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1、Cardiopulmonary ResuscitationPeizhi HuangZhongshan Hospital1 1Diagnosis of cardiac and respiratory arrest Traditional methods : 1. Carotid pulse check by lay rescuers 2. Loss of consciousness 3. Pupil dilation 4. Respiratory arrest2 2 Guideline 2000Elimination of the pulse check for lay rescuersEval
2、uate for signs of circulation in 10 seconds breathing , coughing , movement in response to rescue breath3 3 Assess for a pulseTime is too longerAccurate rate 75 %Sensibitity 90%Specificity 60%4 4Rate of false- positive(40%) Results Pulseless Pulse Mistakenly loss the saving opportunity5 5Rate of fal
3、se-negative (10 %) Results Pulse Pulseless Unnecessarily do CPR6 6 Electrocardiogram changes of Cardiac arrest Ventricular fibrillationA flat line or only atrial wavePulseless Electrical Activity, PEA7 7 The chain of Survival Early access Early access Early CPR Early CPR Early Defibrillation Early D
4、efibrillation Early advanced life supportEarly advanced life support * * patient withpatient with Coma Coma （ immediatelyimmediately do CPR do CPR ， not clear obstructed airways at first not clear obstructed airways at first） 8 8Basic Life Support - the first ABCDAirway ABreathing BCirculation CDefi
5、brillation D9 9 AirwayTilt the head backwardsLift the jaw Open the mouthClearing obstructed airways from choking Subdiaphragmatic abdominal thrust (Heimlich maneuver)1010 BreathingMouth to mouth or mouth to noseMouth to oropharyngeal tube Mouth to shieldMouth to mask(compressing the cricoid cartilag
6、e in order to decrease gastric distention and prevent gastric reflu)Bag-mask ventilation challenged endotracheal intubation resuscitations “gold standard”1111Circulation external chest compression High-frequency（100 compressions per min） aortic pressure myocardial perfusion pressure cardiac outputs
7、rise survival rate Reduce interrupted compression ( compression ventilation ratio simplified to 15:2)Compression-only CPR: unwilling or unable to perform mouth to mouth or cardiogenic cardiac arrest1212Circulation Compression-only CPRResearch suggests: Survival rate with compression-only CPR in firs
8、t 612 minutes is 40.8% Survival rate with chest compression add artificial ventilation is 34.1% , because artificial ventilation may be result in respiratory alkalosis. 1313 Mechanism of external chest compression Chest pumpChest pump - sequential increased and decreased pressure - sequential increa
9、sed and decreased pressure in the thoracic cavity in the thoracic cavity - valves maintaining forward direction of flow - valves maintaining forward direction of flowCardiac pumpCardiac pump -sequential filling and emptying of cardiac -sequential filling and emptying of cardiac chambers chambers -va
10、lves maintaining forward direction of flow -valves maintaining forward direction of flow1414 CirculationThump versionThump version from 20-25 cm high to chest from 20-25 cm high to chestCough VersionCough Version in 10-15 second in 10-15 secondIntermittent abdominal compression-Intermittent abdomina
11、l compression-c cardiopulmonary resuscitationardiopulmonary resuscitation（IAC-CPR)IAC-CPR)Activated compression-decompressionActivated compression-decompression（ACD-CPRACD-CPR) )PhasedPhasedChest and Abdominal ACD-CPRChest and Abdominal ACD-CPR （Life-stick ResuscitationLife-stick Resuscitation） incr
12、ease mean pressureincrease mean pressure，coronary and cerebral perfusion coronary and cerebral perfusion pressure pressure，left ventricular and cerebral blood flowleft ventricular and cerebral blood flow1515Automated external defibrillator - AED Ventricular fibrillation : may be used by 200J*3 Ventr
13、icular fibrillation : may be used by 200J*3 times) or 200Jtimes) or 200J、200-300J200-300J、300J300J If If If If p polymorpholymorphic ventricular tachycardia can not be ic ventricular tachycardia can not be clearly distinguished from ventricular fibrillation clearly distinguished from ventricular fib
14、rillation (VF), treatment would refer to be as VF (VF), treatment would refer to be as VF Atrial fibrillation :100-200J synchronized Atrial fibrillation :100-200J synchronized Atrial flutter or supraventricular tachycardia Atrial flutter or supraventricular tachycardia 50- 100J synchronized 50- 100J
15、 synchronized Ventricular tachycardia Ventricular tachycardia 100J synchronized100J synchronized1616 Biphasic waveform defibrillation A compensated defibrillation for the second time in limited timeLow-energy levels（150J correspond to 200-300J）Reduce the myocardial injury 1717 Advanced Life Support
16、- the second ABCDEndotracheal intubation (A)Mechanical ventilation and oxygen therapy (B)Intravenous injection (C)electrocardiogram electrocardiogram and blood pressure monitoring, resuscitation drug , open chest cardiac compression (C)Differential diagnosis (D)1818 Confirmation of Endotracheal tube
17、 placement Mark estimated depthBreath sounds by auscultation at 5 locus Thorax rise as inspirationincrease of SaO2Steam in canal of artificial ventilation deviceUse a specific technique or device to prevent tube dislodgment1919Mechanical ventilationLow tidal volume 6-7ml/kg（400-600ml）Hyper ventilati
18、on High airway pressure and endogenous PEEP Intracranial hypertension; High tidal volume DistensionToo low tidal volume hypoxia and CO2 retention 2020 Epinephrine EN -(1)-adrenergic receptor stimulating Peripheral arterial vasoconstriction(not cerebral and coronary arterioles) mean arterial pressure
19、 myocardial and cerebral blood flow 2121Epinephrine EN -(2)Recommended dosage : 1.0mg(0.01-0.02mg/kg ) iv every 3-5 minutes, then 1mg + GS 250ml iv gtt, 1g/min3-4g/min, or 1mg、3mg、5mg ivCompared high dosage: 0. 1-0.2mg/kgHigh dosage (0.2mg/kg) may be harmfulEndotracheal administration: NS 20ml + 22.
20、5 time recommended doseIntracardiac injection: only in heart operation or chest trauma2222VasopressinAct by direct stimulation of smooth muscle V1 receptors vasoconstrictionNo increased myocardial oxygen consumptionHalf-life is 10 20 minute, longer than ENApplicable to VF or prolonged cardiac arrest
21、, and with PEA（pulseless electrical activity）or with asystoleEffective in patients who remain in cardiac arrest after treatment with epinephrineUsage: 40IU iv 2323 Amiodarone(1)Persistent VT or VF after defibrillation and epinephrine in cardiac arrestHemodynamically stable VTpolymorphic VT wide-comp
22、lex tachycardiaVentricular rate control of rapid atrial arrhythmias with impaired LV function when digitalis ineffective2424 Amiodarone(2)Initially 300mg iv diluted in 20-30 ml in cardiac arrestInitially 300mg iv diluted in 20-30 ml in cardiac arrestInitial dose of 150mg ivInitial dose of 150mg iv（
23、over 10 min), followed by 1 over 10 min), followed by 1 mg/min infusion for 6 h, then 0.5mg/minmg/min infusion for 6 h, then 0.5mg/minSupplementary 150mg iv repeatedly for recurrent or Supplementary 150mg iv repeatedly for recurrent or resistant arrhythmias or hemodynamically unstable resistant arrh
24、ythmias or hemodynamically unstable VTVT Maximum total dose: 2g Maximum total dose: 2g24h24hadverse effectsadverse effects：hypotensionhypotension and bradycardia and bradycardia 2525Magnesium sulfateTorsades de pointes Arrhythmias caused by magnesium deficiencyLoading dose :12g /50-100ml iv (over 5-
25、60 minutes)Followed by an infusion of 0.5-1.0g/h2626Sodium Bicarbonate（1）Only after the confirmed interventions are ineffectivePreexisting metabolic acidosis, hyperkalemia, tricyclic or phenobarbitone overdose Protracted arrest or long resuscitative efforts2727Sodium Bicarbonate（2）Acid-base balance
26、: chest compressions ROSC adequate alveolar ventilation and restoration of tissue perfusionCO2 more freely diffusible than HCO3 - into myocardial and cerebral cells intracellular acidosisInitial dosage： 5%NaHCO3 1mEq /kg iv gtt ( 1ml 0.6mEq )2828 Etiological factors （5Hs，5Ts) HypovolemiaHypoxiaHydro
27、gen ion (acidosis)Hyperkalemia or HypokalemiaHyperthermia or HypothermiaTablets (drug)Tamponade Tension PneumothoraxThrombosis coronaryThrombosis pulmonary2929 Optimal response to resuscitationAwakeResponsiveBreathing spontaneouslyrestoration of spontaneous circulation (ROSC)3030 Prolong Life Suppor
28、tPostresuscitation care - Prevent and treatment SIRS and MODS - Prevent and treatment SIRS and MODSorgans function supportCerebral resuscitation3131 Postresuscitation syndromeReperfusion failureReperfusion injuryCerebral intoxication from ischemic metabolitesCoagulopathy3232 Postresuscitation syndro
29、me - 4 phases Cardiovascular dysfunction in the hours after ROSC in 24 hoursSIRS leads to MODS over 1 to 3 daysSerious infection occurs and the patient declines rapidlyDeath 3333 DopamineA potent adrenergic receptor agonist and a strong A potent adrenergic receptor agonist and a strong peripheral do
30、pamine receptor agonist. peripheral dopamine receptor agonist. Effects are dose-dependent: 5 Effects are dose-dependent: 5 20g20gminminkgkgLow-dose (2 4 gLow-dose (2 4 gminminkg) is no longer used kg) is no longer used for acute oliguric renal failure, becausefor acute oliguric renal failure, becaus
31、e occasionally diuresis no improve renal occasionally diuresis no improve renal glomerular filtration rate.glomerular filtration rate.Middle dosageMiddle dosage：510g510gminminkg, positive kg, positive inotropic effectinotropic effectHigh dosageHigh dosage：1020 g1020 gminminkgkg， vasoconstrictionvaso
32、constriction3434 Sodium Bicarbonateimmediately after ROSCGuided by the partial pressure of CO2 3535 Cerebral resuscitation Maintain relative high blood pressure during CPRHemodilution and mild hypothermia （3234）for 12 h during CPRthrombolysis for ameliorate hypercoagulable state Antioxidant ，free ra
33、dical scavengerEmergency hypothermia CPBHyperbaric oxygen：suitable for persistent vegetative state3636 Ethical and legal considerations of CPRWhen withdrawal or withhold of life support？DNAR（do not attempt resuscitation) ordersTransporting patient proceed CPR must be continue CPRPatient is in a persistent vegetative state or terminal condition certified by 2 physicians, including 1 with special expertise in evaluation cognitive function 37373838
