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

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

OPEN AIRWAY

If breathing:
recovery position

Head tilt / Chin lift

CHECK BREATHING

BREATHE

Shake and shout

Look, listen and feel

2 effective breaths

ASSESS
10 secs only

CIRCULATION PRESENT
Continue Rescue Breathing

Check circulation
Every minute

Signs of a circulation

NO CIRCULATION
Compress Chest

100 per minute

15:2 ratio

Send or go for help as soon as possible

according to guidelines

External Cardiac Compression

1.
2.
3.
4.

vertically downward 4-5 cm

Push hard push fast
100 x/min.
Ratio Comp : Vent 30 : 2

Cardiac Compression

Defibrillate up to 3

Ventricular fibrillation

times
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

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 patients 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 120150 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 35 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 23 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