Cardiopulmonary Resuscitation Flashcards
- what is the chain of survival?
2. what are the aspects making up the chain of survival?
- Four key, inter-related steps which when delivered effectively optimise survival from out of hospital cardiac arrest
- early recognition and call for help, early bystander CPR, early defibrillation, early advanced life support and standardised post resuscitation care
what can be done to improve out of hospital cardiac arrest survival? (6)
All school children taught CPR and AED use
Everyone who can should learn CPR
Availability of defibrillators in places with large number of people
Owners of defibrillators should register location and availability with ambulance services
Systems to enable ambulance service to identify and deploy nearest defib to scene of suspected cardiac arrest
All out of hospital cardiac arrest resuscitation attempts reported to national out of hospital cardiac arrest audit
what is the algorithm for cardiac arrest out of hospital?
- safety
- response
- airway
- breathing - look, feel, listen for 10 secs
- call for help/ambulance
- send for AED
- circulation - 30 chest compressions
- 2 rescue breaths
- continue 30:2
[if AED arrives follow instructions] - if they start breathing - recovery position
describe the resuscitation of children
5 initial rescue breaths before chest compressions
If on your own perform CPR for 1 minute before going for help
Compress chest by 1/3 depth
Use 2 fingers for an infant under 1 year
Use one or 2 hands as needed for a child over 1 year
what are the signs of cardiac arrest?
Unconscious
Unresponsive
Not breathing or not breathing normally (gasping noises)
what are the causes of cardiac arrest?
Ventricular fibrillation Heart attack Cardiomyopathy Congenital heart disease Heart valve disease Acute myocarditis Electrocution Drug overdose Severe haemorrhage (hypovolaemic shock) Hypoxia
what is the difference between a cardiac arrest and a heart attack?
Heart attack occurs when the blood supply to the heart muscle is cut off due to a clot in one of the coronary arteries. The heart is still pumping and they will be conscious and breathing. A heart attack can lead to a cardiac arrest. A cardiac arrest is an electrical issue and the patient will be unconscious
describe the immediate recovery management following cardiac arrest?
Coronary care or ICU
May need induced coma
describe the mid term recovery following cardiac arrest?
Pacemaker, ICD, cardiac rehabilitation
describe long term recovery following cardiac arrest?
Practical matters eg driving, work
Lifestyle changes
Long term effects of hypoxia during cardiac arrest; personality changes, problems with memory, fatigue, dizziness or balance issues, aphasia/dysphasia, myoclonus, permanent brain injury
describe the first stages of the ALS algorithm if a patient has a cardiac arrest in hospital?
- patient unresponsive and not breathing normally
- call resuscitation team
- CPR 30:2 / attach defib, monitor
- assess rhythm
what are the reversible causes of cardiac arrest?
hypoxia, hypovolaemia, hypo-/hyperkalaemia/metabolic, hypothermia
thrombosis, tension pneumothorax, tamponade, toxins
what are the shockable rhythms?
ventricular fibrillation
pulseless VT
what are the non shockable rhythms?
PEA
asystole
what other interventions should be performed during CPR?
- high quality chest compressions
- minimise interruptions to compression
- give oxygen
- use waveform capnography
- continuous compressions when airway in place
- vascular access
- adrenaline every 3-5mins
- amiodarone after 3 shocks
describe the ALS algorithm for a shockable rhythm?
- Confirm cardiac arrest
- Call resuscitation team
- Uninterrupted chest compressions / apply defib pads
- Plan actions before pausing CPR for rhythm analysis
- Stop compressions – confirm VF/pVT from ecg (<5 seconds)
- Resume chest compressions immediately
- Select at least 150J for first shock
- When defib charged tell rescuer to stand clear and then give shock
- Immediately restart CPR and continue for 2 mins
- Pause to check monitor if still shockable repeat
- repeat
- Give adrenaline 1mg IV and then further dose every 3-5 mins until ROSC achieved
- and 300mg IV amiodarone after 3 defibrillation attempts, condsider another 150mg IV after 5 defib attempts (lidocaine 1mg/kg may be used as alternative)
describe the ALS algorithm for non shockable rhythms?
- CPR 30:2
- Adrenaline 1mg IV ASAP
- Continue CPR 30:2 until airway is secured then continue compressions without pausing during ventilation
- Recheck rhythm after 2 mins
- If electical activity compatible with pulse start post resuscitation care
describe how you would go about treating the 4 H’s
Hypoxia- ensure patient is ventilated, adequate chest rise and bilateral breath sounds
Hypovolaemia- usually due to severe haemorrhage which may be due to trauma, GI bleeding or AAA. Stop haemorrhage and restore intravascular fluid with bloods
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acideamia/metabolic -detect by biochemical tests or history eg renal failure. Give IV calcium chloride in presence of hyperkalaemia, hypocalcaemia and calcium channel blocker
Hypothermia -suspect based on history eg cardiac arrest associated with drowning
describe how you would go about treating the 4T’s
Thrombosis – coronary thrombosis: associated with ACS or ishcaemic heart disease. Most common cause of sudden cardiac arrest. Consider urgent coronary angiography and percutaneous coronary intervention.
Thromboembolic or mechanical circulatory obstruction: massive PE, if this is considered the cause consider fibrinoytic drug immediately. If this is done consider performing CPR for 60-90 mins before termination of resuscitation
Tension pneumothorax – can be primary cause of PEA, associated with trauma. Diagnosis cinically or via ultrasound
Tamponade – cardiac – difficult to diagnose. Cardiac arrest after penetrating chest trauma is suggestive of tamponade – resuscitative throacotomy
Toxins – laboratory investigations may be needed. Antidotes should be used. Treatment is supportive and follow standard ALS
what imaging would you consider during ALS?
Echocardiography/ultrasound may help diagnosis and treatment
Placement of sub-xiphid probe before chest compressions are pausd for planned rhythm assessment
Ultrasound – identify cardiac tamponade, PE, hypovolaemia, pneumothorax
when should CPR be stopped?
it is generally accepted that asystole for more than 20 minutes in the absence of a reversible cause and with ongoing ALS constitutes a reasonable ground for stopping further resuscitation attempts.
what is the purpose of post resuscitation care?
Short term mortality from cardiac arrest is high. The aim in post resuscitation care is to manage post cardiac arrest syndrome which comprises of brain injury, myocardial dysfunction, ishcaemic/reperfusion response, precipitating pathology.
describe airway assessment in immediate post resuscitation care?
if post arrest patient is not waking 5-10 mins after ROSC intubation should be planned
describe breathing assessment in immediate post resuscitation care?
nasogastric/orogastric tube will relieve gastric distension which can improve ventilatory status. Aim for 94-98% O2 sats
describe circulation assessment in immediate post resuscitation care?
patients usually haemodynamically unstable. Target mean arterial pressure should take into account; normal BP, estimated cardiac function, cause of cardiac arrest. Fluid challenges of 125-500mls to optimise patient perfusion and preload. Invasive circulatory monitoring – arterial line provides continuous BP to track response to therapy. Echo can give visual guide to filling status and cardiac index. Non invasive cardiac output monitoring may be useful and can be rapidly established. Inotropes and vasopressors to maintain BP and cardiac output
describe disability assessment in immediate post resuscitation care?
GCS prior to sedation, short acting sedating agents such as propofol preferred control seizures
Glucose control¬ – tight glycaemic control not recommended as comatose patient is a greater risk of undiagnosed hypoglycaeia yet it must be controlled but not unless it is more than 8mmol/l
what investigations are important post resuscitation?
CXR – confirms line and tube position, rules out iatrogenic complications
12 lead ECG – if ischaemia/infarction or arrythmia suspected
Potassium – maintained at 4-4.5mmol/l to limit arrythmias
Improving lactate post arrest demonstrates reducing tissue ischaemia
Ultrasonography – diagnose cause of cardiac arrest
what is post arrest hypothermia?
May suppress chemical reactions associated with reperfusion injury post arrest. ALS group recommend cooling to 32-34 degrees for 12-24 hours after out of hospital VF arrest. Complications include infection, arrythmias, diuresis, electrolye abnormalities and coagulopathy. Pyrexia must be prohibited post cardiac arrest, common in first 48 hours and risk of poor neurological outcome increases each degree rise over 37 degrees
how can clinical neurological findings post arrest inform prognosis?
retention of function is a good predictor of good functional outcome. Myoclonic epilepsy is poor prognostic indicator. Pathophysiological factors eg hypoglycaemia and interventions will affect neurological exam and should be considered
how can comorbidities and age post arrest inform prognosis?
increased age increases short term mortality but doesn’t predict neurological outcome. Increased age and PEA rhythm combined are significant predictors of poor outcome. Poor outcome associated with diabetes, sepsis, cancer, sroke or being housebound before cardiac arrest
can the type of arrest help inform post arrest prognosis?
Non cardiac cause, asystole are unreliable as predictors of poor outcome
how can downtime/delay to start of CPR and quality of CPR influence prognosis?
Poor outcome associated with increasing time interval between collapse and start of CPR and/or from start of CPR to return of spontaneous circulation. Increasing number of shocks or adrenaline doses correlate with poorer neurological outcome. Low ETCO2 of less than 10mmHg during resuscitation is associated with poor outcome
can early ABG interpretation post arrest inform post arrest prognosis?
pH on initial ABG not correlated with survical, high lactate associated with severe neurological impairment
