Ethical Principles

• The main aim of resuscitation is to prevent loss of one’s life through chest compression and oxygenation.

• Decisions as to resuscitate or not are often up to the rescuers in some circumstances or based on advance directive in hospital setting.

• However, patient also has the right to make advance directive not to be resuscitated, thus in that case CPR must not be given to respect their decision. (e.g due to chronic illneses, etc)

Ethical Principles

• There are several factors to consider in giving CPR including:

- Ethical- Legal- Cultural

Definition

• Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.

• However, chance of survival also strongly correlated to the CPR ability of the rescuer, health condition of the victim and available resources (e.g drugs, defibrillator, etc).

• The fundamental challenge: how to achieve early and effective CPR?.

Indication

• CPR can be initiated when unresponsive breathing/ respiratory arrest (apnoea/ gasping) identified & cardiac arrest.

• “Cardiac arrest patients are more than five times more likely to survive if bystanders attempt resuscitation while the patient is still gasping” - Bentley J. Bobrow, MD, director of Arizona emergency medical services.

Key Principles in Resuscitation: Strengtheningthe Links in the Chain of Survival

Successful resuscitation following cardiac arrest requires an integrated set of coordinated actions represented by the links in the Chain of Survival.

The links include the following: Immediate recognition of cardiac arrest and activation

of the emergency response system Early CPR with an emphasis on chest compressions Rapid defibrillation Effective advanced life support Integrated post– cardiac arrest care

Key Principles in Resuscitation: Strengtheningthe Links in the Chain of Survival

• Emergency systems that can effectively implement these links can safe witnessed-VF cardiac arrest patients with survival rate close to 50%.

• Yet again, the individual links are interdependent, and the success of each link is dependent on the effectiveness of those that precede it.

Key Principles in Resuscitation: Strengtheningthe Links in the Chain of Survival

• Diverse level of rescuers’ training, experiences, and skills affect effective CPR. Furthermore, cardiac arrest victim’s status and response to CPR can also be heterogeneous.

• Thus the framework that will be explained next is created to tackle these barriers of performing effective CPR regardless who the rescuers/ victims is, and limited resources.

• The framework will aid to promote understanding of quick and effective CPR.

Conceptual Framework for CPR: Interaction ofRescuer(s) and Victim

• All rescuers, regardless of training, should provide chest compressions to all cardiac arrest victims.

• Rescue breathing may be more important for children than for adults in cardiac arrest. Because most cardiac arrest in adults are resulting from primary cardiac cause, while in children is most often asphyxial (requires ventilation & optimal breathing).

Early Action: Integrating the CriticalComponents of CPR

• The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings.

Early Action: Integrating the CriticalComponents of CPR

1. Recognition and Activation of Emergency Response

• rescuer must first recognize that the victim has experienced a cardiac arrest, based on unresponsiveness and lack of normal breathing

• should immediately activate the emergency response system, get an AED/defibrillator if available, and

• start CPR with chest compressions immediately

2. Chest Compression Rescuers should focus on delivering high-quality CPR:• providing chest compressions of adequate rate (at least

100/minute)• providing chest compressions of adequate depth adults: 5 cm;

infants and children: a depth of least one third the anterior-posterior (AP) diameter of the chest, 4 cm in infants and 5 cm in children

• allowing complete chest recoil after each compression• minimizing interruptions in compressions• avoiding excessive ventilationIf multiple rescuers are available, they should rotate the task of

compressions every 2 minutes.

3. Airway and Ventilations• Opening the airway (with a head tilt– chin lift or jaw

thrust) followed by rescue breaths can improve oxygenation and ventilation.

• Healthcare providers should perform in cycles of 30 compressions to 2 ventilations until an advanced airway is placed; then continuous chest compressions with ventilations at a rate of 1 breath every 6 to 8 seconds (8 to 10 ventilations per minute) should be performed.

4. Defibrillation

• Activate the emergency response system the lone rescuer should next retrieve an AED (if nearby and easily accessible) and then return to the victim to attach and use the AED. The rescuer should then provide high-quality CPR.

• When 2 or more rescuers are present, one rescuer should begin chest compressions while a second rescuer activates the emergency response system and gets the AED (or a manualdefibrillator in most hospitals) (Class IIa, LOE C).

• The AED should be used as rapidly as possible and both rescuers should provide CPR with chest compressions and ventilations.

Managing the Airway

• Perform chest compressions prior ventilations (CAB).

• Airway maneuvers should be performed quickly and efficiently so that interruptions in chest compressions are minimized and chest compressions should take priority in the resuscitation of an adult.

Managing the Airway

1. Mouth to Mouth Rescue• open the victim’s airway, pinch the victim’s

nose,and create an airtight mouth-to-mouth seal.

• Give 1 breath over 1 second, take a “regular” (not a deep) breath, and give a second rescue breath over 1 second

Managing the Airway

2. Mouth-to–Barrier Device Breathing3. Mouth-to-Nose and Mouth-to-Stoma

Ventilation• recommended if ventilation through the

victim’s mouth is impossible (eg, the mouth is seriously severed)

Managing the Airway

4. Ventilation With Bag and Mask• Rescuers can provide bag-mask

ventilation with room air or oxygen.• Provides positive-pressure ventilation

without an advanced airway; therefore, may produce gastric inflation and its complications.

Managing the Airway

5. Ventilation With an Advanced Airway• When the victim has an advanced airway in

place during CPR, rescuers no longer deliver cycles of 30 compressions and 2 breaths

• Continuous chest compressions are performed at a rate of at least 100 per minute without pauses for ventilation, and ventilations are delivered at the rate of 1 breath about every 6 to 8 seconds

Managing the Airway

• 6. Cricoid Pressure• is a technique of applying pressure to the victim’s

cricoid cartilage to push the trachea posteriorly and compress the esophagus against the cervical vertebrae.

• Prevent gastric inflation and reduce the risk of regurgitation and aspiration during bag-mask ventilation, but it may also impede ventilation.

• The routine use of cricoid pressure in adult cardiac arrest is not recommended

Recovery Position• The recovery position is used for unresponsive adult victims

who clearly have normal breathing and effective circulation.

CPR Techniques and Devices

CPR Techniques1. High Frequency Chest Compressios• High-frequency chest compression (typically at a frequency >120x

per minute) has been studied as a technique for improving resuscitation from cardiac arrest and may be considered by adequately trained rescue personnel as an alternative

2. Open-Chest CPR• In open-chest CPR the heart is accessed through a thoracotomy

(typically created through the 5th left intercostal space) and compression is performed using the thumb and fingers, or with the palm and extended fingers against the sternum. Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery

3. Interposed Abdominal Compression-CPR• The interposed abdominal compression (IAC)-CPR is a

3-rescuer technique (an abdominal compressor plus the chest compressor and the rescuer providing ventilations) that includes conventional chest compressions combined with alternating abdominal compressions• IAC-CPR increases diastolic aortic pressure and venous

return, resulting in improved coronary perfusion pressure and blood flow to other vital organs. • IAC-CPR may be considered during in-hospital

resuscitation when sufficient personnel trained in its use are available. There is insufficient evidence to recommend for or against the use of IAC-CPR in the out-of-hospital setting or in children.

4. Prone CPR• When the patient cannot be placed in the supine

position, it may be reasonable for rescuers to provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place

CPR Devices1. Devices to Assist Ventilation• Automatic Transport VentilatorsATV (pneumatically powered and time- or pressure-cycled) may provide ventilation and oxygenation similar to that possible with the use of a manual resuscitation bag, while allowing the Emergency Medical Services (EMS) team to perform other tasks. Disadvantages of ATVs include the need for an oxygen source and a power source.• Manually Triggered, Oxygen-Powered, Flow-Limited

ResuscitatorsManually triggered, oxygen-powered, flow-limited resuscitators may be considered for the management of patients who do not have an advanced airway in place and for whom a mask is being used for ventilation during CPR

2. Devices to Support Circulation• Active Compression-Decompression CPRActive compression-decompression CPR (ACD-CPR) is performed with a device that includes a suction cup to actively lift the anterior chest during decompression. The application of external negative suction during the decompression phase of CPR creates negative intrathoracic pressure and thus potentially enhances venous return to the heart. When used, the device is positioned at midsternum on the chest. There is insufficient evidence to recommend for or against the routine use of ACD-CPR. ACD-CPR may be considered for use when providers are adequately trained and monitored

• Impedance Threshold DeviceThe impedance threshold device (ITD) is a pressure-sensitive valve that is attached to an endotracheal tube, supraglottic airway, or face mask. The ITD limits air entry into the lungs during the decompression phase of CPR, creating negative intrathoracic pressure and improving venous return to the heart and cardiac output during CPR. It does so without impeding positive pressure ventilation or passive exhalation.

Management of Cardiac Arrest

• Cardiac arrest can be caused by 4 rhythms : Ventricular Fibrillation (VF), Pulseless Ventricular Tachycardia (VT), Pulseless Electric Activity (PEA), and Asystole

• Survival from these cardiac arrest rhythms requires both Basic Life Support (BLS) and a system of Advanced Cardiovascular Life Support (ACLS) with integrated post-cardiac assrest care

• The foundation of successful ACLS is high quality CPR, and, for VF/ pulseless VT, attempted defibrillation within minutes of collapse

• For victims of witnessed VF arrest, early CPR and rapid defibrillation can significantly increase the chance for survival to hospital discharge

• Rhythm associated with cardiac arrest are divided into two groups :a. Shockable rhythms : VF/pulseless VTb. Non-shockable rhythms : Asystole and PEA

• Periodic pause in CPR should be as brief as possible and only necessary to assess rhythm, shock VF/VT, perform a pulse check when an organized rhythm is detected, or place an advanced airway

• In the absence of an advanced airway, a synchronized compression-ventilation ratio of 30:2 is recommended at a compression rate of at least 100 per minute

Chest Compression Position

Stop CPRIf there is sign below within 30 minutes

1. No progress2. No electrical cardiac activity3. No spontaneous breathing4. No carotid pulse5. Unresponsive6. Dilated pupil and no light reflex7. Rescuer is to fatigue

CPR can be stopped

Management of Symptomatic Bradycardia and Tachycardia

• If bradycardia produces signs and symptoms of instability (eg, acutely altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock that persist despite adequate airway and breathing), the initial treatment is atropine (Class IIa, LOE B).

• If bradycardia is unresponsive to atropine, intravenous (IV) infusion of β-adrenergic agonists with rate-accelerating effects (dopamine, epinephrine) or transcutaneous pacing (TCP) can be effective (Class IIa, LOE B) while the patient is prepared for emergent transvenous temporary pacing if required.

Shock First Versus CPR First• Immediate CPR by EMS personnel was associated with no

significant difference in survival to discharge but significantly improved neurological status at 30 days or 1 year compared with immediate defibrillation in patients with out-of-hospital VF

• Probability of survival was increased if chest compressions were performed during a higher proportion of the initial CPR period as compared to a lower proportion.

• When VF is present for more than a few minutes, the myocardium is depleted of oxygen and metabolic substrates. A brief period of chest compressions can deliver oxygen and energy substrates, increasing the likelihood that a shock may terminate VF (defibrillation) and a perfusing rhythm will return (ie, ROSC)

1-Shock Protocol Versus 3-Shock Sequence

• First-shock efficacy for biphasic shocks is comparable or better than 3 monophasic shocks.

• The rhythm analysis for a 3-shock sequence performed by commercially available AEDs can result in delays of up to 37 seconds between delivery of the first shock and delivery of the first post-shock compression

• Shortening the interval (efficient coordination) between the last compression and the shock by even a few seconds can improve shock success (defibrillation and ROSC)

Defibrillation Waveforms and Energy Levels

• The term defibrillation (shock success) is typically defined as termination of VF for at least 5 seconds following the shock

• VF frequently recurs after successful shocks, but it’s not a shock failure

• Modern defibrillators are classified according to 2 types of waveforms: monophasic and biphasic

Monophasic Waveform Defibrillators

• Those deliver current of one polarity and can be categorized by the rate at which the current pulse decreases to zero.

• The monophasic damped sinusoidal waveform (MDS) returns to zero gradually, whereas the monophasic truncated exponential waveform (MTE) current returns abruptly (is truncated) to zero current flow.

Monophasic waveforms. Damped sinusoidal wave (A) Truncated exponential (B)

Biphasic Waveform Defibrillators

• Lower-energy biphasic waveform shocks (≤200 J) have equivalent or higher success for termination of VF than either MDS or MTE monophasic waveform shocks of equivalent or higher energy.

• In pediatric defibrillation, it is acceptable to use an initial dose of 2 to 4 J/kg. For refractory VF, it is reasonable to increase the dose to 4 J/kg. Subsequent energy levels should be at least 4 J/kg, and higher energy levels may be considered, not to exceed 10 J/kg or the adult maximum dose

A. Biphasic Waveform B..Triphasic Waveform

Fixed and Escalating Energy

• Several animal studies have shown the potential for myocardial damage with much higher energy shocks.

• Second and subsequent energy levels should be at least equivalent and higher energy levels may be considered, if available (Class IIb, LOE B).

Electrodes

• Electrode Placement• Defibrillation With Implanted Cardioverter

Defibrillator• Electrode Size• Transthoracic Impedance

Electrode Placement

• 4 pad positions (anterolateral, anteroposterior, anterior-left infrascapular, and anterior-right infrascapular) are equally effective to treat atrial or ventricular arrhythmias.

• Lateral pads/paddles should be placed under breast tissue, and hirsute males should be shaved prior to application of pads

Defibrillation With Implanted Cardioverter Defibrillator

• If the patient has an implantable cardioverter defibrillator (ICD) that is delivering shocks (ie, the patient’s muscles contract in a manner similar to that observed during external defibrillation), allow 30 to 60 seconds for the ICD to complete the treatment cycle before attaching an AED

• The anteroposterior and anterolateral locations are acceptable in patients with these devices.

• Do not place AED electrode pads directly on top of a transdermal medication patch, (eg, patch containing nitroglycerin, nicotine, analgesics, hormone replacements, antihypertensives) because the patch may block delivery of energy from the electrode pad to the heart and may cause small burns to the skin

Defibrillation With Implanted Cardioverter Defibrillator

• If shock delivery will not be delayed, remove medication patches and wipe the area before attaching the electrode pad

• If an unresponsive victim is lying in water or if the victim’s chest is covered with water or the victim is extremely diaphoretic, it may be reasonable to remove the victim from water and briskly wipe the chest before attaching electrode pads and attempting defibrillation (Class IIb, LOE C)

• Remove excess chest hair by briskly removing an electrode pad (which will remove some hair) or rapidly shaving the chest in that area provided chest compressions are not interrupted and defibrillation is not delayed.

Electrode Size

• For adult defibrillation, both handheld paddle electrodes and self-adhesive pad electrodes 8 to 12 cm in diameter perform well, although defibrillation success may be higher with electrodes 12 cm in diameter rather than with those 8 cm in diameter

• Small electrodes (4.3 cm) may be harmful and may cause myocardial necrosis

• When using handheld paddles and gel or pads, rescuers must ensure that the paddle is in full contact with the skin.

Transthoracic Impedance

• The average adult human impedance is 70 to 80 Ω• When transthoracic impedance is too high, a low-

energy shock will not generate sufficient current to achieve defibrillation.

• To reduce transthoracic impedance, the defibrillator operator should use conductive materials (the use of gel pads or electrode paste with paddles or through the use of self-adhesive pads)

Synchronized Cardioversion• Synchronized cardioversion is shock delivery that is timed

(synchronized) with the QRS complex. This synchronization avoids shock delivery during the relative refractory portion of the cardiac cycle, when a shock could produce VF

• Synchronized cardioversion is recommended to treat – supraventricular tachycardia due to reentry, – atrial fibrillation, – atrial flutter, – atrial tachycardia,– monomorphic VT with pulses.

• It’s not effective for treatment of – junctional tachycardia – multifocal atrial tachycardia– VF– pulseless VT or polymorphic (irregular VT)

Supraventricular Tachycardias (Reentry Rhythms)

• Initial biphasic energy dose for cardioversion of adult atrial fibrillation is 120 to 200 J

• Cardioversion of adult atrial flutter and other supraventricular tachycardias generally requires less energy; an initial energy of 50 J to 100 J is often sufficient

• Atrial fibrillation with monophasic waveforms should begin at 200 J

• If the initial shock fails, providers should increase the dose in a stepwise fashion.

• For cardioversion of SVT in children, use an initial dose of 0.5 to 1 J/kg. If unsuccessful, increase the dose up to 2 J/kg

Ventricular Tachycardia

• Adult monomorphic VT (regular form and rate) with a pulse responds well to monophasic or biphasic waveform cardioversion (synchronized) shocks at initial energies of 100 J.

• If there is no response to the first shock, it may be reasonable to increase the dose in a stepwise fashion.

• For electric cardioversion in children the recommended starting energy dose is 0.5 to 1 J/kg. If that fails, increase the dose up to 2 J/kg

Post-Cardiac Arrest CareThe initial objectives of post– cardiac arrest care are to Optimize cardiopulmonary function and vital organ

perfusion. Transport the in-hospital post– cardiac arrest patient

to an appropriate critical-care unit capable of providing comprehensive post– cardiac arrest care care.

Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

Post-Cardiac Arrest CareSubsequent objectives of post– cardiac arrest care are to

Control body temperature to optimize survival and neurological recovery

Identify and treat acute coronary syndromes (ACS) Optimize mechanical ventilation to minimize lung injury Reduce the risk of multiorgan injury and support organ

function if required Objectively assess prognosis for recovery Assist survivors with rehabilitation services when

required