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Saturday, September 21, 2019

Adult Cardiac Algorithm and Compression Technique

   Cardiac Pulmonary resuscitation

Adult Cardiac Aresst Algorithm

Basic Life Support consists of.  

.Continuous correctly delivered closed chest compressions at 80–100/minute.

.Ensuring patency of the airway (head-tilt, chin-lift maneuver).

.Ventilation (mouth-to-mouth or bag-mask ventilation) the ratio of chest compression to ventilator breaths being 30:2.

Advanced Life Support consists of—

.A combination of closed chest compressions and defibrillatory shocks for pulseless VT or VF.

.Securing IV access. 

.Advanced Airway Management and Ventilatory Support.

.Pharmacological therapy—epinephrine, 
inotropes, vasopressors, antiarrhythmic drugs, atropine, and other drugs

Position of the Patient and the Rescuer

Proper positioning of the care-giver and the patient is fundamental. In an out-of-hospital scenario, the care-giver kneels perpendicularly to the patient’s torso. For the in-hospital cardiac arrest, the doctor or the rescuer should stand at the bedside at the level of the torso of the patient. A soft mattress defeats the very purpose of mechanical cardiac compressions as the mattress absorbs a great deal of the 
force exerted during compression. If the patient is on an air mattress, it should be promptly deflated. 

Compression Technique

Place the heel of one hand on the lower half of the sternum and then place the heel of the other hand over the top of the first. In adults, depress the sternum with a downward force 
(the down stroke), for at least 2 inches and allow of proper recoil (the upstroke) before starting the next compression. The time for compression and recoil should roughly be 
equal, the chest being seen to re-expand fully before the next compression. The hands should be slightly removed (lifted) from the chest wall during the upstroke to ensure full and adequate recoil. Interruption of the recoil or inadequate recoil leads to increased intrathoracic pressures and a poor 
hemodynamic profile characterized by decreased coronary perfusion pressure, poor myocardial blood flow, decreased cardiac index and reduced cerebral blood flow.The recommended rate of delivery of chest compressions is at least 100/minute. The number of delivered compressions per minute is a predictor of return of spontaneous 
circulation (ROSC) and neurologically intact survival. The best outcomes have been observed with at least 80 chest compressions per minute in in-hospital arrests and 68–89 
compression per minute in out-of-hospital arrests.It was believed earlier that external chest compression maintained circulation as a result of a squeeze or pressure on the heart between the sternum and the thoracic spine. This squeeze pushed blood out into the systemic and pulmonary circulations, followed by a filling of the heart when the pressure was released. The current concept is that external 
pressure on the chest leads to an increased intrathoracic and intrapleural pressure, and this positive pressure is responsible for propelling the blood forward. Release of external pressure leads to a fall in the intrathoracic and intrapleural pressures, 
allowing blood to fill the heart. This thoracic pump theory claims that the entire thorax acts as a pump to propel blood forward, possibly by reducing the afterload of the left ventricle. 
Afterload can be defined as the peak systolic transmural pressure, and increased intrathoracic pressure would reduce this transmural pressure, thus reducing the afterload, and promoting emptying of the ventricles.The general guideline for compression to ventilation ratio is 30 chest compressions to two ventilations if there 
is a single rescuer. If there are two, then one rescuer can administer uninterrupted chest compressions while the other delivers ventilation (see later discussion) keeping the 
chest compression to ventilation ratio at 30:2. It is crucial not to waste time by inserting an artificial airway at the start of resuscitation as this significantly interrupts chest compression. An advanced airway should be inserted at least 3 minutes after uninterrupted chest compression and after attempted defibrillation, if this is found to be necessary.

Problems Preventing Effective Chest Compression

Chest compressions should start promptly and be delivered continuously with the right technique so as to maintain effective coronary and cerebral perfusion pressure. Even 
a short pause results in a sharp fall in the coronary and cerebral circulation pressures.15 It has been noted that interruption in chest compressions are common, consuming 
24–57% of the total resuscitation time.16,17 It has also been noted that chest compressions must be continuous if they are to reach a threshold for successful defibrillation and
resuscitation18 and counter the brain’s extreme vulnerability to ischemic injury.
The following factors encroach upon and can significantly interrupt compression time—

Advanced Cardiac Life Support interventions (ACLS) 

These can result in numerous pauses in chest compression. The insertion of artificial airways is observed to be responsible for 25% of all interruptions with a median duration of 2 minutes. Endotracheal intubation should 
not be attempted at the very start of resuscitation. It should preferably await restoration of the circulation or if deemed 
imperative should be attempted only after 3–5 minutes of continuous chest compression.

 Frequent Pulse Checks form another Source of Interruption 

Pulse check should not exceed 10 seconds; frequent pulse checks are not necessary and should be avoided unless there is other evidence of return of spontaneous 
circulation (ROSC), such as an increase in the patient’s oxygen saturation as measured by an oximeter or an increase in the end tidal CO2 (EtCO2) measurement. Studies have shown that the patients with ROSC had a mean increase of 10 mm in the EtCO2 as compared with patients with cardiac arrest who failed to survive. EtCO2measurement can therefore monitor ROSC, obviating the need to interrupt chest compressions.

 Defibrillation It is another often necessary procedure 

which interrupts chest compression. This interruptioneven while preparing for defibrillation leads to a sharp drop in the coronary perfusion pressure. Till recently 
the traditional method for defibrillation was to stop compression, analyze the ECG rhythm, charge the defirillator and deliver the shock to the patient. This amounts to be an interruption of about 15 seconds. The correct method is to charge the defibrillator in anticipation of shocking the patient, chest compressions being continued throughout and being interrupted only during rhythm analysis and delivery of the shock. The average interruption time for chest compressions is thereby close to just 4 seconds. If rhythm analysis show that defibrillation is not warranted chest compressions are promptly restarted, thereby further saving on interruption time. Recent studies have shown that it is completely safe for a care-giver wearing standard examination gloves to continue chest compressions during the use of a biphasic defibrillator with self adhesive pads.19 There is no danger of an electric shock to the rescuer with biphasic defibrillators in contrast to the legitimate fear with the use of monophasic defibrillators. 

Rescuer fatigue can result in imperfect technique of chest 

compression. The depth and even the frequency of chest compression may be compromised. A shallow depth fails to generate an adequate coronary and cerebral perfusion pressure. It is also associated with an impaired recoil which results in a reduced coronary artery blood flow and 
an increased intrathoracic pressure.

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