Transcript Adult CPR update 2005 (14 Jul 2006)

Adult CPR Update 2005
Dr Adrian Burger
Emergency Medicine Registrar
UCT/Stellenbosch
Background
• ILCOR vs AHA
• 36 Months before 2005 Consensus
Conference
• Awareness - limitations of evidence
- benefits of CPR
• Tipping point - major changes
- re-affirmed others
Background
• USA - 250 000 to 330000 estimated
annual SCA deaths per year
• Survival < 6% worldwide average
• Trials - short term outcomes
- underpowered, small
- not randomized
- design limitations
• Informed consent
Method
• Critical review of sequence and priorities
• Identify factors with greatest impact on
survival
• Recommendations for interventions that
should be performed frequently and well
• Emphasis on HIGH QUALITY CPR
So Why Change Then?
• Poor survival not inevitable
• Lay Rescuer CPR + AED Programs
Witnessed VF SCA 49%-74% Survival
• Make it all easier
Common Elements of Success
• Trained Rescuers
• Rapid Recognition
• Prompt CPR
• Defibrillation < 5 min
The Brief
• Simple
• Appropriate
• All Ages
Simple
• “Lay rescuers not be expected to learn,
select or perform different sequences of
CPR”
Appropriate
• Asphyxial and VF SCA
• ?Compression alone
VF
• ?Ventilation + Compression
Asphyxial and Prolonged arrest
Age Effective
• Infant and Children
- Asphyxial Arrests more likely
• Adults
- VF SCA more likely
Age Groups
• Lay Rescuers
• HCP
Infant under 1 year
Child 1-8 years
Adult 8 and older
Infant under 1 year
Child 1 year to puberty
Adult puberty & older
Airway
• For Lay rescuers - Head Tilt Chin Lift
• For HCP - Jaw Thrust
- Head Tilt Chin Lift
- Manual C-spine control in CPR
• Head Tilt Chin Lift EVEN IN TRAUMA
Breathing
• Match Pulmonary Blood Flow & Ventilation
• Not excessive ventilations
-Initial O2 content adequate in VF SCA
-Reduced perfusion 25%-30% of normal
-Reduced venous return
-Gastric Insufflation
CPR For Lay Rescuers
•
•
•
•
Check normal breathing
2 rescue breaths of 1s each
Visible chest rise
Immediate chest compressions (no pulse
check)
• 2 hands, centre of chest, nipple line,
100/min
• AED when arrives
CPR For HCP
• “Phone First” for all sudden collapse and if lone rescuer
• “CPR First” for unresponsive infants and children, all
victims of likely hypoxic arrest and if lone rescuer
• Check for adequate breathing
• 2 rescue breaths of 1s each
• Visible chest rise
• Check response
• Pulse check
• Rescue breathing without compressions 10-12/min
• Technique of compressions same as lay rescuers
The Ratios
• Universal 30:2
-All Lone Rescuers of Infants (not newborns),
Children & Adults
-All Lay Rescuer situations
-2 Rescuer Adult CPR without advanced
airway
• 15:2
-2 Rescuer CPR for Infants and Children
Put Simply
• 30:2 - All Lone Rescuers (Lay & HCP)
for All victims
- 2 Rescuers Adults (no advanced
airway)
• 15:2 - 2 Rescuers for Infants and Children
And if there’s an ETT or LMA?
• Breathing rate: 8-10/min
• Compression rate: 100/min
• Swap roles regularly
-objectively <1-2 minutes
-subjectively >5 minutes
HIGH QUALITY CPR
• RATE - push hard, push fast 100/min
• DEPTH - 1.5 TO 2 inches
• COMPLETE CHEST RECOIL
• MINIMISE INTERRUPTIONS
• CHANGE REGULARLY
Restore Coronary & Cerebral Blood Flow
Technique of CPR
• Push Hard and Push Fast
• Complete Chest Recoil
• Minimal Interruptions <10s
• Change Regularly
The Shocking Facts
Changes
• Challenged Defib first to all VF victims,
especially > 4 to 5 min
• Improved survival for CPR first?
• Insufficient data for CPR first to all VF
SCA
Consensus
Lay Rescuers
• AED as soon as available
EMS
• Witnessed SCA VF: Defib
• Not witnessed or > 4 to 5 min: CPR first
Non Consensus
• In hospital cardiac arrest
• Ideal duration of CPR before defib
• Ideal duration of VF to switch to CPR first
Only One Shocker
• No specific studies
• 1st shock efficacy - termination of VF at
least 5s after the shock
• Monophasic defib - low 1st shock efficacy
• Biphasic defib - average 90% 1st shock
efficacy
• If 1st shock fails - low amplitude VF, CPR
greater value
So the VF is terminated…
• Most have a nonperfusing rhythm
• PEA/Asystole = CPR
• AED rhythm analysis 29-37 seconds
Therefore
1 shock immediately followed by CPR for
5 cycles or 2 minutes
(+ physicians discretion)
How much?
Adults
• Biphasic Truncated Exponential Waveform use
150J to 200J
• Biphasic Rectilinear Waveform use 120J
• Monophasic Waveform use 360J
Children
• Initial 2J/kg biphasic or monophasic
• Subsequent 2-4J/kg
• AEDS okay for > 1 year old
Drugs - To Use or not use?
• “No Placebo-controlled study has shown
that any medication or vasopressor given
routinely at any stage during human
cardiac arrest increases rate of survival to
hospital discharge”
• Vasopressin vs Epinephrine
• No evidence for routine use of any
antiarrythmic during cardiac arrest
Drug administration
• “LEAN” Lignocaine, epinephrine, atropine,
naloxone, and vasopressin
• IV or IO preferable to ET
• If no IV or IO: 2.5XIV dose in 5-10ml H2O
IV/IO
• Predictable drug delivery
• Predictable drug effect
vs
ET
• low dose of adrenaline
systemically leads to a
B -adrenergic effect
• Vasodilatation
• Lower coronary artery
perfusion pressure & flow
• Reduced potential of
ROSC
• Pulmonary
vasoconstriction
Other drugs in short
• NaBic:
No evidence for routine use
Adverse effects of vasodilatation, alkalosis, CO2 production, catecholamine
Specific instances, eg TCA, hyperkalaemia
•
Calcium:
No benefit from routine use
Indicated for hypocalcaemia, hyperkalaemia, CCB toxicity
•
Fluids:
Indicated with hypovolaemic arrest
Class indeterminate as routine
Avoid glucose unless hypoglycaemic
Implications
•
•
•
•
Deemphasizes drug administration
Reemphasizes BLS
Drug administration during CPR
Co-ordinate - reduced interval increases
shock success
• AEDS - quicker, during CPR, re-program
Post Resus
• Little evidence to support specific Rx
• No standardized Rx
• Supportive - myocardial, organ function
- glucose
- avoid hyperventilation
- temperature
• Therapeutic hypothermia - improved
outcome of out-of-hospital adult VF arrest
FBAO
• Simplified - mild or severe
• Mild - victim coughing: do not interfere
• Severe - silent cough
- respiratory distress
- stridor
- unresponsive
Severe FBAO
• Activate EMS
• Anecdotal evidence
• Adults & >1yo : abdominal thrusts first
: chest thrusts
• Combinations of above most effective
• Chest thrusts: obese, pregnant
• CPR for unresponsive patients
• Look into mouth, but no blind finger sweeps
18 March 2006
www.resuscitationcouncil.co.za
?
References
• Circulation, 2005; 112
• Currents, winter2005-2006
• JAMA, Feb 9, 2000-Vol 283, No6 p783790