Cardiopulmanary and
cerebral resuscitation
Basic Life Support
Advanced Life Support
Prolonged Life Support
ALS
BLS
AED
Survival Rate in
Cardiopulmonary Arrest
0 – 50%
(64%, 80%?)
AED
An AED uses voice prompts to guide the rescuer. It analyses the ECG
rhythm and informs the rescuer if a shock is needed. AEDs are extremely
accurate and will deliver a shock only when VF (or its precursor,
rapid ventricular tachycardia) is present .

Safety use

Permissive legislation to use AED (“Good Samaritan Law”)

1 DEA – 10.000 inhabitants
(population crowds, airports, police cars, fire fighters, casinos, etc.)
Early BLS

Done by lays (from bystanders)

Until an emergency staff is available

Double the surviving
DEFIBRILARE PRECOCE

Fiecare 1 minut scade şansa de supravieţuire cu 7 - 10 %

După 4 - 6 minute - leziuni neurologice

După 10 minute - tentative de resuscitare nereuşite
DEA ÎN 8-10 MINUTE!
SUPORTUL VITAL DE BAZA
SVB
DEFINITION:
Basic life support (BLS) refers to maintaining airway
patency and supporting breathing and the circulation,
without the use of equipment other than a protective device
Scopul SVB: cardiac and cerebral oxygenation
Increase the defibrillation efficiency
Consequences:
- 3-5 min. => irreversible nerve cells lesions.
Optmal time (until) to start CPR = 4 min.
Longer time:
- hypothermia (temp rectală 19-24 grade C)
- barbiturics influence
- child < 1 year old
Shorter time, 2-3 min.:
- respiratory arrest before heart stops
٠ barbiturics overdose
٠ strangle
all cases accompanied
with hypoxia
extracardiac
Causes of cardiac
arrest
cardiac
Primary lesion of cardiac muscle leading to the
progressive decline of contractility, conductivity
disorders, mechanical factors
Causes of circulation arrest
Cardiac


ischemic heart disease (myocardial
infarction, stenocardia)
arrhythmias of different origin and
character

valvular disease

cardiac tamponade

pulmonary artery
thromboembolism
Extracardiac

airway obstruction

acute respiratory failure

shock

electrolytic disorders

embolisms of different origin

drug overdose

electrocution

ruptured aneurysm of aorta

poisoning

reflector cardiac arrest

metabolic acidosis
FIOZIOPATOLOGIE
Încetarea (ceasing) activit de pompă a cordului
- lipsa debitului cardiac
P.pf. miocardică şi coronariană
=> hipoxia cel, metabolism anaerob, acumularea de toxice
lez tisulare ireversibile
-vasodilataţie sitemică
Acidoza
- vasoconstricţie pulm
- rasp la catecolamine
P.pf. cerebrală = PAM – PIC
(P sist)
P.pf. miocard = PAM – P miocard
(P diast)
DIAGNOSTIC of
SCR
- Rapid
- unconscious + no respiration
+ no pulse
- ECG: asistole, FV, TV (activit electrică fără puls), PEA
Late clinical picture:
- cyanosis and pale teguments
- areactive midriasis
BLS - sequence of operations

Check responsiveness

Call for help

Correctly place the victim and ensure the open airway

Check the presence of spontaneous respiration

Check pulse

Start external cardiac massage and artificial
ventilation
In case of unconsciousness it
is necessary to estimate
quickly
 the open airway
 respiration
 hemodynamics
Main stages of resuscitation
A (Airway) – ensure open airway by preventing the falling
back of tongue, tracheal intubation if possible
B (Breathing) – start artificial ventilation of lungs
C (Circulation) – restore the circulation by external cardiac
massage
D (Differentiation, Drugs, Defibrilation) – quickly perform
differential diagnosis of cardiac arrest, use different
medication and electric defibrillation in case of
ventricular fibrillation
Probleme teoretice
Ventilaţia artificială cu aer inspirat (16-18% O2)
Teoria pompei cardiace
- 30 % din perfuzia cerebrală optimă – limita critică a viabil. cel.
corticale
- fluxul miocardic – 20-30% din valoarea normală
- fluxul visceral abdominal – 5%
1 Make sure you, the victim and any
bystanders are safe.
2 Check the victim for a response
Adult basic life support algorithm.
• gently shake his shoulders and ask loudly: ‘‘Are you all right?’’
If he responds
• leave him in the position in which you find him provided there is no further
danger
• try to find out what is wrong with him and get help if needed
• reassess him regularly
If he does not respond
• shout for help
• turn the victim onto his back and then open the airway using head tilt and chin
lift
- place your hand on his forehead and gently tilt his head back keeping your
thumb and index finger free to close his nose if rescue breathing is required. with
your fingertips under the point of the victim’s chin, lift the chin to open the airway
Keeping the airway open, look, listen and
feel for normal breathing
• Look for chest movement.
• Listen at the victim’s mouth for breath
sounds.
• Feel for air on your cheek.
In the first few minutes after cardiac arrest, a victim may be barely
breathing, or taking infrequent, noisy gasps. Do not confuse this with normal
breathing. Look, listen, and feel for no more than 10 s to determine whether
the victim is breathing normally.
normal.
If you have any doubt whether breathing is normal, act as if it is not
If he is breathing normally
• turn him into the recovery position
• send or go for help/call for an ambulance
• check for continued breathing
If he is not breathing normally
• send someone for help or, if you are on your own, leave the victim and alert the
ambulance service; return and start chest compression as follows:
. kneel by the side of the victim
. place the heel of one hand in the centre of the victim’s chest. place the heel of your
other hand on top of the first hand
. interlock the fingers of your hands and ensure that pressure is not applied over the
victim’s ribs.
. position yourself vertically above the victim’s chest and, with your arms straight,
.after each compression, release all the pressure on the chest without losing contact
between your hands and the sternum; repeat at a rate of about 100/min. . .
compression and release should take equal amounts of time
Combine chest compression with rescue breaths.
• After 30 compressions open the airway again using head tilt and chin lift.
• Pinch the soft part of the nose closed, using the index finger and thumb of your hand
on the forehead.
• Allow the mouth to open, but maintain chin lift.
• Take a normal breath and place your lips around his mouth, making sure that you
have a good seal.
• Blow steadily into the mouth while watching for the chest to rise, taking about 1 s as
in normal breathing; this is an effective rescue breath.
• Maintaining head tilt and chin lift, take your mouth away from the victim and watch
for the chest to fall as air passes out.
• Take another normal breath and blow into the victim’s mouth once more, to achieve a
total of two effective rescue breaths. Then return your hands without delay to the
correct position on the sternum and give a further 30 chest compressi.
• Continue with chest compressions and rescue breaths in a ratio of 30:2.
• Stop to recheck the victim only if he starts breathing normally; otherwise do not
interrupt resuscitation.
If your initial rescue breath does not make the chest rise as in normal breathing, then
before your next attempt:
• check the victim’s mouth and remove any obstruction
• recheck that there is adequate head tilt and chin lift
• do not attempt more than two breaths each time before returning to chest compr.
If there is more than one rescuer present, another should take over CPR every 1—2 min
to prevent fatigue. Ensure the minimum of delay during the changeover of rescuers
• Stop to recheck the victim only if he starts breathing normally;
otherwise do not interrupt resuscitation.
Continue resuscitation until
• qualifed help arrives and takes over
• the victim starts breathing normally
• you become exhausted
Ventilation
During CPR the purpose of ventilation is to maintain adequate oxygenation. The
optimal tidal volume, respiratory rate and inspired oxygen concentration
to achieve this, however, are not fully known. The current recommendations are
based on the following evidence:
1. During CPR, blood flow to the lungs is substantially reduced, so an adequate
ventilation perfusion ratio can be maintained with lower tidal volumes and
respiratory rates than normal.
2. Not only is hyperventilation (too many breaths or too large a volume) unnecessary,
but it is harmful because it increases intrathoracic pressure, thus decreasing
venous return to the heart and diminishing cardiac output. Survival is consequently
reduced.
3. When the airway is unprotected, a tidal volume of 1 l produces significantly more
gastric distention than a tidal volume of 500 ml.
4.
Low minute-ventilation (lower than normal tidal volume and respiratory rate)
can maintain effective oxygenation and ventilation during CPR. During adult CPR, tidal
volumes of approximately 500—600 ml (6—7 ml kg-1) should be adequate.
5.
Interruptions in chest compression (for example to give rescue breaths) have
a detrimental effect on survival. Giving rescue breaths over a shorter time will help to
reduce the duration of essential interruptions.
6.
The current recommendation is, therefore, for rescuers to give each rescue
breath over about 1 s, with enough volume to make the victim’s chest
rise, but to avoid rapid or forceful breaths. This recommendation applies to all forms of
ventilation during CPR, including mouth-to-mouth and bagvalve-mask (BVM) with and
without supplementary oxygen.
7.
Mouth-to-nose ventilation is an effective alternative to mouth-to-mouth
ventilation. It may be considered if the victim’s mouth is seriously injured or cannot be
opened, the rescuer is assisting a victim in the water, or a mouth-to-mouth seal is difcult
to achieve.
RESUSCITAREA
EFECTUATĂ DE UN SINGUR SALVATOR
RATA CTE : RESPIRAŢII 15:2
EFECTUATĂ DE DOI SALVATORI
RATA CTE : RESPIRAŢII 5:1
RECOMANDAREA ANULUI 2002
RATA CTE : RESPIRAŢII 15:2
INDIFERENT DE NUMĂRUL DE SALVATORI
RECOMANDAREA ANULUI 2006
RATA CTE : RESPIRAŢII 30:2
INDIFERENT DE NUMĂRUL DE SALVATORI
OBSTRUCŢIA CRS PRIN CORP STRĂIN
RECUNOAŞTERE
- TUSE
- FLUX AERIAN BUN
- PARŢIALĂ
- EFORT
RESPIRATOR
- FLUX AERIAN PROST
-TUSE INEFICIENTĂ
-INSPIR ZGOMOTOS
Noisy inspiration
-CIANOZĂ
- COMPLETĂ
OBSTRUCŢIA CU CORP STRĂIN
A CĂILOR AERIENE
EVALUAREA SEVERITĂŢII
OBSTRUCŢIE SEVERĂ
(tuse ineficientă)
INCONŞTIENT
RCP
OBSTRUCŢIE UŞOARĂ
(tuse eficientă)
CONŞTIENT
5 LOVITURI INTERSCAPULARE
5 COMPRIMĂRI ABDOMINALE
ÎNCURAJAREA
TUSEI
ÎNDEPĂRTAREA OBSTRUCŢIEI
5 LOVITURI CU PODUL PALMEI LA
NIVELUL SPAŢIULUI INTERSCAPULOVERTEBRAL
5 COMPRESIUNI ABDOMINALE
MANEVRA HEIMLICH
MANEVRA HEIMLICH
VICTIMĂ CONŞTIENTĂ
VICTIMĂ INCONŞTIENTĂ
CPR
Advanced Life Support
SUPORTUL VITAL AVANSAT
Scop: restore heart pomp activity by medication and defibrillation
- 8 min. since the heart stoped
- maintaining BLS!!
- IOT
- venous acces
- medication
- DEFIBRILLATION !! – as soon as possible
Recognize ECG waves
FIBRILATIA VENTRICULARA
= activitatea anarhica a mai multor centri ectopici raspanditi difuz in
micoardul ventricular; acesti centri genereaza automatism producand
descarcari electrice zonale ce duc la contractii parcelare, facand incapabila
functia de pompa
FV primara – apare pe un cord indemn hipoxic ( frecvent la copii)
FV secundara – un mecanism de alterare morfofunctionala a miocardului
TAHICARDIA VENTRICULARA
= expresia unor depolarizari succesive de origine ventriculara (sub bifurcatia
hisiana), de obicei cauzata de boala cornoraniana ischemica
TV nesustinuta < 30 sec.
TV sustinuta > 30 sec. + colaps hemodinamic
In functie de morfologia complexului ORS clasificarea TV se va face in TV
monomorfa si TV polimorfa
O forma particulara de TV este torsada varfurilor generata de posdepolarizarea
precoce in anumite conditii: QT lung (efect toxic a fenotiazidelor, antidepresive
triciclice, haloperidol, antiaritmice), bradicardie severa, AVC-uri, dezechilibre
hidroelectrolitice, hipotermie, boli cardiace
ASISTOLA
= lipsa totala a activitatii electrice a cordului, cu un prognostic rezervat,
rata de supravietuire 1-2%
- reprezentata de o linie sinusoidala (nu izoelectrica) compusa de mici
unde date de depolarizarile de mica intensitate a musculaturii scheletice
- trebuie diferentiata de FV cu unde mici
DISOCIATIA ELECTROMECANICA
= entitate patologica particulara a SCR, caracterizata prin asocierea dintre o activitate electrica prezenta (alta decat FV/TV) si lipsa activitatii
mecanice a miocardului ventricular.
DEM cu complexe QRS largi cu frecventa scazuta apar in: IM masiv,
hipopotasemie severa, hipotermie, hipoxie acidoza, supradoajul de
antidepresive triciclice, beta-blocante, blocante ale canalelor de calciu,
digitalice.
DEM cu complexe inguste cu frecventa crescuta (d.p.d.v. electric cordul
raspunde relativ normal): hipovolemie, tampodana cardiaca,
pneumotorace compresiv, TEP masiv.
Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia)
* VF may be preceded by a period of VT or even supraventriculr tachycardia (SVT)
VF/VT confirmed
one shock (150 – 200 J biphasic)
without reassessing the rhythm
resume CPR (CV ration 30:2) 2 min.
check monitor if there is still VF/VT
second shock (200 J biphasic)
resume CPR (CV ration 30:2) 2 min.
check monitor if there is still VF/VT
Adrenaline 1 mg**
3rd shock (200 J biphasic)
resumption of CPR for 2 min.
analyze the rhythm if is still present VF/VT
i.v. bolus of Amiodarone 300 mg
4th shock
** - adrenaline 1 mg every 3-5 min., once every two loops of the algorithm
Non-shockable rhythms (PEA and asystole)
Asystole
PEA = pulseless electrical activity is defined as cardiac activity in the absence of any palpable
pulses
- mechanical myocardial contractions, but these are too weak to produce pulse
- caused by reversible conditions
Asystole/PEA
CPR 30:2
i.v. + Adrenaline 1mg
Atropine 3 mg
secure airway, IOT
Recheck the rhythm every 2 min
Airway and ventilation
- without a good oxygenation it may be impossible to restore a spontaneous
cardiac output.
- consider reversible causes (4 H’s and 4 T’s) and, if identified, correct them.
Tracheal intubation provides the most reliable healthcare provider but only for
trained staff.
- do not hyperventilate, ventilate the lungs at 10 breaths/min.
Alternatives:
- combitube
- laryngeal mask airway (LMA)
- laryngeal tube
Deliver chest compressions, uninterrupted during ventilation.
Suportul Vital Avansat
Intubatia oro-traheala
PRESIUNEA CRICOIDIANĂ
PENTRU EVITAREA REGURGITĂRII
CONŢINUTULUI GASTRIC
Recunoasterea traseelor EKG
DEFIBRILAREA
- trebuie aplicata cat mai rapid pt o recuperare neurologica cat m completa;
- este tratamentul propriu-zis al FV
= aplicarea unui soc electric miocardului pt a realiza depolarizarea fibrelor
miocardice simultan si pt a permite preluarea controlului de catre struct
naturale generatoare de impulsuri.
Mecanismul defibrilarii
- depolarizarea unei mase de miocard prin traversarea curentului electric
- marimea electrozilor 10-30 cm
- plasarea corecta a padelelor, gel transconductor
150 - 200 J bifazic
Energia socului electric
360 J monofazic
CARDIOVERSIA SINCRONA
tratamentul:
- TV, TA (pacientul constient trebuie sedat)
- socul sincronizat cu unda R a complexului QRS
- 50 J, 100J, 200J, 300J, 360J
Securitatea manoperei
LOVITURA CU PUMNUL
poate :
-stimula activitatea electrica
- “converti” o TV (11-40%)
- “converti” o FiV (2,5%),
in asistola
LOVITURA CU PUMNUL
Leziuni fizice directe:
-fracturi sternale,
-fracturi costale,
-contuzii miocardice
-rupturi(?)de cord
*Accelerarea frecventei unei TV
*Precipitarea FiV(risc mai mare la bolnavii digitalizati).
TERAPIA MEDICAMENTOASA
ADRENALINA
= amina simpaticomimetica
- primul medicament utilizat în algoritmul SCR
- acţiune betaexcitatoare – efect B, D, C, I (+)
- alfa adrenergic – creşte R.art.perif. – ameliorarea PAM
Doze în SCR: - 1 mg i.v – repetabil la 3 min.
- 3 mg IOT – diluat in 10-20 ml SF.
Ef. sec. – artimogenă când miocardul este ischemic sau hipoxic
ATROPINA
Ind: - asistolă
- DEM cu fc<60/min.
- bradicardii sinusale, atriale sau nodale + hTA
- antagonizează ef. parasimpatic al acetilcolinei la niv. rec. muscarinici;
- determină bloc ef vagale la niv nodului sinoatrial sau AV - creşeterea
automatismului sinusal + facilitarea conducerii
Doze: - 0,5 – 1 mg i.v., repetabilă la 5 min. – in bradicardii
- max 3 mg i.v. o singura data in SCR - asistolie
- IOT 9 mg/20 ml soluţie de diluţie
AMIODARONA
- scade automatismul nodului sinusal, alungeste timpul de conducere si perioada refractara a
nodului AV si a miocardului V.
- creste durata potentialului de actiune in miocardul atrial si ventricular.
- eficace inotrop negativ si cronotrop negativ – proprietati antianginoase
- poate deveni paradoxal proartimogena.
INDICATII
- FV/TV fara puls refractara la defibrilare (dupa 3 socuri)
- doza este de 300 mg diluata in 20 ml G 5% bolus
- a doua doza este ½ din prima, poate fi urmata de perf continua 1 mg/min timp de 6 ore
in anumite situatii (doza totala este 2 g)
LIDOCAINA
Ind: - TV instabile hemodinamic
- FV refractară la defibrilare
Efecte: - scade automatismul V.
- ef anestezic local suprimă activitatea ectopică V
- creşte pragul FV
!!! Nu are efect pe artimiile atriale
- eficienţa scade în hipo-K, hipo-Mg
Doza: - iniţial 100 mg i.v sau 1 mg/kg (efect 10 min), repetabil
- pfz 2-4 mg/min
CALCIU
Ind: - disociaţia electromecanică dat hiper-K, hipo-Ca, supradozarea Ca-blocan
Doze:
- CaCl 10% - 2 ml/70kg
- gluconat de Ca 10% - 3-8ml/70 kg
- repeabile la interval de 10 min.
BICARBONATUL DE Na
Ind: - acidoză metabolică severă, pH < 7,1
- hiper-K (exces de baze – 10mmol/l)
Doze mici de bicarbonat de Na 8,4%, repetabile
!! Monitorizarea gazelor sanguine
SUPORTUL VITAL PRELUNGIT
Scop:
mentinerea activitatii cordului si a respiratiei si refacerea
integrala a functiilor neuronale
- recuperarea pacientului intr-o sectie ATI
- supraveghere si monitorizare permanenta
- Rx toracica !!
Protectie cerebrala
- ameliorarea fluxului sanguin cerebral
- reducerea metabolismului cerebral
- prevenirea autolizei postischemice