15.RESUSCITAREA 2010
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Transcript of 15.RESUSCITAREA 2010
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Dr. Elisabeta Badila
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Oriunde, Oricine Personal calificat
BLS - BASIC LIFE SUPPORT
ALS – ADVANCED LIFE SUPPORT
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masuri de resuscitare pe un pacient aflat in stop CR, fara a se folosi echipamente specifice
Scop: flux minim de sange pentru organele vitale
Ideal: initiere in primele 5 min (creierul este inca viabil)
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Stopul respirator din:
• inec• strangulare• supradoze• electrocutie• traumatisme• aspirare de corp strain/fum• epiglotita
Stopul cardiac
• absenta circulatiei spontane insotita intotdeauna de stop respirator/respiratii agonice
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1. Oprirea accidentului
2. Evaluarea constientei – AVPUAVPU
3. Evaluarea respiratiei
4. Masaj cardiac extern ± respiratii artificiale
in sigurantavictima
salvatorul
Pozitia de siguranta
112
++
--
3030 22
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Se face rapid; se scutura usor
Ask loudly: “Are you all right?”A – pacient alert
V – raspuns la stimul verbal
P – raspuns la stimul dureros (pain)
U – nu raspunde la stimuli (unresponsive)
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STRIGA DUPA AJUTOR !
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths
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Daca pacientul nu raspunde Deschide CA & verifica respiratia
Daca nu respira normal sau nu respira
Apeleaza 112, gaseste un AED
Incepe RCP imediat
Nu lasa victima singura decat daca nu exista alta optiune
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Pacient pe plan dur
Manevra “head-tilt-chin-lift”
Impingerea mandibulei spre inainte
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ATENTIE ! – traumatismele coloanei cervicale
Se poate produce subluxatia anterioara a mandibulei
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Look Privim toracele Listen Ascultam zgomotul produs de aer
FeelSimtim aerul expirat
ATENTIE ! la respiratiile agonice 4-6/minut
MAX 10 SECUNDE !
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Daca pacientul respira normal
Pozitia de siguranta
Apeleaza 112
Urmareste ca respiratia ramane normala
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Locul MCE: centrul toracelui (1/2 inf stern), pe linia mediana, in punctul de maxima presiune
ambele maini, degete intrepatrunse, coate in extensie, fara a se ridica palmele
100/min; 5cm comprimarea sternului
dupa fiecare compresie – elibereaza toata presiunea din torace fara a pierde contactul cu sternul
30 MCE
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centrul sternului, linie mediana, punct de
maxima presiune
Maini incrucisate, degete intrepatrunse
In Jos
In Sus
Pistonul:Bratele
5 cm
Pivotul:Artic.soldului
Cinetica:Bratele
Punctul de rezistenta:1/3 inf.a sternului
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“Pompa toracica”
-↑ pres.intratoracice det. un gradient intre aa. intra-toracice (aorta, a. pulmo-nara) si cele extratoracice (aa.carotide)
“Pompa cardiaca”
- inima comprimata intre stern si coloana det. un gradient intre ventriculi si arterele mari
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MCE TAS 60-80 mmHg
MCE un flux sangvin redus dar esential pentru creier si miocard ↑ probabilitatea succesului defibrilarii
plasarea mainii fara intarziere in centrul toracelui
frecventa - 100 compresii/min
fiecare miscare compresie stern cu 5 cm
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Permiteti toracelui sa revina dupa fiecare compresie, fara a lua mana de pe pacient
Timpul de compresie = timpul de relaxare
Minimizati intreruperile in compresii (min 60/min)
Nu va bazati pe palparea pulsului carotidian sau a altui puls ca semnificand flux arterial eficient in timpul MCE
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Fracturi de stern/coaste ± hemotorax sau embolii grasoase
Contuzie miocardica, hemopericard
Aspiratia traheobronsica, urmata de pneumonie, ARDS
Traumatism hepatic cu soc hemoragic
Leziuni gastro-esofagiene cu dezvoltarea de mediastinita
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Respiratia gura la gura• Dupa 30 compresii toracice• Deschiderea cailor aeriene• Pensarea nasului• Gura resuscitatorului etans pe gura pacientului• Inspir profund apoi expir lent (500ml) 1 sec in CRS ale pacientului
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• Urmarim expansiunea toracelui• Mentinem pozitia capului, indepartam gura si observam cum iese aerul• Efectuam a 2-a respiratie • Max 5 secunde• Daca respiratiile salvatoare nu determina expansiunea toracelui verifica cav. bucala a victimei si pozitia capului
Variante:• Gura la nas• Gura la gura si nas• Gura la traheostoma
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Stopul cardiac sangele arterial nu se misca si ramane saturat cu O2 mai multe min
Initierea RCP in primele min continut adecvat in O2 – eliberarea de O2 cerebral si miocardic limitata de reducerea DC
Ventilatia initiala – mai putin importanta decat compresiile
RCP – initiata cu compresia toracelui mai degraba decat cu ventilatia
Nu se pierde timp pentru explorarea cavitatii bucale in ideea corpilor straini decat daca respiratiile salvatoare nu realizeaza expansiunea toracelui
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In timpul RCP - fluxul sangvin pulmonar e redus semnificativ raportul adecvat ventilatie/perfuzie -mentinut cu un volum tidal si o rata resp mai mici ca normalul
Hiperventilatia – ↑ p intratoracica - intoarcerea venoasa - debitul cardiac
Intreruperea compresiilor (pt verificare ritm cardiac sau a prezentei pulsului) – efect nefavorabil pe supravietuire
Volumul tidal de 1 l distensie gastrica >> volum tidal 500 ml
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COMPRESII TORACICE : RESPIRATII SALVATOARE
30:2
Nu se intrerupe resuscitarea pana cand: • soseste personalul calificat;
• victima da semne de trezire: misca, deschide ochii, respira normal;• resuscitatorul este epuizat.
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1 salvator 2 salvatori
30 MCE
2 ventilatii
Schimba la 2 min
! Numaratoare cu voce tare
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Chest compresion only
daca salvatorul nu este antrenat / nu e capabil sa execute respiratiile salvatoare
MCE – continuu cu frecventa 100/min, dar nu peste 120/min
ar putea fi eficient doar in primele min
nu e la fel de eficienta ca RCP conventionala pentru stopul cardiac de cauza non-cardiaca (exp. inec, sufocare)
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Switch on the AED & attach pads
Atasati padelele:◦ I - pe linia axilara
mijlocie sub axila stanga
◦ II - sub clavicula dreapta
Daca sunt mai multi resuscitatori NU SE INTRERUPE RCP !
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Sigla ILCOR pt AED
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Stand clear & deliver shock Compresiile continua
cand AED se incarca
Nimeni nu atinge victima◦ in timpul analizei ritmului◦ in timpul socului
! Intreruperea < 5 sec
Riscul resuscitatorului◦ minim, mai ales daca
poarta manusi
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Reincepe imediat RCP dupa soc
Alterneaza 30 compresii toracice cu 2 respiratii
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Daca victima da semne de trezire – misca, deschide ochii, respira normal RCP se opreste
Daca victima respira normal dar e inca inconstienta pozitia de siguranta
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1 2
34
O mana in unghi drept pe langa corp
Cealalta mana sprijina capul
Indoim un genunchi
Intoarcem pacientul a.i. sa aiba punct de sprijin in:• mana• genunchi
Daca victima incepe sa respire normal
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In caz de sufocare din cauza unui corp strain
Secventa 5 lovituri in spate cu podul palmei / 5 miscari abdominale
Aplecam usor pacientul, in timp ce stam in spatele lui
Strangem un pumn
Unim pumnul de cealalta mana si cuprindem pacientul la nivelul epigastrului
Miscare rapida, spre interior si in sus
11 22
33 44
Adulti, copii> 1 an
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Copilul mare Sugar
• 1 mana MCE• 1 mana pe frunte
• 2 degete
5 resp apoi 15 compresii : 2 resp
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• 5 lovituri in spate
• 5 compresii toracice
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echipament si tehnici speciale pentru stabilirea si mentinerea ventilatiei si circulatiei eficiente
Monitorizare ECG si Defibrilare
Intubare orotraheala cu ventilatie pe masca
Acces IV si administrarea medicatiei specifice
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Cei 4 “H”
1. Hipovolemia
2. Hipoxia
3. Hipo/hiperK+/hipoCa2+
4. Hipotermia
De obicei post-hemoragie severa – datorita:1. Traumelor2. HDS/HDI3. Anevrism aortic rupt
PerfuzareInterventie chir.
Asigurarea unei ventilatii coresp. cu O2 100%
Evaluare ECG Clorura de Ca2+ iv
Invelirea pacientului, Perfuzii cu solutii incalzite NU caldura directa pe piele
Vasodilatatie periferica !!!
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Cei 4 “T”
1. Tamponada cardiaca
2. Tablete (supradozaj)
3. Tromboza coronariana sau pulmonara
4. Tension Pneumotorax
Sugestiv: traumatism de perete toracic
Pericardiocenteza/ Toracotomie !
Folosirea unui antidot daca se stie subst.
Tromboliza cat mai rapid
Decompresie rapida cu ac de toracocenteza, apoi tub de dren
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Evaluarea ABCDE secundara in SCR A – airway- eliberarea si protectia CAS – IOT
B – breathing - ventilatia
C – circulation - acces venos
D – disability
E – exposure
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Atasare defibrilator si observarea ritmului
FV sau TV fara Puls
• SEE 360 J monofazic (150-200 J bifazic)
• Apoi RCP 2 min.
• Reevaluare ritm
Asistola sau Activitate electrica fara puls
• RCP 2 min.
• Reevaluare ritm
NU SEE! !
Ritm socabil Ritm nesocabil
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Fibrilatie ventriculara
Tahicardie ventriculara fara puls
SOC ELECTRIC EXTERN !!!
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Asistola
Activitate electrica fara puls
NU DAM SOC ELECTRIC !!!
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Mod transtoracic, nesincron, mono(360J)/ bifazic (150-200J)
Aplicata precoce – amelioreaza prognosticul
Sansele de reusita ↓ cu fiecare min. de la instalarea FV (undele de FV ↓ in amplitudine dat. epuizarii rezervelor de fosfat ale inimii)
Fara paste si geluri
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Undele deFV scad in amplitudinecu trecerea timpului
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Pozitia padelelor Evaluarea ritmului
sub clavicula dreapta, pe LMC
langa apexul cardiac, evitand tesutul glandular la femei
Defibrilatorul analizeaza ritmul automat
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Aplicarea SEE RCP 2 minute
1. Incarcam defibrilatorul2. Ne asiguram ca nu atinge nimeni pacientul (inclusiv noi)3. Aplicam socul
30 MCE
2 ventilatii
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Primul SEE de 150-200 J bifazic/360 J mono RCP 2 min fara pauza pt analiza ritmului/pulsapoi scurta pauza pt analiza ritmului
Al 2-lea SEE de 150-200 J bifazic/360 J monoRCP 2 min imediat dupa, apoi pauza scurta
Al 3-lea SEE 150-200 J bifazic/360 J mono RCP 2 min imediat dupa, apoi pauza scurta
!
!
!
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Daca s-a obtinut accesul iv / io Adrenalina 1mg
amelioreaza fluxul miocardic ↑ sansa defibrilarii la urmatorul SEE 1 mg la fiecare 3-5 min pana la revenirea
circulatiei spontane (la fiecare 2 cicluri)
Amiodarona 300mg doza unica; dupa 3 SEE ineficiente
repeta 150 mg bolus, apoi 900 mg/24 h
Lovitura precordiala: • pentru stopul cu martori sau monitorizat• numai de catre personal pregatit• in ritmurile socabile, m.a. in TV fara puls• cand nu avem un def la indemana• creaza un stimul impuls-like
1 lovitura cu marginea cubitala a mainii
!
20 cm
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AEP si asistola AEP = stop cardiac in prezenta activitatii
electrice care in mod normal se asociaza cu un puls palpabil
exista contractii mecanice slabe – ineficiente pt a produce puls detectabil sau TA
frecvent cauzata de conditii reversibile
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Start RCP 2 min Adrenalina 1 mg iv imediat dupa obtinerea
accesului venos Verifica fara a opri RCP ca electrozii sunt
corect atasati Ventilati corespunzator Evaluati ritmul dupa 2 min RCP
◦ tot asistola RCP◦ ritm + palpeaza puls puls abs continua RCP
Adrenalina 1 mg iv/io la fiecare 3-5 min Puls + ingrijirea post-resuscitare
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AEP si asistola Asistola – verifica ECG pt undele P raspuns la
pacing Dg dificil asistola/FV cu unde fine nu astepta
– continua RCP si ventilatia FV cu unde fine – sanse mici de defibrilare intr-
un ritm perfuzabil; continuarea RCP poate creste amplit undelor – creste succesul defibrilarii
Daca apare ritm socabil schimb algoritm
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Obiectiv: asigurarea de aer cu cat mai mult O2
Tehnici:a)Ventilatia cu balon Ruben si masca facialab)Ventilatia cu balon Ruben si adjuncti ai CAS:
1. sonda traheala 2. masca laringiana 3. Combitube
c)Ventilatoare automateEvaluarea eficacitatii ventilatiei:
• Gazele sangvine arteriale (EAB)• Pulsoximetria• Capnografia
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Laringoscopul
tinut corect
Sonda traheala cu balonas
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Incarcarea limbii
Balonasul se umfla dupace sonda a trecut de
corzile vocale
Corzile vocale
Pauza scurta max 10 sec in compresiile toracice – necesara uneori la trecerea tubului printre corzile vocale
sau IOT dupa reluarea circulatiei spontane
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Balon Ruben si masca faciala
1 singur salvator
2 salvatori
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Masca laringiana
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2 tuburi
Combitube
Combitube in esofag
Combitube in trahee
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Tub laringian I-Gel
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Nu exista studii ca IOT creste supravietuirea dupa stop cardiac
Frecventa ventilatiei – 10 resp/min
Dupa ce tubul a ajuns in trahee – continua MCE 100/min fara pauze (pauzele intrerupere semnificativa a circ coronariene)
In absenta personalului calificat in IOT device supraglotic, exp. masca laringiana – alternativa acceptabila
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Calea venoasa◦ periferica – preferabila dat accesului rapid / CVC◦ optima, dar nu trebuie sa intarzie defibrilarea/RCP◦ Post inj. flush 20 ml fluid si ridicarea extremitatii
10-20 sec pt a facilita eliberarea medicamentului in circulatia centrala
Calea intratraheala◦ absorbtie incompleta, conc plasmatica imprevizibila◦ doze de 3-10 x mai mari ca iv◦ nu mai e recomandata
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Calea intraosoasa ◦ device-uri speciale in tibie / humerus ◦ alternativa pentru accesul vascular la copil, dar si la
adult◦ concentratie plasmatica intr-un timp comparabil cu
adm pe CVC
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Adrenalina◦ creste supravietuirea pe termen scurt◦ fara dovezi / supravietuirea cerebrala◦ doza optima ?◦ recomandarile expertilor in FV/TV fara puls
adrenalina dupa al 3-lea SEE si repeta la fiecare 3-5 min
◦ nu se intrerupe RCP in timpul administrarii Lidocaina
◦ doza 1mg/kg – ca alternativa la amiodarona ◦ NU DACA AMIODARONA S-A ADMINISTRAT
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Atropina ◦ Asistola – patologie miocardica primara si
mai putin tonus vagal crescut◦ Nu de rutina in algoritmul asistola / AEP◦ In bradicardie sinusala, atriala, nodala cu
instabilitate hemodinamica
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pentru:
pentru:
pentru:• EAB din sg periferic nu reflecta statusul tisular (pH mai mic in tesuturi)• EAB din sg venos central – mai fiabil
!
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Masuri terapeutice postresuscitare
evaluarea clinica si paraclinica a bolnavilor care au depasit celelalte etape ale RCP
scop - recuperarea cerebrala si terapia insuficientelor multiviscerale produse
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Evaluare clinica si paraclinica
la 10-15 min de la reluarea activitatii cardiace, in conditii de relativa stabilitate a functiilor vitale
se examineaza aparatul respirator, sistemul nervos central, viscerele abdominale si circulatia ( periferica, presiunea venoasa centrala)
monitorizare diureza
recoltare probe pentru hemograma, glicemie, uree, creatinina, enzime, electroliti, echilibru acido-bazic
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Human mentation:sustinerea activitatii SNC
bolnav agitat barbiturice sau diazepam
edem cerebral manitol si/sau furosemid in functie de starea hemodinamica
control EAB
temperatura
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Intensive Care
hTA - cauze multiple◦ hipovolemie (scaderea volumului circulant/vasodilatatie periferica)◦ soc cardiogen ◦ disfunctie miocardica postresuscitare
insuficienta respiratorie acuta – cauze◦ sindromul de debit cardiac scazut cu edem pulmonar cardiogen◦ pneumo/hemotorax ( ca si complicatii ale MCE)◦ aspiratia de continut gastric◦ bronhospasm sever prelungit◦ sindromul de detresa respiratorie
insuficienta renala acuta◦ consecinta opririi pasagere a fluxului sanguin renal◦ tratament
manitol 100-200 ml iv furosemid iv hemodializa
retentie azotata severa ( creatinina > 10mg%) hiperpotasemie necontrolata ( K > 7mEq/l) acidoza metabolica severa necorectabila
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Algoritmul tahicardiei (cu puls)
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Sosirea ajutorului
Epuizarea fizica
Reaparitia semnelor vitale
Coma profunda, fara activitate respiratorie spontana, cu midriaza fixa >10 min, in conditiile efectuarii corecte a RCP
Constatarea decesului de catre un medic
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Organizarea echipei de resuscitare cardio-respiratorie
min 4 oameni cu responsabilitati diferite
Asigurarea libertatii CAS si a ventilatiei eficiente Asigurarea circulatiei, defibrilare, controlul ritmului
cardiac Montarea unei linii venoase sigure si administrarea
de medicatie Liderul echipei integreaza masurile de resuscitare
ale celorlalti membrii si asigura legatura cu laboratorul si celelalte departamente
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Schimbarile esentiale fata de ghidul 2005 “A-B-C”-ul resuscitarii “C-A-B” (Compressions
-Airway-Breathing)◦ Initierea resuscutarii cu A pierderea a ~ 30 sec◦ Compresiile toracice – esentiale pentru a mentine sangele
bogat in oxigen
Cresterea ratei compresiilor toracice ~ 100/min
Cresterea profunzimii compresiilor ~ 5 cm
Intre compresii – permiterea toracelui sa revina la pozitia de start
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Schimbari fata de ghidul 2005
Echipa de lucru – practica regulata
Pt resuscitatori neantrenati compresii toracice ghidate prin telefon
Evitarea pauzelor in compresii si a ventilatiei excesive
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Schimbari fata de ghidul 2005
Compresiile toracice continua si in perioada de incarcare a AED minimizarea pauzei pre-soc
Lovitura precordiala – importanta redusa
Strategia cu 3 SEE succesive ◦ FV/TV fara puls din lab cateterism/imediat dupa
chirurgia cardiaca◦ la pacientul conectat deja la un defibrilator manual◦ compresii dupa al 3-lea SEE
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Schimbari fata de ghidul 2005
Calea de administrare pe tubul traheal nerecomandata
Daca nu avem acces i.v. calea intraosoasa
Tratam stop cardiac prin FV/TV adrenalina 1mg dupa al 3-lea SEE dupa reluarea MCE si apoi la fiecare 3-5 min
Amiodarona 300mg – dupa al 3-lea SEE
Atropina – nu de rutina in asistola /PEA
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Schimbari fata de ghidul 2005
IOT ◦ importanta mai mica daca nu e efectuata de personal inalt
calificat cu intreruperea minima a MCE
Capnografia cantitativa◦ masoara CO2 expirat◦ persistenta CO2 dupa 6 expiratii in aerul expirat - corect◦ confirma IOT si monitorizeaza calitatea RCP
Hipotermia terapeutica◦ utila in terapia post-resuscitare prin stop cardiac (mai ales
prin FV/TV fara puls) in afara spitalului la pacientii comatosi
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Schimbari fata de ghidul 2005
PCI si la comatosi dupa SCR resuscitat
Recunoasterea rolului eco in ALS
Hiperoxemia dupa revenirea la circulatia spontana◦ de evitat; SO2 (pulsoximetrie/EAB) sa fie 94-98%
Glicemia ◦ Valorile > 180 mg/dl – tratate ◦ Hipoglicemia – evitata
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Referinte bibliografice
Circulation. 2010;122 [suppl 3]: S640-S656
Resuscitation. 81 (2010) 1219–1276
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MULTUMESC PENTRU ATENTIE !