CPR; selected aspects
MBChB V
A Alberts
Kalafong Provincial Tertiary Hospital
January 2022
CPR; the right way
https://za.pinterest.com/pin/471259548480661738/
▪ Chest compressions X2 min – rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪
▪
Evaluate rhythm
Administer drugs
Rhythmic 2min
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
cycles of chest
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
compressions while
s s
▪
▪ Administer drugs
Chest compressions X2 min - rotate compressor
the H and T are
▪ Evaluate rhythm urgently investigated
▪ Chest compressions X2 min - rotate compressor
▪
▪
Evaluate rhythm
Administer drugs
and managed
▪ Chest compressions X2 min – rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm Rhythmic 2min
ROSC
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
cycles of chest
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
compressions while
s s
▪
▪ Administer drugs
Chest compressions X2 min - rotate compressor
the H and T are
▪ Evaluate rhythm urgently investigated
▪ Chest compressions X2 min - rotate compressor
▪
▪
Evaluate rhythm
Administer drugs
and managed
Resuscitation Council of Southern Africa
Advanced Cardiac Arrest Algorithm
Adult and Paediatric
▪ Chest compressions X2 min – rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
https://resus.co.za/subpages/RCSA_Information/Resources/Algorithms.html
Resuscitation Council (UK)
Adult Advanced Life Support
Patient unresponsive
and not breathing normally
https://resus.co.za/subpages/RCSA_Information/Resources/Algorithms.html
American Heart Association CPR Guidelines
Adult Cardiac Arrest Algorithm
(VF / pVT / Asystole / PEA)
▪ Chest compressions X2 min – rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
American Heart Association CPR Guidelines
Adult Cardiac Arrest Algorithm
(VF / pVT / Asystole / PEA)
▪
▪ Evaluate rhythm
Administer drugs
ROSC
Chest compressions X2 min – rotate compressor
Chest compressions X2 min - rotate compressor
▪
▪
Evaluate rhythm
Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
Chest compressions X2 min - rotate compressor
▪
▪
Evaluate rhythm
Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm
▪ Administer drugs
https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms
Chest compressions, cardiac rhythm, and drugs
▪ Chest compressions X2 min – rotate compressor
▪ Evaluate rhythm Technique of
▪ Chest compressions X2 min - rotate compressor high quality CPR
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm Shockable vs
▪ Chest compressions X2 min - rotate compressor non-shockable
▪ Evaluate rhythm
▪ Administer drugs
▪ Chest compressions X2 min - rotate compressor
▪ Evaluate rhythm Used during
▪ Chest compressions X2 min - rotate compressor resuscitation
▪ Evaluate rhythm
▪ Administer drugs
CPR; beyond the bare-bones basics
Mechanism of action
Drugs used during CPR
MBChB V Kalafong Anaesthesiology rotation 2022
Catecholamines and vasopressors
Mechanism of action
▪ Alpha–adrenergic properties
▪ Peripheral vasoconstriction
▪ Increased ADP
▪ Increased coronary and myocardial blood flow
▪ Beta-adrenergic properties
▪ Potentially negative during ventricular fibrillation
▪ O2 consumption is increased
Adrenalin
Adrenalin = epinephrine
▪ Increased coronary pressure and flow
▪ Increased myocardial blood flow
▪ Current recommendations
▪ 1mg intravenously every 3 to 5min
▪ May be increased if
▪ Ineffective
▪ Beta-blocker or calcium channel-blocker overdose
Vasopressin
Arginine vasopressin = antidiuretic hormone
▪ Potent vasoconstrictor
▪ In comparison to adrenalin
▪ Stimulates V1 smooth muscle receptors (non-adrenergic vasopressor)
▪ Longer half-life (15min)
▪ Impressive hemodynamic effects during prolonged resuscitations
▪ Overall
▪ Equivalent to adrenalin
https://twitter.com/jamesdgriffiths/status/1202463714957381633?lang=ar-x-fm
Amiodarone
VF = Ventricular Fibrillation
When VF is recognized, defibrillation should be attempted. No antiarrhythmic agent is superior to electrical defibrillation in
the treatment of VF. Defibrillation should hence not be delayed to establish IV access or to administer drugs
▪ Pharmacologically complex drug; Na+, K+, Ca++, α-adrenergic, β-adrenergic blocking properties
▪ Hypotension and bradycardia when infused rapidly in patients with an intact circulation
▪ Intravenous dosing
▪ Cardiac arrest
▪ 300mg rapid infusion, supplemental infusions of 150mg prn (≤ 2gm / 24h)
▪ Aids defibrillation in DC-shock resistant VF, or when VF recurs post DC-shock
▪ Dysrhythmias with an intact circulation
▪ 150mg over 10min, then 1 mg/min for 6hr, then 0.5mg/min thereafter
Amiodarone
VF = Ventricular Fibrillation
D
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Lignocaine
Lignocaine and amiodarone help suppress ectopic ventricular rhythms
When VF is recognized, defibrillation should be attempted. No antiarrhythmic agent is superior to electrical defibrillation in
the treatment of VF. Defibrillation should hence not be delayed to establish IV access or to administer drugs
Lignocaine, primarily an anti-ectopic agent with few hemodynamic effects, tends to reverse the
reduction in VF threshold caused by myocardial ischemia or myocardial infarction
▪ Alternative therapy in refractory fibrillation if amiodarone is not available
▪ Depresses automaticity
▪ by reducing the slope of Phase 4 depolarization
▪ reducing the heterogeneity of ventricular refractoriness
▪ Initial bolus of 1 to 1.5 mg/kg
▪ Additional boluses of 0.5 to 0.75 mg/kg every 5 to 10min during CPR
▪ Total dose of ≤ 3 mg/kg
Calcium chloride
▪ With normal cardiovascular physiology
▪ Ca++ increases myocardial contractility
▪ Consequently, it has been advocated as a treatment for asystole and PEA
▪ During CPR; routine use is not recommended. There are three specific indications
▪ Hyperkalemia
▪ Hypocalcemia
▪ Calcium-channel blocker toxicity
▪ Dosing
▪ 2 to 4 mg/kg of the 10% solution administered slowly IV
Atropine
Anticholinergics; atropine and glycopyrrolate
Intra-operative vagal stimulation may result in severe bradycardia even to the point of asystole. Atropine
enhances SA-node automaticity and AV-conduction by its vagolytic effects
▪ Asystole or slow PEA during CPR
▪ No evidence of improved outcome; asystole or PEA
▪ Routine use during CPR is not recommended
▪ High index of suspicion during certain surgical procedures
▪ Vagolytic effects may prevent severe bradycardia and asystole
▪ Dosing
▪ 10-20mcg/kg (0.5 – 1mg in 70kg adult)
Sodium bicarbonate
NaHCO3 8.5% solution
▪ Little evidence to support efficacy
▪ Fibrillation threshold, and physiologic response to catecholamines
▪ Well documented evidence of adverse effects
▪ Metabolic alkalosis, hypernatremia, and hyperosmolarity
▪ Common after administration of bicarbonate during CPR
▪ Associated with low resuscitation rates and poor outcomes
▪ Routine use not recommended. Current practice;
▪ Hyperkalemia / pre-existing metabolic acidosis / tricyclic or phenobarbital overdose
▪ May be considered - protracted CPR attempts
Thank You
