Circulation

When to start CPR (CPG)

Unconscious & pulseless, or unsure of the presence of a pulse in the setting of gasping/agonal respirations

What is high quality CPR

• Compressions 1/3rd of chest, allowing for recoil. 100-120 per minute.

• Charge the defib during compressions

• on-screen interpretation in manual mode

• pulse checks only for potentially perfusing rhytmns

When to start CPR (CPG)

Unconscious & pulseless, or unsure of the presence of a pulse in the setting of gasping/agonal respirations

What is high quality CPR

• Compressions 1/3rd of chest, allowing for recoil. 100-120 per minute.

• Charge the defib during compressions

• on-screen interpretation in manual mode

• pulse checks only for potentially perfusing rhytmns

Drug order for Cardiac Arrest

Amiodarone 300mg after 3rd shock
Lignocaine 100mg after 5th shock

Amiodarone 150mg after 7th shock
Lignocaine 50mg after 9th shock

Reversible causes of arrest (4Hs and 4Ts + others)

• Hypovolemia

• Hypoxia

• Hyperkalemia

• Hypothermia

• Anaphalaxis

• Asthma

• Upper airway obstruction

• Tension pnemothorax

• Tamponade

• Thrombosis

• Pulmonary embolism

• Toxins

What do you do for all cardiac arrest patients?

SGA insertion, at a CPR ratio of 15:1

IV access with normal saline TKVO

Adrenaline 1mg every second cycle

Flush with 20-30mL saline

What do you do if the patient is interfering with CPR?

Ketamine 50-100mg every 1-2, no MAX OR 200mg IM

High Performance CPR Notes

Compression/Ventilation ratios

NO SGA/ETT - 30:2, w pause for ventilations
SGA IN SITU: 15:1, 6-8 per minute, NO PAUSE

Pad placement

Sternal: Right side of the chest, under the clavicle & above the nipple.
Apex: Left mid-axilliary line, 6th intercostal space

When is a patient in REFRACTORY VT/VF

When they remain in a shockable state after 3 defib attempts

How to ‘stack shocks’

Deliver first shock within 20 seconds of arrest occuring. Aim for 10 seconds between each shock with interpretation. THREE SHOCKS!

HP CPR SCRIPT

Approaching the end of the two minute cycle, this looks like (heart pattern) do you agree?
Continue compressions, everyone else clear
Charing to (X) joules
(SLAP) stop compressions, clear?
Still in (heart pattern), shocking/disarming

Medical Cardiac Arrest Guideline

ROSC Management

VACAR Report Facts

• 78% of cardiac arrest occured at home

• 65% were male

• 7830 OOH cardiac arrests

• 12% survived on bystander CPR

• 53% survived when shocked by public AED

• 83% if survivors were dispatched to their homes

• 118 per 100K people

3 Components of Cardiac Arrest

Unconscious, Apnoeic, Pulseless

What is actually happening during a cardiac arrest?

• Lack of blood circulation causing lack of oxygen to the body

• Lack of O2 causes loss of consciousness, abnormal or absent breathing - which can result in brain injury after 5 minutes

• O2 lack causes organs to start dying, anearobic metab, cellular receptors stop resonding, acidosis, etc..

3 Phase Model of Cardiopulmonary CPR

• Electrical phase: onset of arrest to >4 minutes

• Circulatory phase: from 4-10 minutes

• Metabolic phase: beyond 10 minutes

Where is the heart?

• size of the fist

• rests on the diaphragm in the mediastinum, 2/3rd of the midline

• pointed end at the 5th IC space, MC line, broad portion is the base level of the 2nd rib

Heart Anatomy

3 layers of the heart wall

Epicardium (external), Myocardium (middle layer contraction), Endocardium (inner layer. layer of thin connecitve tissue)

How is the heart made up (chambers & valves)

• four chambers - two atria & ventricles

• four valves - two atrioventricular & semilunar

What is the purpose of CPR?

• sufficent vital organ blood flow

• preserves life until definitive procedures/interventions

• compression & recoil generates a proportion of normal cardiac output

Cardiac pump Model

• direct compression of heart between the sternum and veretbral body

• blood is squeezed out of the heart with compression & fresh blood entering the heart during recoil

Thoracic pump Model

• blood flow is a result of pressure changes within the thoracic cavity

• heart is more passive

• blood is forced out of the thorax when intrathoracic pressure is high

• blood is drawn into the thoracic cavity due to sudden decrease in pressure (recoil)

Thoracic VS Cardiac Differences

Cardiac:

• direct squeezing of the heart

• works best in kids & young adults

• blood is rejected from the heart

• direct compression of the heart

Thoracic:

• pressure changes in the chest

• larger patients, more flexible chest walls

• blood moves due to the pressure changes in the thotax

• compression of the entire chest cavity

Good CPR?

Depth must be 1/3rd, more than 5cm in adults

Rate must be 100-120 pm

Allow for full recoil

Changes every 2 minutes to prevent fatigue

1 second per ventilation

Non shockable rhythm

Asystole (NO HEART FUNCTION)

PEA (electrical activity not coheisve with output - NO PULSE)

Ventricular Fibrillation

• chaotic & bizzare originates in the ventricles

• uncoordinated ineffective contraction of ventricles

• quiver X contract

• no effective ventricular contractions

• SHOCKABLE

Ventricular Tachycardia

• can be conscious

• do not shock with pulse present

• fast, wide, regular

• LETHAL - can become VF or asys

• SHOCKABLE

Defibrillation

An attempt to cause depolarisation of all the cardiac cells at once in the hope that the heart’s natural pacemakers will try and pace the heart in a more coordinated fashion, leading to uniform contraction of the heart & restoration of perfusion

What is ROSC?

Return of Spontaneous Circulation - evidence of perfusion. BP, improvement in colour, ETCO2 valuables better, increase in GCS & spont ventilations

What do do when ROSC is achieved?

• return to primary survey

• maintain management

• continue your clinical assessment

• reassume the clinical approach