1. Cardiopulmanary and cerebral resuscitation

2. BLS ALS Basic Life Support Advanced Life Support Prolonged Life Support AED

4. Survival Rate in Cardiopulmonary Arrest 0 – 50% (64%, 80%?)

5. AED Safety use Safety use Permissive legislation to use AED (“Good Samaritan Law”) Permissive legislation to use AED (“Good Samaritan Law”) 1 DEA – 10.000 inhabitants 1 DEA – 10.000 inhabitants (population crowds, airports, police cars, fire fighters, casinos, etc.) 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.

6. Early BLS Done by lays (from bystanders) Done by lays (from bystanders) Until an emergency staff is available Until an emergency staff is available Double the surviving Double the surviving

7. DEFIBRILARE PRECOCE Fiecare 1 minut scade şansa de supravieţuire cu 7 - 10 % Fiecare 1 minut scade şansa de supravieţuire cu 7 - 10 % După 4 - 6 minute - leziuni neurologice După 4 - 6 minute - leziuni neurologice După 10 minute - tentative de resuscitare nereuşite După 10 minute - tentative de resuscitare nereuşite DEA ÎN 8-10 MINUTE!

8. SUPORTUL VITAL DE BAZA SVB Scopul SVB: cardiac and cerebral oxygenation Increase the defibrillation efficiency 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 DEFINITION:

9. 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

10. Causes of cardiac arrest cardiac extracardiac Primary lesion of cardiac muscle leading to the progressive decline of contractility, conductivity disorders, mechanical factors all cases accompanied with hypoxia

11. Causes of circulation arrest Cardiac ischemic heart disease (myocardial infarction, stenocardia) ischemic heart disease (myocardial infarction, stenocardia) arrhythmias of different origin and character arrhythmias of different origin and character valvular disease valvular disease cardiac tamponade cardiac tamponade pulmonary artery thromboembolism pulmonary artery thromboembolism ruptured aneurysm of aorta ruptured aneurysm of aorta reflector cardiac arrest reflector cardiac arrestExtracardiac airway obstruction airway obstruction acute respiratory failure acute respiratory failure shock shock electrolytic disorders electrolytic disorders embolisms of different origin embolisms of different origin drug overdose drug overdose electrocution electrocution poisoning poisoning metabolic acidosis metabolic acidosis

12. 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 P.pf. cerebrală = PAM – PIC (P sist) P.pf. miocard = PAM – P miocard (P diast) Acidoza -vasodilataţie sitemică - vasoconstricţie pulm - rasp la catecolamine

13. 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

14. BLS - sequence of operations r Check responsiveness r Call for help r Correctly place the victim and ensure the open airway r Check the presence of spontaneous respiration r Check pulse r Start external cardiac massage and artificial ventilation

15. In case of unconsciousness it is necessary to estimate quickly the open airway respiration hemodynamics

16. 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

17. 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%

18. 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

19. 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

20. 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. If you have any doubt whether breathing is normal, act as if it is not normal. 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.

21. If he is breathing normally turn him into the recovery position send or go for help/call for an ambulance check for continued breathing

23. 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

24. 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.

25. 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

26. 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

27. 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.

28. 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.

29. RESUSCITAREA RATA CTE : RESPIRAŢII 15:2 EFECTUATĂ DE UN SINGUR SALVATOR 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

30. OBSTRUCŢIA CRS PRIN CORP STRĂIN RECUNOAŞTERE - PARŢIALĂ - FLUX AERIAN BUN - FLUX AERIAN PROST - COMPLETĂ - TUSE - EFORT RESPIRATOR -TUSE INEFICIENTĂ -INSPIR ZGOMOTOS -CIANOZĂ Noisy inspiration

31. OBSTRUCŢIA CU CORP STRĂIN A CĂILOR AERIENE EVALUAREA SEVERITĂŢII OBSTRUCŢIE SEVERĂ (tuse ineficientă) INCONŞTIENT RCP CONŞTIENT 5 LOVITURI INTERSCAPULARE 5 COMPRIMĂRI ABDOMINALE OBSTRUCŢIE UŞOARĂ (tuse eficientă) ÎNCURAJAREA TUSEI

33. ÎNDEPĂRTAREA OBSTRUCŢIEI 5 LOVITURI CU PODUL PALMEI LA NIVELUL SPAŢIULUI INTERSCAPULOVERTEBRAL 5 COMPRESIUNI ABDOMINALE MANEVRA HEIMLICH

34. VICTIMĂ CONŞTIENTĂVICTIMĂ INCONŞTIENTĂ

36. CPR Advanced Life Support

37. 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

38. Recognize ECG waves

39. 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

40. 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

43. 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

45. DISOCIATIA ELECTROMECANICA = entitate patologica particulara a SCR, caracterizata prin asocierea dintr- e 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.

47. Shockable rhythms (ventricular fibrillation/pulseless ventricular tachycardia) * VF may be preceded by a period of VT or even supraventriculr tachycardia (SVT) VF/VT confirmedone 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.

48. check monitor if there is still VF/VT Adrenaline 1 mg** 3 rd 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 4 th shock ** - adrenaline 1 mg every 3-5 min., once every two loops of the algorithm

49. Non-shockable rhythms (PEA and 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 Asystole

50. Airway and ventilation - consider reversible causes (4 H’s and 4 T’s) and, if identified, correct them. Tracheal intubation Tracheal intubation provides the most reliable healthcare provider but only for trained staff. - do not hyperventilate, ventilate the lungs at 10 breaths/min. Alternatives Alternatives:- combitube - laryngeal mask airway (LMA) - laryngeal tube Deliver chest compressions, uninterrupted during ventilation. - without a good oxygenation it may be impossible to restore a spontaneous cardiac output.

51. Suportul Vital Avansat Intubatia oro-traheala

61. PRESIUNEA CRICOIDIANĂ PENTRU EVITAREA REGURGITĂRII CONŢINUTULUI GASTRIC

69. Recunoasterea traseelor EKG

70. 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.

71. - depolarizarea unei mase de miocard prin traversarea curentului electric - marimea electrozilor 10-30 cm - plasarea corecta a padelelor, gel transconductor Mecanismul defibrilarii Energia socului electric 150 - 200 J bifazic 360 J monofazic

72. 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

73. poate : -stimula activitatea electrica in asistola - “converti” o TV (11-40%) - “converti” o FiV (2,5%), LOVITURA CU PUMNUL

74. Leziuni fizice directe: -fracturi sternale, -fracturi costale, -contuzii miocardice -rupturi(?)de cord *Accelerarea frecventei unei TV *Precipitarea FiV(risc mai mare la bolnavii digitalizati).

75. TERAPIA MEDICAMENTOASA

76. ADRENALINA - 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 = amina simpaticomimetica

77. 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

78. 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)

79. 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

80. 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

81. 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