麻醉学教学课件：Cardiopulmonary Cerebral Resuscitation

CardiopulmonaryCerebralResuscitationChapter6ContentsOverviewofCPCRBasicLifeSupport,BLSAdvancedLifeSupport,ALSProlongedLifeSupport,PLS1.OverviewofCPCRCanyousavealife?Inanemergency,wheneverysecondiscritical,wouldyouknowwhattodo?EtiologyforCardiacandRespiratoryArrestHeartdiseases(e.g:acutecoronarysyndrome)StrokePoisoningDrowningHypothermiaAnaphylaxisTraumaElectricshockorlighteningstrikesCARDIACARREST5101520?CLINICALDEATHAPPROXIMATETIME,MIN.RESTORATIONOFCIRCULATIONSPONTANEOUSBREATHINGCONSCIOUSSPONTANEOUSBREATHINGCONSCIOUSORSTUPORSPONTANEOUSBREATHINGUNCONSCIOUSAPNEAUNCONSCIOUSNEUROLNORMALNEUROLDEFICITVEGETATIVESTATEEEGABNORMALBRAINDEATHEEGISOELECTRICPANORGANICDEATHCessationofcirculationWecandiagnoseitbasedonthefollowing:UnconsciousnessNobreathingNopalpablepulseinanymajorartery(eg.carotid,orfemoralartery)DilatedpupilsAnalarmingpalegreyskinECGshowsinsuddencardiacarrest

Ventricularfibrillation

Ventricularstandstill

(asystole)

Electro-mechanicaldissociation

2.BasicLifeSupport,BLSChainofSurvivalImmediaterecognitionofcardiacarrestandactivationoftheemergencyresponsesystemEarlyCPRwithanemphasisonchestcompressionsRapiddefibrillationEffectiveadvancedlifesupportIntegratedpost–cardiacarrestcareⅠCheckforresponsivenessbyshoutingandshakingthevictimⅡCall120ⅢRememberyourC-A-B:

Circulation

Airway

BreathingⅣCheckforpulseandifnecessaryperformthecycleagainAdultBLSAlgorithmTimetoforgetyourABC's!30compressionsfirstDonotknowhowtoORDonotwanttoperformA&B,justperformCTodeterminethevictim’sheartisbeatingornotPalpatethecarotidartery’spulsesC”isforcirculationCarotidarterypalpation2fingers/cmlateralthethroatLocatesternumInterlocktwohandsPlaceheelofonehandoncenterofchestbetweenthenipplesBesuretokeepyourfingersupoffthechestwallExternalChestCompression

NoticeKeepelbowsStraightCompressiondepth:atleast5cmAllowcompletechestrecoilaftereachcompression

ExternalchestcompressionPUSHHARD,PUSHFASTNoticeRate:atleast100times/minTimeofcompressionand Releaseratio:50/50Compressionandbreathingratio:30:2

ExternalchestcompressionComplicationsRibsandsternumfractureInjuriestotheheart,greatvessels,lungs,liver,spleenHemothorax,pneumothorax,cardiactamponade.Inflationofthestomach.ContraindicationsSeriousmalformationofchestwall.SerioustraumaofchestwallCardiactamponadeCardiacvalvereplaced

IndicationsContraindicationsofECCCardiacarrestduringthoracotomyIneffectiveECC,timemorethan10min.

ComplicationsTraumaticinjuriestotheheart,lungs,andsurroundingtissuesIntrathoracicbleedingandinfectionOpenChestCompression“A”isforAIRWAYTilttheheadbackandliftthechinuptoopenthevictimsairway.Putyoureartothevictim'sopenmouthtolistenforanyairflowthroughthemouthornose.Lookdowntowardsthechesttoseeifthechestismoving.Withyourcheekfeelifthereisanyaircomingoutofthemouth.

Howto

determineifthevictimisnotbreathingCleartheairwaySupinePositionChinlift&HeadtiltbackwardMouth-to-mouthventilation

“B”isforBreathingOpenairwayPinchnoseKeepaneyeonhischesttoseevisiblechestriseTrynottoover-inflatethevictim’slungsGivetwofullbreaths.BetweeneachbreathallowlungstorelaxasthevictimexhalesMouth-to-noseventilationCannotopenmouthMouthisseverelyinjuredMouthhasnoteeth

Mouth-to-maskventilationBag-valve-maskventilationAdvancedairwayventilationComplicationsofartificialventilationInadequateventilationDistentionofthestomachAspirationofgastriccontentsCrossinfection

ThemostfrequentinitialarrhythmiainBLSisVFVFtendtoasystolewithinafewminutesTheprobabilityofsuccessfuldefibrillationdiminishesrapidlyovertime.TheeffectivetreatmentforVFiselectricaldefibrillationEarlydefibrillation“D”isfordefibrillationTheright

(sternal)chestpad:superior-anteriorchestTheleft(apical)pad:inferior-lateralleftchest.Electrodeposition:thesternal-apicalpositionDefibrillationwaveformsandenergylevels

Monophasicwaveformdefibrillator:360JBiphasicwaveformdefibrillator:200JChildren:2J/kgforECD.Openchestdefibrillation:Adult:20to80JChildren:5to50J3.AdvancedLifeSupport,ALS

AdvancedLifeSupport

---thesecondABCDEndotrachealintubation(A)Mechanicalventilationandoxygentherapy(B)Electrocardiogramandbloodpressuremonitoring(C)Intravenousinjection(C)Differentialdiagnosis(D)EndotrachealintubationMarkestimateddepthBreathsoundsbyauscultationat5locus

ThoraxriseasinspirationIncreaseofSaO2SteamincanalofartificialventilationdeviceUseaspecifictechniqueordevicetopreventtubedislodgmentMechanicalventilationLowtidalvolume

6-7ml/kg（400-600ml）HyperventilationHighairwaypressureandendogenousPEEPIntracranialhypertension;HightidalvolumeDistensionToolowtidalvolumehypoxiaandCO2retention

MonitoringPerformanceofCPRGeneralexaminationPalpablelarge-arterypulsePupillarysizeRestorationofbrainfunctionLimbmovementIncreasedmuscletoneswallowingmovementsRecoveryofspontaneousbreathingColoroflipandnailbedEnd-tidalCO2ReflectpulmonarybloodflowandcardiacoutputRapiddecreasewithonsetofcardiacarrestImmediateincreasewithresuscitationIndicatorofreturnofspontaneouscirculation

IV:

PeripheralvenousaccessCentralvenousaccess

Endotrachealroute

Epinephrine,AtropineandLidocainecanbeinjectedintotracheo-bronchialtreethroughendotrachealetubewhichisabsorbedrapidlytoproducepromptpharmacologiceffects.

Directinjectionintoventricularchamber

RoutesofdrugadministrationObjectives:Tostimulatespontaneouslycirculationandincreasemyocardialcontractility.Toincreasesystemicvascularresistance,increasemyocardialandcerebralbloodflowperfusion.Topreventrefibrillation.Totreatacid-baseelectrolyticunbalance.DrugTreatmentEpinephrine:centralroleLidocaineCordarone

Atropine(2010guidelines,AtropineisnolongerainitialtherapyofCPR)DrugTreatment4.ProlongedLifeSupport,PLSDefinition:Post-cardiacarrestsyndrome,alsoreferredtoaspost-resuscitationsyndrome,isasyndromeofmulti-organdysfunctionwhicharisesasaresultofwholebodyischemiaandreperfusion.Post-cardiacArrestSyndromeInitialObjectivesOptimizecardiopulmonaryfunctionandvitalperfusionTransportcardiacarrestvictimtoanintensivecareunitcontinuecarecapableofprovidingcomprehensivepost–cardiacarrestcare;Trytoidentifyandtreatthecausesofthearrestandpreventrecurrentarrest.SubsequentObjectivesControlbodytemperaturetooptimizesurvivalandneurologicalrecoveryIdentifyandtreatacutecoronarysyndromesOptimizemechanicalventilationtominimizelunginjuryReducetheriskofmultiorganinjuryandsupportorganfunctionifrequiredObjectivelyassessprognosisforrecoveryBrainisveryvulnerabletoischemiaandhypoxiaHighmetabolicrate60%electrophysiologicalactivitymembranepotentialneurotransmittersynthesisanduptake2%ofbodyweigh15%ofcardiacoutputjugularveinoxygensaturation55-7010secondsUnconsciousness15-25secIsoelectric2to4minutesGlucoseandglycogenstoreofthebrainaredepleted3to5minutesATPisexhaustedElectricalpumpfailureCessationofcirculationCerebralbloodflowdependsoncerebralperfusionpressureCerebralperfusionpressure=meanarterialpressure-intracranialpressureCerebralBloodFlowCerebralmetabolismmatchedwellwithcerebralbloodflowCarbondioxideOxygenHypothermiaAnestheticsRegulationofCerebralBloodFlowNeuronalinjuryNeuronalswellingIncreasedintracranialpressureDecreasedintracranialbloodflowICP>MAPisincompatiblewithlifeClinicalManifestationsComaSeizuresNeurocognitivedysfunctionBraindeathHowtoprotecttheBrain?TherapeutichypothermiaEarlyoptimizecerebralperfusionSeizurecontrolMechanicalventilationControlledreoxygenation(SaO294%to96%)SupportivecareModerateHypothrmia32°Cto34°Catleast12to24hInitiatecoolingassoonaspossibleTherapeuticHypothermiaCoolingtechniques:Head-neck-trunksurfaceNasopharyngealEsophagogastricIVcoldinfusionVenovenousshuntwithpump,heatexchangeArteriovenousshunt,heatexchangePeritonealcoldlavageIntracarotidcoldflushCardiopulmonarybypassTherapeuticHypothermiaPhasesoftherapeutichypothermia:InductionIce-cold0.9%salineorRinger’slactate(30mL/kg)MaintenanceAvoidsignificanttemperaturefluctuationsRewarmingSlowrewarming(0.25°Cto0.5°Cperhour)TherapeuticHypothermiaComplications:ShiveringIncreasesystemicvascularresistanceArrhythmiasDiuresisHyperglycemiaImpaircoagulationImpairtheimmunesystemDecreaseclearanceofdrugsTherapeuticHypothermiaMeanarterialpressureMaintaininganormalorslightlyelevatedmeanarterialpressureHigherpressureisneededtoovercomethepotentialno-reflowphenomenonCirculatorysupportOptimizepreloadInotropesDobutamine,dopamine,milrinoneVasopressorsEpinephrine,norepinephrineOptimizecerebralperfusionReducingintracranialpressureHeadelevatedto30°IncreasecerebralvenousdrainageDiureticsMannitol,furosemidumAnestheticsDecreasecerebralmetabolismandbloodflowOptimizecerebralperfusionOccurin5%to15%ofadultpatientsIncreasecerebralmetabolismDrugs:ForseizuresBenzodiazepines,phenytoin,sodiumvalproate,propofol,orbarbiturateFormyoclonusClonazepam,phenytoin,sodiumvalproateSeizureControlAvoiding:HyperventilationHypoventilationVentilationshouldbeadjustedtoachievenormocarbiaVentilationHyperoxiaharmsneuronsbycausingexcessiveoxidativestressduringtheearlystagesofreperfusionAdjustingtheFIO2toproduceanarterialoxygensaturationof94%to96%OxygenationGlucoseControl8to10mmol/LAvoidinghypoglycemiaNeuroprotectiveDrugsThiopental,glucocorticoids,nimodipine,lidoflazine,diazepam,andmagnesiumsulfateNoneuroprotectionbenefitwasobservedSupportiveCarePrognosticationofNeurologicalOutcomeNeurologicalAssessmentElectroencephalogramEvokedPotentialsNeuroimagingBloodandCerebrospinalFluidBiomarkersPoorOutcomeAbsenceofbothpupillarylightandcornealreflexesat72hoursaftercardiacarrestAbsenceofvestibulo-ocularreflexesat24hoursGlasgowComaScale(GCS)score<5at72hoursBrainDeathThetraditionalconceptofdeathisthecessationofcardiacandrespiratoryfunctionsBraindeathistheirreversiblecessationofallfunctionsoftheentirebrain,includingthebrainstem.ReasonsforRedefiningDeathAllowpatientstobedeclareddeadandnotmaintainedonmachinesAllowdonationofvitalorgansbeforethecirculationstoppedDiagnosticstepsofbraindeath:EstablishingthecauseofdiseaseExcludingcertainpotentiallyreversiblesyndromesthatmayproducesignssimilartobraindeathDemonstratingclinicalsignsofbraindeath:coma,brainstemareflexia,andapneaDiagnosticProcedureofBrainDeathDiagnosticCriteriaofBrainDeath

Prerequisites:

Braindeathistheabsenceofclinicalbrainfunctionwhentheproximatecauseisknownanddemonstrablyirreversible