescue breathing, the airway is assumed to be still obstructed. The rescuer should reposition the head trying an alternative head-tilt method, make a firm mouth-to-mouth seal again, and repeat rescue breathing. If airway obstruction persists, the victim is rolled into the supine position, and the Heimlich maneuver (manual thrusts to the upper abdomen or, in the case of pregnant or extremely obese patients, chest thrusts) should be given. The Heimlich maneuver is performed by sitting astride the unconscious victim (above the knees) and placing the heel of a hand in the upper abdominal area below the xiphoid process (to avoid damage to chest structures and to the liver, the hand should never be placed on the xiphoid process or over the lower rib cage); the other hand is placed on top of the first and a firm upward thrust is delivered. (Note: A straight downward thrust may injure the aorta.) For chest thrusts, the unconscious victim is placed supine and the hand is placed over the sternum similar to that used for cardiac compression (see Circulation Restored, below). With both techniques, 6 to 10 thrusts may be necessary to dislodge a foreign body. Children with airway obstruction should have the Heimlich maneuver performed; in small children, it should be performed more gently, kneeling at the feet rather than astride. Infants < 1 yr should be held in a head-down position while the rescuer delivers four back blows (see Fig. 206-2A). Up to four chest thrusts can be delivered by placing the infant's back on the rescuer's thigh in the head-down position. The rescuer can also support the infant by placing one hand behind the neck and the other behind the back. Blind finger sweeps: In adults, a foreign body may also be removed by sweeping the index finger along the cheek through the mouth and pharynx after the tongue and lower jaw have been displaced forward (tongue-jaw lift). Care should be taken so as not to dislodge the foreign body further into the airway. Additional finger sweeps and manual abdominal thrusts may be required to dislodge the foreign body completely or to relieve the blocked airway. Blind finger sweeps are not recommended in children or infants. However, if the obstructing object can be seen, it should be carefully removed. Progressive hypoxemia may relax the throat muscles; finger sweeps frequently dislodge a supralaryngeal foreign body after initial attempts have failed. Once airway obstruction is cleared: CPR must be implemented quickly. If obstruction persists, cricothyrotomy must be performed; surgical establishment of an airway (tracheostomy) may also be necessary in the presence of severe orofacial injuries or massive inflammation of the neck and pharyngeal structures (see Airway Establishment and Control in Ch. 65). The most common errors in performing expired-air resuscitation are delays in diagnosing respiratory or cardiac arrest; failure to establish a patent airway; delays in instituting BLS promptly; and inadequate ventilation (eg, poor seal around mouth or nose, failure to deliver the initial two full breaths, or inadequate amount of expired-air pressure generated to cause chest movements). Circulation Restored While tilting the victim's head backward to open the airway, the rescuer should use a free hand to gently palpate for the carotid pulse for 5 to 10 sec (the pulse may be irregular, weak, or rapid). If no pulse is felt, the rescuer should immediately begin external (closed-chest) cardiac compression with rescue breathing. To do this effectively, the victim must be placed horizontally on a flat hard surface (eg, floor, operating table, bedside tray, bed board). With the middle finger in the xiphisternal junction, the rescuer places the index finger on the lower end of the sternum and the heel of the other hand on the sternum just above the index finger of the palpating hand. The heel of the palpating hand is placed on top of the hand on the sternum--not the xiphoid process--to begin compressions. The rescuer should be positioned directly over the victim and, keeping the arm straight, should exert sufficient force directly downward over the sternum (to avoid rib fractures), depressing the sternum 4 to 5 cm (1.5 to 2 inches) in the adult. The fingers may be extended or interlocked but must be kept off the chest wall. Compression time should equal release time. The rescuer's hands should remain on the sternum during the release phase. This cycle should be repeated smoothly; jerky, bouncing, or irregular compressions increase the chance of injuries. In children > 1 yr but < 8 yr, the heel of one hand is used to perform external cardiac compression over the lower sternum (not as low as in the adult); the depth should be 2.5 to 3.8 cm (1 to 1.5 inches) at a rate of 80 to 100/min. An infant's heart is higher in the chest, and the chest wall is more pliable. For compression, the tips of the index and middle fingers are used over the midsternum to a depth of about 1.3 to 2.5 cm (0.5 to 1 inch) at a rate of 100/min. The effectiveness of CPR should be monitored periodically during resuscitation efforts. The carotid pulse should be palpated 1 min after beginning BLS, after the arrival of a second rescuer, and q 4 to 5 min to determine whether spontaneous circulation has returned. Ideally, external cardiac compression produces a palpable pulse with each compression; although cardiac output is only 30 to 40% of normal, the systolic BP should be > 80 mm Hg. Restored pupillary responsiveness is a sign of adequate brain circulation and oxygenation. Dilated, light-responsive pupils may indicate that brain damage has not occurred but that cerebral oxygenation is inadequate. However, persistently dilated pupils do not prove brain damage or death because high doses of cardioactive drugs, other drugs, or cataracts in the elderly may modify pupil size and reaction. Open-chest cardiac compression may be effective after penetrating chest trauma, cardiac tamponade, cardiac arrest in the operating room with the patient's chest already open, and crushed-chest injury. However, this procedure requires training and experience in the performance of thoracotomy and is best performed only in extreme, extenuating circumstances. Complications Laceration of the liver is the most serious (sometimes fatal) complication and is usually caused by pressing too low on the sternum. Do not press down on the xiphoid process! Delayed rupture of the spleen after CPR has been reported, and rupture of the stomach can occur (particularly if gastric distention with air has occurred) after forcible abdominal thrusts. A serious complication is regurgitation followed by aspiration of gastric contents, producing an aspiration pneumonitis that may be fatal. Excessive gastric distention during artificial ventilation can be avoided by using the recommended amounts of air, by completely opening the airway before attempting rescue breathing, and by early endotracheal or nasotracheal intubation. If marked distention develops, the airway should be rechecked for patency and excessive airway pressure avoided. Attempts to relieve gastric distention should wait until suction equipment is available because regurgitation with aspiration of gastric contents may occur. If marked gastric distention interferes with ventilation and cannot be corrected by the above methods, the victim should be positioned on his or her side, the epigastrium compressed, and the airway cleared. Costochondral separation and fractured ribs sometimes cannot be avoided if pressing hard enough to produce a palpable pulse. Bone marrow emboli to the lungs have rarely been reported after external cardiac compression, but there is no clear evidence that they contribute to mortality. External cardiac compression does not cause serious myocardial damage unless there is a preexisting ventricular aneurysm. Lung damage is rare, but pneumothorax secondary to rib fracture can occur. Overall, concern for these injuries should not deter or modify appropriately performed CPR. Defibrillation A forceful precordial thump can convert VF or VT into functional cardiac rhythm, or, conversely, it can convert an organized cardiac rhythm into VF, VT, or asystole. A forceful precordial thump is advised only when a defibrillator is not available. The initial call for help should result in the prompt arrival of someone with a defibrillator. The success of defibrillation is time-dependent, with a 2 to 10% decline in success rate per minute of cardiac arrest. Prompt DC cardioversion appears to be more effective in resuscitation than do other therapies (eg, antiarrhythmic drugs). Automated external defibrillators provide prompt treatment of VT or VF without physician intervention. Defibrillating paddles (with conducting paste or moist saline pads beneath them) are placed over the 2nd intercostal space along the right sternal border and over the 5th or 6th intercostal space at the apex of the heart. If an immediate countershock of 200 joules is unsuccessful, a second countershock of 200 to 300 joules is given. A third countershock of 360 joules is used if VF persists. These three countershocks should be delivered consecutively, without interruption for CPR or drug therapy. The defibrillating paddles should be immediately recharged after each countershock without removal from the chest wall if conventional paddles are used. If VF is seen on the monitor after the initial countershock, the patient should immediately receive a second countershock. If a non-VF rhythm is seen, the paddles should be removed from the chest wall, the defibrillator disarmed, and the presence of a pulse determined. If rapid defibrillation is unsuccessful, BLS should be resumed, and drug therapy is based on the secondary survey (see below). Special Circumstances In electrical shock, the rescuer must be certain that the victim is no longer in contact with the electrical source to avoid shock to him- or herself. Use of nonmetallic grapples or rods and grounding of the rescuer enables safe removal of the victim, and CPR then can be started. In near drowning, artificial ventilation may be started in shallow water, although chest compression cannot be done effectively when the victim is not horizontal. Placing the victim on a surfboard or float may help. In trauma, CPR may present several problems. A cervical spine injury requires modification of the airway-opening techniques described above. Facial injuries associated with oropharyngeal bleeding or debris may require clearing the airway before beginning ventilation. Severe facial injuries may make mouth-to-mouth resuscitation impossible without adjunctive devices and advanced procedures (eg, endotracheal intubation). Chest trauma, including flail chest injury or penetrating lesions of the heart or lungs, may present similar obstacles. In these situations, stabilization in the field by trained medical personnel and immediate transport to a specialized facility are indicated. SECONDARY SURVEY Secondary survey comprises advanced cardiac life support (ACLS) with BLS. ACLS includes drug therapy, cardiac monitoring (ECG diagnosis), adjunctive equipment, and special techniques for establishing and maintaining effective oxygenation and circulation. The secondary survey follows a sequence similar to that of the primary survey (ABCD--see Table 206-1). The need for the secondary survey implies that the patient has failed initial resuscitative efforts. The rescuer must thus consider the differential diagnosis of cardiac arrest and the need for basic treatment of arrhythmias and specific interventions. Causes such as electrolyte abnormalities (hypokalemia or hyperkalemia), acid-base disorders (metabolic acidosis), hypovolemia, massive pulmonary embolism, or pneumothorax will lead to different treatments in the secondary survey. Arrhythmia recognition and clinical circumstances dictate the specific therapy to be used. VF, bradycardia, and electromechanical dissociation (EMD) require prompt recognition and intervention. Therefore, ECG monitoring should be established in unconscious or collapsed persons as soon as feasible. An IV line should be started; two lines minimize the chance of losing IV access at a critical time. Large volumes of fluid can be delivered through short, large-bore peripheral IV lines. Antecubital veins are the initial preferred access sites. Long femoral vein lines do not require that CPR be interrupted and have less potential for lethal complications. A subclavian or internal jugular central line can be placed by experienced personnel if initial treatment does not restore circulation (see Invasive Procedures in Ch. 198). Implementation of ACLS should not interrupt BLS (ventilations and cardiac compressions) for > 15 to 30 sec. In a patient without IV access, lidocaine, atropine, and epinephrine may be given via the endotracheal tube at 2 to 2.5 times the IV dose. The type and volume of fluids or drugs given depend on the clinical circumstances; in cardiac arrest complicating myocardial ischemia, IV fluids (eg, normal saline) are usually given only to keep an IV line open, whereas vigorous volume replacement (crystalloids, colloid solutions, blood) may be required to expand the plasma volume in circulatory collapse resulting from volume losses. Drug Therapy Epinephrine (1 mg given as 10 mL of 0.1 mg/mL q 3 to 5 min) is the first-line drug for ventricular fibrillation (VF) when initial defibrillation fails. Rhythm should be reassessed about 30 to 60 sec after administration. If VF or ventricular tachycardia (VT) persists, up to three consecutive cardioversions can be given before further drug therapy. This sequence can be repeated for persistent VF or VT. The incremental value of additional drugs over continued cardioversion with intermittent epinephrine administration is not accepted. Lidocaine 1.0 to 1.5 mg/kg is given rapidly IV and may be repeated in 3 to 5 min to a total dose of 3 mg/kg. Onset of action is immediate after rapid IV administration, but constant infusion is required to maintain therapeutic blood levels. Advanced age and decreased hepatic function can impair lidocaine metabolism, and lower loading doses should be considered. Thirty-second to 60-second cardioversion may be used. VF or VT that is resistant to epinephrine, defibrillation, and lidocaine or recurs on lidocaine may be treated with bretylium tosylate by rapid IV injection (with a loading dose of 5 mg/kg q 15 min followed by cardioversion). A second dose of 10 mg/kg may be given by rapid IV injection in 5 min (total maximum loading dose, 30 mg/kg). In refractory VF or VT, procainamide may be administered at a dose of 30 mg/min up to a total of 17 mg/kg. Faster infusion rates may be desired but are largely undocumented. Phenytoin may be used to treat VF or VT due to digitalis toxicity that is refractory to other drugs. A dose of 100 mg up to 1 g total dose is given slowly (<= 50 mg/min) in an IV running 0.9% sodium chloride solution. Magnesium sulfate has not been shown to be useful in randomized clinical studies. Rapid IV administration of Mg 1 to 2 g is considered to help patients with known or suspected Mg deficiency (ie, alcoholism). Sodium bicarbonate is no longer recommended as initial, automatic therapy for cardiac arrest because it may induce paradoxical acidosis of the brain and heart, hyperosmolarity, or hypernatremia or alkalemia and may inhibit the release of O2 by the blood. Other adjuncts (eg, defibrillation, ventilation, cardiac compression, drugs) should be tried first unless the cardiac arrest is caused by preexisting bicarbonate-responsive acidosis, hyperkalemia, or tricyclic overdose with complex ventricular arrhythmias. When sodium bicarbonate is used, administration should be dictated by arterial pH monitoring (q 5 min). Calcium chloride is no longer recommended in the absence of hyperkalemia, hypocalcemia, or Ca blocker toxicity because high circulating levels of Ca++ may have adverse effects. When necessary, calcium chloride 2 mL of a 10% solution (100 mg/mL = 1.36 mEq/mL) can be given IV prn at <= 1 mL/min. Other forms of Ca may be used (calcium gluceptate 3 mL [0.9 mEq/mL], calcium gluconate 6 mL [0.45 mEq/mL]). Caution is necessary when digitalis toxicity is a potential cause of the cardiac arrest. Asystole is treated by epinephrine 0.5 to 1.0 mg given rapidly IV q 5 min. Epinephrine has combined alpha- and beta-adrenergic receptor properties. Alpha effects may augment peripheral and coronary diastolic pressure, thereby increasing perfusion to subendocardial regions during chest compressions. This may generate electrical activity and increase cardiac contractility, thus increasing cardiac output. Because good absorption of epinephrine occurs from the lungs, endotracheal administration should not be delayed if starting an IV line is difficult. Intracardiac injection of epinephrine is not recommended unless IV or airway routes are inaccessible because pneumothorax, coronary artery laceration, cardiac tamponade, and prolonged interruptions of CPR are complications. A flat line on the ECG is most commonly due to operator error (false asystole), eg, from leads that are loose or not connected to the patient or monitoring equipment, lack of power, or low signal gain. Changing to another lead or reorientation of the defibrillation paddles is appropriate. Atropine sulfate 0.5 to 1.0 mg q 5 min (to a total of 0.03 to 0.04 mg/kg) can also be given if asystole persists. Atropine is a parasympatholytic drug that increases heart rate and conduction through the atrioventricular node. It may be useful for bradyarrhythmias with myocardial ischemia (especially inferior wall) or high-degree atrioventricular nodal block. If neither epinephrine nor atropine restores regular ECG complexes, temporary transcutaneous pacing should be instituted immediately. A temporary transvenous electrical pacemaker (which can be passed into the right ventricle) or transthoracic percutaneous pacing electrodes placed subcostally can be substituted if transcutaneous pacing is unavailable or unsuccessful. However, pacing is less successful the longer the cardiac arrest. Electrical thresholds to sensing and pacing are determined immediately after insertion; successful temporary pacing thresholds are usually about 1 to 2 milliamperes. Maintenance electrical output should be two to three times this threshold, and the pacemaker should be set to maintain a heart rate of >= 70 to 80 beats/min. If pacing is unsuccessful, epinephrine, atropine, or lead repositioning may be attempted. Routine defibrillation of asystole is discouraged, because it can result in profound parasympathetic discharge. Pulseless electrical activity is circulatory collapse that occurs despite satisfactory electrical complexes on the ECG. This may be caused by pump failure from extensive myocardial dysfunction, profound loss of peripheral vasomotor tone, massive volume loss, cardiac tamponade, intracardiac tumor or thrombus impaction, tension pneumothorax, or massive pulmonary embolus. Pulseless electrical activity is not necessarily synonymous with electromechanical dissociation (EMD) because the myocardium may still contract but insufficiently to allow detection of BP by the usual methods. In pulseless electrical activity, BLS should be combined with volume infusion, epinephrine (0.5 to 1.0 mg IV), and other ACLS measures. Atropine may be given for bradycardia. A common cause of pulseless electrical activity is relative or absolute volume depletion. Crystalloid or colloid solutions 500 to 1000 mL should therefore be infused; larger volumes may be required in anaphylaxis or massive volume loss. Dopamine or epinephrine infusions may be titrated to augment systemic venous return. Cardiac tamponade is an important cause of pulseless electrical activity and is readily treatable by pericardiocentesis at the bedside (see Ch. 209). Tension pneumothorax is another important cause that can be remedied by needle placement or chest tube insertion. Drug overdose with tricyclic antidepressants, digitalis, beta-blockers, or Ca blockers is another cause. Careful monitoring in pulseless electrical activity for blood flow undetectable by routine arterial palpation using Doppler ultrasound or intraarterial pressure monitoring is indicated. Patients with detectable cardiac contractility should be treated aggressively. In circulatory shock, if left ventricular failure is not evident, initial treatment is with cautious IV volume infusions. For severe arterial hypotension unresponsive to volume replacement, the following drugs are useful by continuous infusion with titration as needed to restore BP: the inotrope dopamine 400 mg in 250 mL of 5% D/W (1.6 mg/mL) beginning at 3 to 5 µg/kg/min; the inotrope and vasoconstrictor epinephrine 8 mg in 250 mL 5% D/W (32 µg/mL) at 2 to 10 µg/min; or the peripheral vasoconstrictors norepinephrine 8 mg in 250 mL of 5% D/W or 0.9% sodium chloride solution (32 µg/mL) at 2 to 16 µg/min, or phenylephrine 50 mg in 250 mL of 5% D/W (200 µg/mL) at 0.1 to 1.5 µg/kg/min. Vasoactive drugs should be used in the minimal dose necessary to achieve satisfactory BP because they may increase vascular resistance and decrease organ perfusion, especially in the mesenteric bed. Sometimes CPR must be resumed after resuscitation and continued until adequate ventilation, palpable pulse, and acceptable BP indicate stabilized cardiopulmonary function. Mechanical Resuscitation Devices Mechanical devices are adjunctive and should not routinely replace immediate mouth-to-mouth ventilation and manual external cardiac compression during BLS. They should be used only when available within seconds, to replace manual methods during sustained resuscitation, or when the patient must be moved. Specialized equipment should be used only by experienced personnel. In clinics and hospital areas where the need for CPR is predictable and the risk of HIV, hepatitis, or other infection is high (eg, ICU, emergency room, operating room), these devices should be readily available, minimizing the need for rescue breathing. Airway support: The primary purpose of airway support is to provide supplemental O2 and ventilation during resuscitation efforts. Bag-valve-mask devices incorporate a self-inflating bag and a nonrebreathing valve mechanism (resuscitator bags, Ambu bag). These devices should be used with supplemental O2 and can achieve from 60 to 100% delivered O2, assuming the highest acceptable O2 flow rate, the longest possible bag refill, and a reservoir for O2 collection to avoid entrainment of room air (whenever possible). Bag-valve-mask devices are best used with artificial airways, which should be used only when the patient is unconscious. Airway obstruction and subsequent hypoxemia, vomiting, and aspiration may occur if an airway is forced into a conscious or stuporous patient's mouth. Cuffed endotracheal tubes are used to secure a compromised airway, prevent aspiration, initiate mechanical ventilation, and suction the lower respiratory tract. They are indicated in comatose patients and those in whom artificial ventilation is required. Manual airway control, ventilation, and oxygenation during BLS and supplemental O2 during ACLS are always indicated before attempts at tracheal intubation. Orotracheal intubation is faster than nasotracheal intubation in emergencies; suction apparatus and other emergency equipment should always be present. Bag-valve-mask devices with adaptors are fitted to endotracheal tubes, and the patient should be manually ventilated until cardiovascular stability is restored. When a deformity or muscle spasm prevents orotracheal intubation, blind nasotracheal intubation may be attempted. If this is impossible, special techniques to gain airway control (eg, transtracheal catheter ventilation, cricothyrotomy) may be required (see Airway Establishment and Control in Ch. 65). Double oropharyngeal airways have been used instead of mouth-to-mouth ventilation during BLS, but they are more difficult to use because the rescuer's fingers must seal the victim's lips around the tube while the thumb clamps the nose. Opening the mouth and maintaining a patent airway may be difficult, and stimulation of the victim's hypopharynx may cause vomiting as consciousness is regained. Esophageal obturator airways have been used as adjuncts in treatment of cardiac arrest but should be inserted by personnel experienced in their use but not trained in endotracheal intubation. Complications include esophageal perforation and excess Introduction lThe most common cause of death is a heart attack. lA disturbance in the electrical rhythm of the heart called ventricular fibrillation. lBecause up to 80% of all cardiac arrests occur in the home, you are most likely to perform CPR on a family member or loved one. Obr: AIM front wall + septum What is CPR? Combination of chest compressions and rescue breathing delivered to victims thought to be in cardiac arrest. lBasic Life Support = Základní neodkladná resuscitace lAdvanced Cardiac Life Support = Rozšířená neodkladná resuscitace Basic Life Support 2005..2010 DR ABC lDanger lResponse lAirway l lCirculation lBreathing Top-less CPR lopening of airway and chest compressions without breathing to casualty lrisk of infection When to start? Person without sign of life When Not to start? lend stage disease, no prognosis ltrauma with no hope for life (decapitation) lsigns (indication) of death (patch, Tonelli sign) ltime factor (15 – 30 minutes from stop of circulation to your arrival), temperature, age. When stop CPR: lrestored vital functions ldoctor takes care of victim lno power to continue with CPR Alphabet of CPR BLS /basic life support/ A - airway B - breathing C - circulation ACLS /advanced cardiac life support/ D – Defibrilation E – everythink else Advanced Cardiac Life Support = BLS + lA+ B: lOxygen lIntubation, LM, Combitube lPositive Pressure Ventilation lC: lVein access, drugs, fluids lTherapy of fibrilation Alphabet of CPR BLS /basic life support/ A - airway B - breathing C - circulation ACLS /advanced cardiac life support/ D - drugs and fluids E - ECG F - fibrilation treatment 2010 VF/ VT Co je to? Co je to? Co je to? Co je to? Co je to? Co je to? Asystoly ?? low amplitude VF ?? ¡if in doubt - asystoly VENTRICULAR Fibrillation Ventricular fibrillation lelectrical instability of heart muscle (ischemia, hypothermia) sings: lpulselessness Th: defibrillation, adrenalin, vasopressin amiodarone Please Shock-Shock-Shock, EVerybody Shock, And Let's Make Patients Better l (Please = precordial thrump) l Shock 200J bifasic / 360J mono l EVerybody = Epinephrine / Vasopressin lAnd = Amiodarone lLet's = Lidocaine lMake = Magnesium lPatients = Procainamide lBetter = Bicarbonate Defibrillation lDefibrillation sends a high energy DC electric shock through the heart, stopping it momentarily. The sinoatrial node should then take over and a coordinated rhythm restart. However, ventricular fibrillation often recurs so multiple shocks are used routinely. Position of electrodes: Energy: Joule (Watt × sec.) heard - ONLY 4%/ monophasic shock 360 J biphasic shock 200 – 300 - 360J internal shock 25 - 35 J Biphasic versus monophasic lMonophasic defibrillation delivers a charge in only one direction. lBiphasic defibrillation delivers a charge in one direction for half of the shock and in the electrically opposite direction for the second half. Defibrillation Voltage 1,5 – 3 kV Current 30 – 40 A Time 15 ms Impedance of Th 70 – 80 ohms lSkin burns l"stand clear" order • Diagnosis on ECG monitor – flat line • Airway management - hypoxia • Adrenalin 1 mg i.v. á 3 min. children 10 μg/kg Asystole The worst situation Asystole ..... Check me in another lead, then let's have a cup of TEA." l((T = Transcutaneous Pacing)) ex 2005 lE = Epinephrine l((A = Atropine)) ex 2010 • Hypovolemia • Hypoxia • H acidosis • Hyper/hypocalemia • Hypothermia + Pulseless Electrical Activity reasons: PEA - reasons: • „Tablets“ (overdose) • Cardiac Tamponade • Tension pneumothorax • Trombosis of C.a. • Trombosis of a.pulm. (embolie) Pulseless electrical activity are guided by the letters P-E-A lProblem (H, T) lEpinephrine l(atropin) ex2010 Chest compressions lRescuer should stand or kneel next to victim's side. lin the centre of the chest lPlace heel of 1 hand on lower sternum and other hand on top of hand lApply pressure only with heel of hand straight down on sternum with arms straight and elbows locked into position so entire weight of upper body is used to apply force. lDuring relaxation all pressure is removed but hands should not lose contact with chest wall. lSternum must be depressed at least 5 cm in average adult (palpable pulse when SBP >50 mm Hg) lDuration of compression should equal that of relaxation. lCompression rate should be at least 100 max 120/min. Adequacy of chest compressions l is judged by palpation of carotid or femoral pulse (palpable pulse primarily reflects Systolic Blood Pressure). C – circulation Signs of circulation = pulsations la. carotis communis la. femoralis children l a. brachialis Airway Problem = obstruction lrelaxed tongue and neck muscles in an unconscious person lforeign body Solution: lhead tilt-chin lift lairway llaryngeal mask lcombitube lintubation lconiotomy Esmarch: lHead tilt lChin lift lMouth open Airway LM Combitube Intubation lLaryngoskope lMagill pincers ltracheal tubes lIntroducer lsyringe rarely: lbronchoscope Coniotomy lurgent preservation of airways llig. cricothyreoideum (lig. conicum) B – breathing ACLS positive pressure ventilation lbug („ambu“), holding mask by 1 or 2 hands l(ventilator – Volume Control Ventilation) l6 ml/kg; 10/min, fiO2 100% lACLS 2 breaths linspiration 1st ratio – 2 : 30 - ventilated by mask no ratio = 10 : 100 – advanced airway l Oxygen las high FiO2 as possible – during compressions lHypoxia and acidosis contra efficiency of electric and pharmacology therapy Hyperoxemia after recovery of circulation is harmfull SpO2 .. 94% Circulation l pulsations on central arteries (a.carotis; a.femoralis) lNEVER - periferal – wrist art. lNEVER – (heart rate) lNEVER – blood pressure lNEVER - (capilary refill ) Ratio 2005..2010 compressions : breaths ladult nonintubated 30 : 2 ladult intubated 100:10 lchild 30:2 - 2medical team 15:2 lnewborn 3:1 Drugs - administration Intravenously – periferal cath. - v. jugul. externa - v. femoralis - central v. cath. - v. subclavia - v. jugul. interna Intraoseal access - children lAdd 20ml i.v of fluids to move the drug. lEffect in 1 min • after 3rd defibrilation: • Adrenalin 1 mg i.v. á 3 min. children 10 μg/kg • Antiarhythmics: Amiodaron 5 mg/kg 300 mg slowly i.v. drugs of VF Epinephrine = Adrenalin Alfa effect = raise diastolic pressure - raise brain, heart perfusion pressure Beta effect - raise contractility - change of type of fibrillation D: 1 mg i.v. a 3 min Amiodarone (CORDARONE) lantiarytmic drug I: lrecurent VF D: l5mg/kg (150mg iv.) Fluids lBolus of 20ml after each dose = movement of drug lAcute bleeding – rubt. AAA, EUG; Types: lCrystaloids – Ringer, Hartman, physiol. sol. lColoids – Gelatina, HAES = stark lGlc – do NOT use – wrong neurology result After recovery of circulation lStabilisation of vital functions (circulation, ventilation, AB) lDiagnosis and treatment of reason of cardiac arrest lHypothermia 32 – 34 °C for 12 – 24 h (better neurological outcome)