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BY
MONA ADEL,MD, MACC
A.PROFESSOR OF CARDIOLOGY
Cardiology Consultant Elite Medical center
Mona Adel 2012
CPR
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TEAM WORK
Mona Adel 2010
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Mona Adel 2010
1- PHYSCIAN:
EVALUATE THE SITUATION PULSE CHECK
SUPERVISE PERFORMANCE
PARTICIPATE IN CPR
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Three assisstants
Mona Adel 2010
CALL FOR HELP
GET THE CRASH CART
START CPR
PUT IV LINE CONTINUE CPR
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EPIDEMIOLOGY AND
SURVIVAL
Mona Adel 2010
Sudden cardiac arrest (SCA) is a leading cause
of death in both the United States and Canada ,
outranked only by cancer
The most common etiology of SCA is ischemiccardiovascular disease resulting in the
development of lethal arrhythmias
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Resuscitation is attempted in up to two-thirds of people who sustain SCA.
Despite the development of
cardiopulmonary resuscitation (CPR),electrical defibrillation, and other
advanced resuscitative techniques over
the past 50 years, survival rates for SCAremain low
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Out of hospital survival studies have reportedrates of 1 to 6 %percent.
Systematic reviews of survival-to-hospital
discharge from out-of-hospital SCA reported 5 to
10 percent survival among those treated by
emergency medical services (EMS) and 15
percent survival when the underlying rhythm
disturbance was ventricular fibrillation (VF) .
An analysis of a national registry of in-hospital
SCA reported a 17 percent survival to discharge.
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Mona Adel 2010
Not performing CPR or low quality performanceare important factors contributing to poor
outcomes .
Multiple studies assessing both in-hospital and
prehospital performance of CPR have shown that
trained healthcare providers consistently fail tomeet basic life support guidelines .
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The American HeartAssociation (AHA) 2010
Guidelines
Mona Adel 2010
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Mona Adel 2010
Emphasizing early recognition of sudden cardiacarrest
Activating emergency medical services as soon
as possible
immediate initiation ofexcellent CPRpush
hard, push fast with continuous attention to the
quality of chest compressions, and to the
frequency of ventilations
Minimizing interruptions in CPR
Using automated external defibrillators as soon
as available
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Mona Adel 2010
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Mona Adel 2010
Patient survival depends
primarily upon
immediate initiation ofexcellent CPR and early
defibrillation
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Phases of arrest
Mona Adel 2010
. Electrical phase The electrical phase is defined as the first
four to five minutes of arrest due to ventricular fibrillation (VF).Immediate DC cardioversion is needed to optimize survival ofthese patients. Performing excellent chest compressions whilethe defibrillator is readied also improves survival
Hemodynamic phase The hemodynamic or circulatoryphase, which follows the electrical phase, consists of the periodfrom 4 to 10 minutes after SCA, during which the patient mayremain in VF. Early defibrillation remains critical for survival inpatients found in VF. Excellent chest compressions should bestarted immediately upon recognizing SCA and continued until
just before cardioversion is performed (ie, charge the defibrillatorduring active compressions, stopping only briefly to confirm therhythm and deliver the shock). Resume CPR immediately afterthe shock is delivered.
Metabolic phase Treatment of the metabolic phase, definedas greater than 10 minutes of pulselessness, is primarily basedupon postresuscitative measures, including hypothermia therapy.
If not quickly converted into a perfusing rhythm, patients in thisphase generally do not survive
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Recognition of cardiac arrest
Mona Adel 2010
Rapid recognition of cardiac arrest is the essentialfirst step of successful resuscitation.
The lay rescuer who witnesses a person collapse orcomes across an apparently unresponsive personshould check to be sure the area is safe before
approaching the victim and then confirmunresponsiveness by tapping the person on theshoulder and shouting: are you all right?
If the person does not respond, the rescuer calls forhelp, activates the emergency response system, and
initiates excellent chest compressions. Lay rescuers should not attempt to assess the
victims pulse and, unless the patient has what appearto be normal respirations, should assume the patientis apneic.
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Chest compressions
Mona Adel 2010
Push hard and push fast on
the center of the chest"
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Mona Adel 2010
Chest compressions are the most important element of
cardiopulmonary resuscitation (CPR
The following goals are essential for performing excellentchest compressions:
Maintain a rate of at least 100 compressions per minute
Compress the chest at least 5 cm (2 inches) with each
down-strokeAllow the chest to recoil completely after each down-
stroke (eg, it should be easy to pull a piece of paper from
between the rescuers hand and the patients chest just
before the next down-stroke) Minimize the frequency and duration of any interruptions
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Mona Adel 2010
1- optimal position of the PT and
rescuers2-surface
3-Technique4-It is imperative that each facet of
performing excellent chest
compressions be continuallyreassessed and corrections made
throughout the resuscitation
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Mona Adel 2010
Compression-only CPR If a sole lay rescuer is
present or multiple lay rescuers are reluctant to
perform mouth-to-mouth ventilation, the AHA2010 Guidelines encourage the performance of
CPR using chest compressions alone.
Lay rescuers should not interrupt chest
compressions to palpate for pulses and shouldcontinue CPR until an AED is ready to defibrillate,
EMS personnel assume care, or the patient
wakes up.
Note that CO-CPR is not recommended for
children or arrest of noncardiac origin (eg, near
drowning).
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Mona Adel 2010
Inadequate compression and incomplete recoilare more common when rescuers fatigue, which
can begin as soon as one minute after beginning
CPR .
the rescuer performing chest compressions bechanged every two minutes whenever more than
one rescuer is present.
Interruptions in chest compressions are reduced
by changing the rescuer performing
compressions at the time defibrillation is
performed.
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Minimizing interruptions
Mona Adel 2010
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Interruptions in chest compressions during CPR,
no matter how brief, result in unacceptable
declines in coronary and cerebral perfusion
pressure and worse patient outcomes .
Once compressions stop, up to 2 minute of
continuous, excellent compressions may berequired to reattain steady perfusion pressures at
desirable levels .
Pulse check should not exceed 10 seconds,
except for specific interventions, such asdefibrillation.
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C-A-B
Mona Adel 2010
During the initial phase of SCA, when thepulmonary vessels and heart likely contain
sufficient oxygenated blood to meet markedly
reduced demands, the importance of
compressions supersedes ventilations .Consequently, the initiation of excellent chest
compressions is the first step to improving oxygen
delivery to the tissues .
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Ventillation
Mona Adel 2010
Proper ventilation for adults includes thefollowing:
Give 2 ventilations after every 30 compressions
for patients without an advanced airway
Give each ventilation over no more than one
second
Provide enough tidal volume to see the chest rise
Avoid excessive ventilation Give 1 asynchronous ventilation every 8 to 10
seconds (6 to 8 per minute) to patients with an
advanced airway (eg, supraglottic device,
endotracheal tube) in place
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Defibrillation
Mona Adel 2010
For BLS, a single shock from an automatedexternal defibrillator (AED) is followed by the
immediate resumption of excellent chest
compressions.
For advanced cardiac life support, a single shock isstill recommended regardless of whether a
biphasic or monophasic defibrillator is used
In adults, we suggest defibrillation using the highest
available energy (generally 200 J with a biphasic
defibrillator and 360 J with a monophasic
defibrillator)
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Mona Adel 2010
When preparing for defibrillation, rescuers shouldcontinue performing excellent chest
compressions while charging the defibrillator until
just before the single shock is delivered, and
resume immediately after shock delivery withouttaking time to assess pulse or breathing.
No more than three to five seconds should elapse
between stopping chest compressions and shock
delivery.
If a single lay rescuer is providing CPR, excellent
chest compressions should be performed
continuously without ventilations
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Pulse checks and rhythm
analysis
Mona Adel 2010
It is essential to minimize delays and interruptionsin the performance of excellent chestcompressions. Therefore, pulse checks andrhythm analysis should be done sparingly and are
best performed during a planned interruption atthe two minute interval following a complete cycleof cardiopulmonary resuscitation (CPR).
Even short delays in the initiation or briefinterruptions in the performance of CPR can
compromise cerebral and coronary perfusionpressure and decrease survival.
Following any interruption, sustained chestcompressions are needed to regain pre-
interruption rates of blood flow
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Mona Adel 2010
The AHA 2010 Guidelines recommend that CPRbe resumed for two minutes, without a pulse
check, after any attempt at defibrillation,
regardless of the resulting rhythm.
Data suggest that the heart does not immediatelygenerate effective cardiac output after
defibrillation, and CPR may enhance
postdefibrillation perfusion
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CONCLUSION
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Despite the development of cardiopulmonaryresuscitation (CPR), electrical defibrillation, and
other advanced resuscitative techniques over the
past 50 years, survival rates for SCA remain low
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Mona Adel 2010
Phases of resuscitation : The electrical phase comprises the first four to
five minutes and requires immediate defibrillation.
The hemodynamic phase spans approximately
minutes four to ten following sudden cardiacarrest (SCA). Patients in the hemodynamic phasebenefit from excellent chest compressions togenerate adequate cerebral and coronaryperfusion and immediate defibrillation.
The metabolic phase occurs followingapproximately ten minutes of pulselessness; fewpatients who reach this phase survive.
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Mona Adel 2010
Chest compressions are the most
important element of cardiopulmonaryresuscitation (CPR).
Interruptions in chest compressions during CPR,
no matter how brief, result in unacceptable
declines in coronary and cerebral perfusion
pressure.
The CPR mantra is: "push hard and push fast
on the center of the chest."
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Defibrillation Early defibrillation is critical to the
survival of patients with ventricular fibrillation.
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All healthcare providers should receive
standardized training in CPR and be familiar with
the operation of automated external defibrillators
(AED).
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THANK YOU