A useful emergency medical aid information

1. CARDIO-PULMONARY
RESUSCITATION

2. 2005 AHA
Guidelines
for Cardiopulmonary Resuscitation
and Emergency Cardiac Care
2005 International Consensus Conference on CardioPulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommandations
and
ILCOR (International Liaison Committee on Resuscitation)
2005 CPR Consensus.
These recommendations replace or complete the 2000 CPR guidelines.
published in Circulation - December 2005

3. Grading of evidence
Grade 1
Randomized clinical studies or metaanalysises with significant
therapeutic effects
Grade 2
Clinical studies with less significant therapeutic effects
Grade 3
Prospective controlled nonrandomized studies or case series
Grade 4
Retrospective nonrandomized studies
Grade 5
Uncontrolled case series
Grade 6
Experimental animal or mechanical studies
Grade 7
Theoretical analysis
Grade 8
Rationale and common practice without evidence base

4. Hierarchy of recommendations depends upon
risk/benefice ratio.
Class
I
IIa
Risk/benefice ratio.
benefice>>>risk
benefice>> risk
IIb
benefice >/= risk
III
risk >/= benefice

5. CARDIO-PULMONARY RESUSCITATION
DEFINITIONS
‡
‡
‡
‡
‡
‡
Respiratory arrest = the absence of breathing movements.
Cardiac arrest = the clinical picture of overall cessation of circulation.
Clinical death = coma, apnea and pulselessness in large arteries with cerebral
failure still potentially reversible.
Biological death = the irreversible absence of body functions due to irreversible
structural cell damage.
Cerebral death = the irreversible absence of brain and brainstem functions with
temporary presence of respiration and circulation.
Persistent vegetative state = absence of motility and reaction to external stimuli
due to persistent absence of cerebral activity with preservation of vegetative
functions (respiration, circulation, swallowing).

6. CARDIO-PULMONARY ARREST
Physiopathology
respiratory arrest ? / cardiac arrest ?
‡
There are semnificative differences, related to age, in the incidence of
primary respiratory arrest (more frequent in newborns and children) and
primary cardiac arrest (more frequent in adults and old persons)
‡
There are semnificative differences of BLS in primary respiratory arrest
and primary cardiac arrest.
understanding physiopathology
of cardio-pulmonary arrest
correct CPR
efficient CPR maneuvers

7. RESPIRATORY ARREST
‡ Pathophysiology
± Heart and lungs continue the tissue delivery of oxygenated blood until exhaution of
alveolar O2 reserves; pulse is present, altered consciousness;
± Delay to cardio-circulatory arrest: variable (seconds-minutes); it depends on:
‡ Oxygen reserve in the moment of respiratory arrest (PAO2 şi PaO2)
‡ Miocardial capacity to sustain hypoxemia
± Uncorrected respiratory arrest results in cardiac arrest;
‡ Causes
± Drowning,, foreign body aspiration, toxic inhalation, epiglotitis, strangulation, etc.
± Coma of any origin, stroke, etc.
± Electrocution, trauma, etc.
‡ Clinical signs
±
±
±
±
Absence of breathing movements
Progressive cyanosis
Alterations of consciousness
Muscle hypotony
‡ Treatment
± Artificial ventilation in order to oxygenate the blood and to prevent
secondary cardiac arrest

8. CARDIAC ARREST
‡
Pathophysiology
±
±
±
±
‡
Causes
±
±
±
±
±
‡
Loss of conscience (10 seconds; izoelectric EEg in 15-30 seconds);
Agonic respirations or apneea (10-15 seconds)
Pulseless
Midriasis (30-60 secunde)
General aspect of ³death´
ECG signs
±
±
±
±
‡
Myocardial infarction
Rhythm disturbances (myocardial infarction, myocardial ischemia electrolyte disturbances,etc.)
Hypovolemia (exsanguination, politrauma)
Pulmonary embolism
Cardiac tamponade
Clinical signs
±
±
±
±
±
‡
Cardiac arrest results in circulatory arrest with the immediate cessation of tissue O2 delivery;
Cessation of brain O2 delivery:
‡ Depletion of O2 reserves in 10 seconds
‡ Depletion of phosphocreatine reserves in 2 minutes
‡ Depletion of glucose and ATP reserves in 5 minutes
For a short time delay (always seconds): agonal respiration (Gasping) (unefficient respiratory efforts with
recruitment of accessory respiratory muscles);
Always cardiac arrest result in respiratory arrest;
Ventricular fibrillation
Pulseless ventricular tachycardia
pulseless electrical activitity
Asystole
Treatment
±
Artificial support of ventilation and circulation

9. CARDIO-PULMONARY RESUSCITATION
INDICATIONS of CPR:
‡ Respiratory arrest
‡ Cardiac arrest
‡ Cardio-respiratory arrest
Primary/secondary - respiratory/cardiac arrest

10. CARDIO-PULMONARY RESUSCITATION
DEFINITION
= system of standard maneuvers, drugs and
techniques indicated in case of cardio-respiratory
arrest in order to artificially deliver the oxygenated
blood to systemic circulatory beds at rates that are
sufficient to preserve the vital organ function and at
the same time providing the physiologic substrate for
the return of spontaneous circulation.

11. CARDIO-PULMONARY RESUSCITATION
FACTORS WHICH INFLUENCE THE RESULT OF
RESUSCITATION:
Patient related factors:
‡ The cause of cardio-respiratory arrest
‡ The functional status in the moment of cardio-respiratory
arrest
‡ Co-existing diseases
Resuscitator related factors:
‡ Precocity of CPR
‡ Correctness of CPR

12. CARDIO-PULMONARY RESUSCITATION
CHAIN OF SURVIVAL
Early
access
Early
BLS
BLS in <4 min
Early
defibrillation
Early
ALS
ALS in <8 min

13. ‡ The most important determinant of survival from sudden
cardiac arrest is the presence of a trained rescuer who is
ready, willing, able, and equipped to act.´
(2005 AHA Guidelines for CPR and ECC, Circulation, 2005)
‡ ÄIn the 1990s some predicted that cardio-pulmonary
resuscitation (CPR) could be rendered obsolete by the
widespread development of community automated external
defibrillator (AED) programs. Cobb noted, however, as more
Seatle first responders were equipped with AEDs, survival
rates from sudden cardiac arrest fell. He atributted this
decline to reduces emphasis on CPR....´
(2005 AHA Guidelines for CPR and ECC, Circulation, 2005)

14. What means a successful
cardio-pulmonary resuscitation?
Signs of successful CPR:
±
±
±
±
return of spontaneous circulation
hospital admission
neurologic improvement
hospital discharge

15. CARDIO-PULMONARY RESUSCITATION
Phases of CPR:
‡ Basic life support
± First phase of CPR;
± Goals:
‡
‡
‡
‡
Artificial delivery of oxygenated blood to systemic circulatory beds;
Prevention of irreversible brain damage;
Preservation of chances for successful resuscitation;
Return of spontaneous circulation;
± Provided without medical equipment (³with bare hands´);
‡ Advanced life support
± The second/first phase of CPR;
± Goals:
‡
‡
‡
‡
Preservation of vital organ function;
Return of spontaneous circulation;
Postresuscitation stabilization;
Cerebral protection;
± Provided using equipment, drugs and medical devices.

16. CARDIO-PULMONARY RESUSCITATION
THE ARMAMENTARIUM of CPR
‡
‡
‡
‡
‡
‡
‡
‡
‡
A (airway) ± airway maneuvers
B (breathing) ± evaluation and support of ventilation
C (circulation) ± evaluation and support of circulation
D (drugs)- IV access and medication
E (electrocardiography)- evaluation of electrical form of cardiac arrest
F (fibrillation treatment) - defibrillation
G (gauging) ± postresuscitation evaluation
H (human mentation) ± cerebral protection
I (intensive care) ± postresuscitation intensive care
THIS IS NOT THE PROPER ORDER TO APPLY

17. Primary steps of basic life support
±
±
±
±
±
±
±
±
±
±
±
Securing the inviroment
Evaluation of consciousness
Activation of emergency medical system (call 112)
Victim positioning
Airway maneuvers
Assessment of spontaneous breathing (10 seconds)
Artificial ventilation (2 ventilation)
Assessment of circulation (10 seconds)
Chest compresion (100/minute)
CPR sequence: 30 chest compressions /2 artificial breath
Automatic external Defibrillation

18. CARDIO-PULMONARY RESUSCITATION
BLS ALGORHYTHM
1.
2.
3.
4.
5.
6.
7.
8.
9.
Evaluation of consciousness
Activation of emergency medical system
Victim positioning
Airway maneuvers
Assessment of spontaneous breathing
Artificial ventilation Artificial ventilation
Assessment of circulation
Chest compresion
CPR sequence: 15 chest compressions /2 artificial breath
(no matter the number of rescuers)

19. CPR recomendations 2006 ± 2 esential aspects for the success of CPR:
‡ Avoid hiperventilation
±
±
±
±
±
for a pulmonary gas exchange (pulmonary blood flow decreased)
encrease the intrathoracic pressure
decrease the cardiac upload
decrease the efficience of chest compresions
stomach insuflation (encrease the risk of regurgitation/aspiration, push up the
diaphragm and encrease the intrathoracic pressure)
‡ Avoid interupting the chest compresions
± CPR performed by trainned medical team ± total time of interupting chest
compresions 24-49% of the cardiac arrest duration.
± Any interuption in chest compresions means the decrease of coronary
perfusion pressure, which slowly rises when the chest compresions are
delivered once again, and so the chances of returning to spontaneous
circulation are decreased.
± In the first minutes of cardiac arrest (VF) the artificial ventilation is not so
important as the chest compresions because the hipoxy is primary caused by
the lack of tissulary perfussion, and there are sufficiently blood O2 rezerves
in the first minutes. That is why the rescue person should concentrate in
delivering efficient chest compresions. The new recommendations regarding
the sequence chest compresions/ventilation 30:2 are made to minimalise the
time of chest compresion interuptions.

20. The age
‡ newborn ± immediately after birth and until
hospital discharge.
‡ infant ± untill the age of 1 year.
‡ child ± from 1 year until puberty (12-14 years).
‡ adult ± from puberty along

21. CARDIO-PULMONARY RESUSCITATION
A AIRWAY MANEUVERS:
±
±
±
±
±
Should be applyied in case of any unconscious victim;
Should preceed assessment of spontaneous breathing;
Should be maintained during assessment of spontaneous breathing;
Should preceed artificial ventilation;
Should be maintained during artificial ventilation;

22. A AIRWAY MANEUVERS:
DURING BASIC LIFE SUPPORT:
±
±
±
±
±
±
±
Safety position
Head tilt
Chin lift
Head tilt and chin lift
Subluxaţia anterioară a mandibulei
Subluxaţia anterioară a mandibulei şi deschiderea gurii
Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii (tripla
manevră Safar);
± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a capului şi
deget înfăşurat în pânză)
DURING ADVANCED LIFE SUPPORT:
± Airway devices
± Tracheal intubation

23. A AIRWAY MANEUVERS:
in pacient with posible cervical spine injury
When to suspect cervical spine injury?
‡ Know the mechanism of injury
± Strangulation
± Cădere de la înălţime
± Deceleration or acceleration s.o.
‡ Traumaticsigns
±
±
±
±
At the cephalic extremity
In the cervical region
In the region of thorax (the superior 1/3)
So, superior to the intermamelonary line
Mentain the had in neutral position

24. A AIRWAY MANEUVERS:
in pacient with posible cervical spine injury
BASIC LIFE SUPORT:
± Safety position
± Hiperextension of the had
± Chin lift
± Head tilt and chin lift
± Subluxaţia anterioară a mandibulei
± Subluxaţia anterioară a mandibulei şi deschiderea gurii
± Hiperextensia capului, subluxaţia anterioară a mandibulei şi deschiderea gurii
(tripla manevră Safar);
± Îndepărtarea corpilor străini solizi (deget cârlig) sau lichizi (poziţie laterală a
capului şi deget înfăşurat în pânză)
ADVANCED LIFE SUPPORT: :
± Airway devices
± Traceal intubation

25. Tracheal intubation in CPR
advantages
‡ maintenance of airways patency
‡ protection of airways against the aspiration of gastric
content
‡ delivery of machanical ventilation
‡ drug administration
‡ long term access to the airways
‡ endotracheal aspiration

26. AIRWAY MANEUVERS:
Clinical signs of proper tracheal intubation
± visualising the endotrachel tube passing through vocal
cords
± simetrical thoracic expansions
± equal respiratory sounds on bouth lungs
± water vapors on the inside surface of the endotracheal tube
± the abscence of aeric sounds in epigastric region

27. CARDIO-PULMONARY RESUSCITATION
B EVALUATION AND SUPPORT OF VENTILATION:
‡
Assessment of spontaneous breathing
± maintaining MECA
± ³lisen, feel and see´
‡
Artificiale ventilation
± În SVB
‡
‡
‡
‡
‡
‡
Artificial ventilation ³mouth-to-mouth´
Artificial ventilation ³mouth-to-nose´
Artificial ventilation ³mouth-to-tracheostomae´
Artificial ventilation ³mouth-to-mouth and nose´
The exhalated air containe 16-18% O2
Evaluation of the efficience of artificial ventilation: chest movements
± În SVA
‡
‡
‡
‡
Mask and Rueben baloon
Trachel tube and Rueben baloon
Trachel tube and ventilatory device
Mechanical ventilation:
±
±
±
±
±
IPPV (intermitent positive pressure ventilation)
Current volume 8ml/kg
Frequence: 14-16/min
FiO2 1 (O2 100%)
PEEP (positive end expiratory pressure) 0

28. Artificial ventilation
CHARACTERISTICS OF ÄMOUTH-TO-MOUTH´ VENTILATION
± The rescue person take a normal inspiratory
± Insuflation - 1 second
± Current volume 500-600ml
± Chest rise
± Frecquence 10-12/minute

29. VENTILAŢIA ARTIFICIALĂ
CHARACTERISTICS OF MECHANICAL
VENTILATION IN SVA IN ADULT
± Current volume 6-8ml/kg
± Frecquence 8-10/minute
± Oxigen 100%
± No PEEP
± No interuptions of chest compressions for
ventilation

30. CARDIO-PULMONARY RESUSCITATION
C CIRCULLATORY EVALUATION AND SUPPORT:
ASSESSMENT of CIRCULATION
± Always in the large arteries
± Adult: carotid or femoral artery; infant: brachial artery;
CHEST COMPRESSION
± It is performed during BLS and ALS
± Best achievable results: 25-30% of spontaneous cardiac output
± Chest compression technique:
‡
‡
‡
‡
Victim position
Rescuer position
Technique
Parameters: depth, frequency/min, compression/decompression ratio
± Mechanisms of cardiac output during chest compression:
‡ Cardiac pump theory
‡ Thoracic pump theory
± Evaluation of chest compression efficency: pulse assessmente during CPR
± Options to increase the efficency of chest compression:
‡
‡
‡
‡
‡
‡
Maximal values of recommended depth and frequency
Concomitantly performed chest compression and artificial ventilation
Interposed abdominal compression
Kower limb elevation at 60º (not in case of ongoing bleeding or trauma)
Active compression/decompression device
Internal cardiac massage (only during ALS)
‡ Extracorporeal circulation

31. CHEST COMPRESSIONS
Äpush hard, push fast, allow full chest recoil
after each compression, and minimize
interruptions in chest compression´

32. CHEST COMPRESSIONS
The indication for chest compresions is the
absence of pulse in large arteries.
There are no contraindications for chest
compressions.

33. CHEST COMPRESSIONS
ADULT
‡ Depth of sternal compression 4-6 cm
‡ Frecquence of compressions 100/minute
‡ Duration of compression/Duration of decompression
equal
‡ Full chest recoil after each compression
‡ Rithmic compresions
‡ Avoid interupting chest compressions

34. CHEST COMPRESSIONS
complications
Fractures
Ribs fractures
Sternal fractures
Pathology of the
serosas
Pneumothorax
Hemothorax
Hemopericardium
Hemoperitoneum
Pulmonary rupture
Hepatic rupture
Splenic rupture
Gastric rupture
Aspiration of gastric content
Visceral injuries
Other complications

35. ALTERNATIVE TECHNIQUES OF
CARDIAC MASSAGE
‡
‡
‡
‡
High frecquence chest compressions
Interpose abdominal compression
Internal cardiac massage
CPR through Äcoughing´

36. MECHANICAL DEVICES FOR
CARDIOCIRCULATORY SUPPORT
‡
‡
‡
‡
‡
Active compression-decompresion device
Resistance-level valve device
Mechanical Piston device
CPR vest
Fazic toraco-abdominal compression-decompression
manual device
‡ Extracorporeale circulation

37. CARDIO-PULMONARY RESUSCITATION
C MEDICATION:
‡ Routes for drug administration
±
±
±
±
±
Peripheral intravenous access ± standard route
Central intravenous access
Intratracheal administration
Intraosseous administration
Intracardiac administration
‡ Drugs:
±
±
±
±
±
±
±
±
±
±
±
Oxygen
Epinephrine
Atropine
Lidocaine
Vasopresine
Sodium bicarbonate
Amiodarone
Procainamide
Magnesium sulphate
Dopamine
Volume solutions

38. PERIPHERAL VENOUS ACCESS
Advantages
‡Simple technique
‡Short time for instalation
‡No need for the interuption
of chest compressions
Disavantages
‡Long time of drug
circulation
‡Easy to lose venous access

39. ACCESUL INTRAOSOS
‡ Este a doua opţiune de acces venos în RCR.
‡ Oferă acces la un plex venos necolababil, deci, administrarea
drogurilor este similară administrării venos centrale.
‡ Există truse dedicate cu toate materialele necesare.
‡ Doza medicamentelor în administrarea intraosoasă este aceiaşi
ca în administrarea intravenoasă.
‡ La bolnavul hipovolemic cu acces venos periferic imposibil
accesul intraosos oferă o bună alternativă de refacere a
volemiei.

40. CENTRAL VENOUS ACCEESS
Advantages
‡Short time of drug circulation
‡Safe and longlasting access
‡Hipertonic solutions/cathecolamines
Disavantages
‡Temporary interuption of cardiac
massage
‡Long time for instalation
‡Vital complications possible

41. ENDOTRACHEAL DRUG
ADMINISTRATION IN CPR
‡
‡
‡
‡
through trachel tube
2-2,5x of intravenous dose
diluted in NaCl 0,9% 5-10 ml
5 vigurous ventilations

42. CARDIO-PULMONARY RESUSCITATION
E ELECTROCARDIOGRAPHY:
± Electrical forms of cardiac arrest
‡ Ventricular fibrillation
‡ Pulseless ventricular tachycardia
‡ Pulseless electrical activity
±
±
±
±
±
Electromechanical dissociation
Pseudo Electromechanical dissociation
Idio-ventricular rhythm
Escape rhythm
Bradiasystole
‡ Asystole
Identification of the eletrical form of cardiac arrest allows
the choise of the proper CPR algorhythm

43. RESUSCITAREA CARDIO-RESPIRATORIE
F DEFIBRILAREA:
Defibrilarea este un termen utilizat pentru a desemna
livrarea nesincronizată cu complexul QRS a unui şoc
electric.
Şocul electric induce o depolarizare sincronă urmată de
repolarizare sincronă a tuturor fibrelor miocardice.
Deci, după şocul electric toate fibrele miocardice
ajung la un numitor comun: ´zero´ electric. Acest
fenomen permite intrarea în funcţie a centrului cardiac
cu funcţie spontană de pacemaker, care va prelua
controlul activităţii electrice şi mecanice a inimii.

44. CARDIO-PULMONARY RESUSCITATION
F DEFIBRILLATION:
± Goal
± Defibrillation technique:
‡
‡
‡
‡
‡
‡
Patient position
Rescuer position
Paddles preparation and position
³Clear´ order
Energy
Checking for efficiency
± Indications
± Differences cardioversion/defibrillation:
‡
‡
‡
‡
Synchronic/asynchronic shock
Preparations
Energy
Indications

45. DEFIBRILAREA
TEHNICA DEFIBRILĂRII:
±
±
±
±
±
±
Poziţia pacientului
Poziţia resuscitatorului
Pregătirea şi poziţionarea padelelor
Atenţionarea
Energia utilizată
Verificarea eficienţei

46. CARACTERISTICILE DEBIBRILĂRII
‡
‡
‡
‡
‡
Precocitatea defibrilării
ÄShock first versus CPR first´
Scurtarea intervalului între ultima compresie sternală şi şoc
Ä1-Shock Protocol´
RCR după şoc

47. ENERGIA UTILIZATĂ ÎN DEFIBRILARE
‡ curent monofazic ± iniţial 360 J şi continuă cu
aceiaşi energie la următoarele şocuri.
‡ curent bifazic - iniţial o energie de 200 J, apoi
energii crescânde de 300 J şi 360 J.
‡ În fibrilaţia ventriculară/tahicardia ventriculară
fără puls recurentă - energia utilizată pentru
următorul şoc va fi energia care a convertit
ritmul.

48. ŞOCUL ELECTRIC EXTERN
‡ Termenul de cardioversie este utilizat pentru
livrarea sincronizată cu complexul QRS a unui
şoc electric. Sincronizarea evită livrarea
şocului în perioada refractară relativă a ciclului
cardiac, perioadă în care şocul electric poate
induce fibrilaţie ventriculară.
‡ Termenul de defibrilare este utilizat pentru
livrarea nesincronizată cu complexul QRS a
unui şoc electric.

49. CARDIOVERSIA
PREGĂTIRI PENTRU CARDIOVERSIE
‡ Bolnavul trebuie să aibă monitorizare ECG şi monitorizarea
noninvazivă a TA.
‡ Se instituie oxigenoterapia.
‡ Se instituie un acces venos.
‡ Instrumentarul, materialele şi drogurile de resuscitare trebuie
să fie pregătite.
‡ Se practică analgezie şi sedare.

50. CARACTERISTICI COMPARATIVE ALE
CARDIOVERSIEI ŞI DEFIBRILĂRII
PARAMETRU
CARDIOVERSIE
DEFIBRILARE
Energia iniţială
50-100 J
200 J
Sincronizarea
cu complexul
QRS
Indicaţii
DA
NU
TPSV
Flutter atrial paroxistic
Fibrilaţia atrială paroxistică
Tahicardia ventriculară cu puls
Fibrilaţia ventriculară
Tahicardia ventriculară fără
puls
Tahicardia ventriculară
polimorfă cu puls

51. MONITORIZAREA ÎN CURSUL RCR
‡ CO2 expirat
‡ ECG

52. STATUSUL POSTRESUSCITARE
‡ după reluarea circulaţiei spontane
‡ perioadă de mari dezechilibre homeostatice
‡ generate de:
± leziunile hipoxice
± leziuni ischemice
± leziuni de reperfuzie.

53. FIZIOPATOLOGIA
STATUSULUI POSTRESUSCITARE
Hemodinamic Disfuncţie miocardică
(prin ischemia miocardică globală şi defibrilare)
Sindrom de debit cardic scăzut
Creştere tranzitorie a enzimelor miocardice
Instabilitate hemodinamică
Tulburări de ritm
Neurologic
Comă
Iniţial hiperemie cerebrală, apoi reducerea fluxului sanguin cerebrale
(chiar la valori normale ale TA medii)
Hipertemie de origine centrală
Convulsii
Respirator
Disfuncţie ventilatorie
Tulburări de oxigenare sanguină
Metabolic
Acidoză metabolică
Hiperglicemie

54. STATUSUL POSTRESUSCITARE
Tulburările pot fi:
‡ modeste şi cu tendinţă progresivă spre rezoluţie
‡ severe şi persistente
coma persistentă
hipertermia centrală
convulsiile
sindromul de disfuncţie multiplă de organe
frecvente la 48-72 ore postresuscitare
prognostic nefavorabil