Cardiopulmonary Resuscitation (Cpr) In Adults

CPR is a regulated response to cardiac arrest. These include the following points, the first two are among the most basic measures:

(For neonatal resuscitation, neonatal resuscitation;. For resuscitation in infants and children, Cardiopulmonary resuscitation in infants and children) CPR is a regulated response to cardiac arrest. These include the following points, the first two are among the most basic measures: check for missing respiration and blood circulation, clearing the airway cardiac massage and artificial respiration Advanced measures: Advanced Cardiac Life Support (ACLS) with definitive control of breathing and rhythm Subsequent actions The key to success is in any case the rapid start of the intervention with chest compressions and early defibrillation. One of the few exceptions to check out the deep hypothermia decision (approximately after a long stay in cold water). The result is directly influenced by the speed of the procedure, but also the effectiveness and careful implementation of all measures. Here resuscitation can still be successful to an hour even after a period of arrest up. Overview The guidelines for health care professionals from the American Heart Association should be followed (s. Procedure for cardiac emergency adult.). If a person kollabaiert with possible cardiac arrest (cardiac arrest) is, provides a helper first be unconsciousness and lack of breathing or only gasping breathing. Then the helper calls EMS. Everyone who answers the call for help is required to activate the emergency system (or other appropriate resuscitation in hospital) and, if possible, to keep a defibrillator available. If no one responds, the helper initially activates the emergency system, and then starts the basic measures by 30 times depressing the chest with a frequency of 100 / min, the airways makes free (lift chin and tilt the front to back) and a respiration are (2 breaths). The cycle of oven jerk massage and respiration continues without interruption (s CPR methods for health workers.); preferably the helper can be alternated every 2 minutes. If a defibrillator (either manually adjustable or automated) is present, it will try the person with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) to give an unsynchronized shock. If the cardiac arrest of witnesses is observed and is a defibrillator nearby, immediately should be defibrillated; early defibrillation can immediately bring to a perfusing rhythm VF or pulseless VT. More Defibrillation in Cardiopulmonary resuscitation (CPR) in adults: airway and breathing. It is recommended that untrained viewers start giving continuous chest compressions until professional help arrives. How to cardiac emergencies in adults. The techniques of one or two helper methods of cardiopulmonary resuscitation are shown in CPR techniques for health workers. In order to obtain reasonable assurance in practical approach here, is a regular training, as offered in the US under the auspices of the American Heart Association or other countries with comparable organizations essential. CPR methods for health workers age group A helper CPR * Two helper CPR breathing serving adults and children> 8 years 2 breaths (1 s) after every 30 chest compressions at a rate of 100 / min 2 breaths (jweils 1 s ) after every 30 chest compressions at a rate of 100 / min † each breath should be about 500 ml of volume have (as a precaution against hyperventilation) children 1-8 years 2 Atemstöß e (1 s) after every 30 chest compressions at a rate of 100 / min 2 breaths (jweils 1 s) after 15 chest compressions at a rate of 100 / min † smaller breaths as in adults (enough so that the breast lifts) infants (<1 year) 2 breaths (each 1 s) after every 30 chest compressions at a rate of 100 / min 2 breaths (jweils 1 s) after 15 chest compressions at a rate of 100 / min † only small breaths from the jaws of the helper * For a lay rescuers only chest compressions is recommended. † breaths be given without interrupting chest compressions. For children there is the first step, if no immediate help is there, 5 cycles of CPR's. perform cardiopulmonary resuscitation in infants and children, unless the collapse is sudden and was observed before an emergency call is abesetzt. Respiratory tract and respiratory In contrast to previous recommendations, the freeing of the airways is now the second priority (Restoring and Backing up the airways: clearing and opening the upper respiratory tract) after the onset of chest compressions. The technical methods of resuscitation of children, s. Guidelines for pediatric resuscitation: mechanical measures. Word-of-mouth (in adults and older children) or a combined word-of-mouth and nose resuscitation must be started without delay. Alternatively, a bag ventilation for an asphyxial cardiac arrest can be started. If possible, an oropharyngeal airway can be placed. The Krikoiddruck is no longer recommended. Should, however, the swelling of the abdomen, must again keeping open the airway are examined to then reduce the applied volumes of respiration may. The introduction of a nasogastric probe takes place only when effective Absauginstrumentarium exists. Otherwise, it could come from the stomach contents already upon insertion of a nasogastric tube to undesirable regurgitation. Is an appreciable distension of the abdomen occurred which can not be eliminated with the above methods, the patient is brought into the recovery position, compresses the epigastrium and kept free of the airway. When qualified people are present, an enhanced respiratory action is initiated (tube or supraglottic device), without having to interrupt chest compressions as Restoring and Backing up the airways described. A respiratory shock is given every 6-8 seconds (8-10 breaths per minute) without interruption of chest compression. However, having chest compressions and defibrillation override intubation. Unless experienced personnel is available, the intubation favor ventilation with bag-valve-mask and the laryngeal mask or similar device can be delayed larynx masks. Bloodstream chest compressions in the case of an observed cardiac arrest should be performed chest compressions until defibrillation is available. When non-reactive patient whose collapse has not been observed, the trained rescuer should begin immediately with the external (carried out at the thorax closed) pressure compression. This measure will be followed by artificial respiration. Chest compressions should be interrupted as little as possible (eg. As for intubation, central placement i.v. catheter or transportation). A compression cycle should consist of 50% compression and 50% break. Mechanical chest compression devices are available, but these devices are not more effective than properly performed manual cardiac massage, but can minimize effects of errors and fatigue of the helper and can also be helpful during patient transport. After a few minutes of cardiac massage rhythm is controlled and performed defibrillation. Ideally, the external cardiac massage leads to a palpable peripheral pulse per chest compression. However, it is the cardiac ejection little more than 20-30% of normal. Nevertheless, the palpation of peripheral pulse is often very difficult in the course of resuscitation, even for trained personnel, and quite unreliable. Monitoring of end-tidal CO2 value gives a better idea of ??the putative cardiac output during compression measures. Patients with low venous return flow to the lungs thus have little end-tidal CO2 values. The return of spontaneous breathing as well as the spontaneous opening of the eyes indicate a sufficient circulation (ROSC). Although compression therapy at the open thorax may be a safe and effective method, but their use is limited (within 48 h), Herzbeuteltamponaden and intraoperative cardiac arrest when the chest is already open anyway to patients with penetrating thoracic injuries. Finally, the implementation of a thoracotomy requires a certain amount of experience and is also only under specific clinical conditions with a legitimate chance of success durchführbar.Komplikationen chest compressions tear injury of the liver are rare, but dangerous (and often fatal) complications. These are often due to compression measures carried out below the sternum. A gastric rupture (especially if the stomach is inflated with air) is also a rare complication. The delayed, two-stage splenic rupture can be considered as rare. More commonly found, however, the regurgitation of stomach contents with the consequences of oftmalig then life-threatening aspiration pneumonia in resuscitated patients. Separations of osteochondral transitions or rib fractures can often not be avoided. Finally, it is necessary for the production of a Minim Alper merger to achieve a certain compression depth. In children, however, such a fracture consequences are found only very rarely due to the higher thoracic elasticity. Embolization of bone marrow material into the pulmonary circulation in one of the rarely reported consequences of external cardiac massage. But even in these individual cases is not clear to what extent these phenomena are relevant for mortality. Also lung injuries are rarely found. Nevertheless, the possibility of pneumothorax must be considered secondary to penetrating rib fractures forever. Serious myocardial injury from chest compressions occur almost never. The exceptions are the already pre-existing Ventrikelaneurysmen here. But the overall consideration of all these possible complications should not diminish the commitment to a cardiopulmonary resuscitation. Defibrillation Most can be found in the observed occurred cardiac arrest fibrillation. Here the speedy transfer to a perfusionswirksamen rhythm is required. Ventricular tachycardia without peripheral pulses is tackled as ventricular fibrillation therapy. The immediate electrical cardioversion is more effective than the administration of antiarrhythmic drugs. The defibrillation is time-dependent, each minute of persistence of ventricular fibrillation, the success rate can decrease by 10% (or pulseless ventricular tachycardia). Automated external defibrillators (AEDs) allow even less experienced workers, ventricular tachycardia or ventricular fibrillation to treat. Their use by first responders (police and fire) and their prominent availability in public places has increased the likelihood of resuscitation. The paddles for defibrillation or AED-adhesive electrodes are positioned between the clavicle and the second intercostal space at the right Sternalrands as well as the fifth or sixth intercostal space above the apex of the heart. The AED units have pads that have conductive material. By using the defibrillation using electrode paste or gel pads is common. 1 only an initial counter shock is now recommended (the previous recommendation to perform 3 shocks in close succession), whereupon the cardiac massage is resumed. For this purpose, one selects the biphasic defibrillators power levels between 120 and 200 joules, and 360 joules for repeat (in children 2 Joule / kg body weight). Monophasic defibrillators are used with an energy level of 360 joules. The rhythm after the shock is checked only after 2 min chest compressions. Each subsequent current pulses are of equal or higher energy level run (maximum 360 joules; 2-4 Joule / kg body weight in children). Patients who continue to have VF or VT, continue to receive cardiac massage and artificial respiration and optional drug therapy, cardiopulmonary resuscitation (CPR) in adults: drugs for Advanced Life Support (ALS). Monitoring and drug administration to determine the existing rhythm is essential, ECG monitoring. Then can be manufactured intravenous access. The system of two indwelling serves as additional security for the event that intravenous access is lost during the resuscitation. Large bore additions to armpits are here mostly preferred. In adults and children, a subclavian or internal jugular approach centerline, when a peripheral line can not be prepared, placed, provided that it can be carried out without interruption, the cardiac massage, even if this is difficult. Intraosseous access or those on the femoral veins (vascular access: intraosseous infusion) are useful alternatives especially in children. Femoral veins catheter procedure (long stretches of catheters that are fed to a central position) offer the advantage here that resuscitation should not be interrupted during their installation. In addition, they carry far less potentially lethal complications. At the same time the system seems complicated by the fact that the lack of femoral pulsation complicates the prospect of suitable puncture site. The answer to the question of the infusion and what volumes should be administered depends on the particular clinical situation. Typically, a 0.9% NaCl solution is slowly added. This allows both a keeping open the intravenous line. The accelerated volume rendering (crystalloid or colloid solutions, possibly blood) is only indicated if the cause of the occurred cardiac arrest is seen in a volume deficiency (The intravenous fluid replacement). Special situations At an accidental electrocution as the cause of the workers must ensure that the patient is no longer connected to the power source so as to eliminate the risk for themselves. The use of non-metallic handles or rods and the grounding of the helper enables the safe removal of the patient from the area of ??power supply. Then only CPR can begin. In the case of Beinaheertrinken ventilation can possibly be started already in shallow water. Nevertheless, the chest compression is only really effective feasible if the patient is lying flat on a solid surface such. B. on a surfboard or raft. the cardiac arrest occurred in the context of a trauma situation, the open keep the airways open and at least a short-term external ventilation of the highest priority are. Sun can be switched off as the cause of the cardiac arrest airway obstruction. In order to reduce injuries to the cervical spine to a minimum, only the jaw should be brought forward without overstretch the neck or having to lift even the chin. The causes of cardiac arrest that are survived most likely to have cardiac tamponade and tension pneumothorax. In these cases, the mere relief via puncture is initially sufficient. Can not be achieved this, all other measures to regain vital signs remain ineffective. However, most patients with traumatic cardiac arrest is a severe hypovolemia from blood loss (which is why the chest compressions may be ineffective) or potentially fatal brain injury. Drugs for Advanced Life Support (ALS) Despite widespread and long-term use, there is ultimately no substance to reliable evidence that the survival rate of patients is improved with cardiac arrest due to their application. However, some drugs appear to improve the recovery of its own circulation. thus provide for their commitment to good reasons (dosage for pediatric use, s. Drugs for fluid replacement therapy *). Drug therapy for shock and cardiac arrest is still under investigation. Drugs for fluid replacement therapy drug * † adult dose Pediatric dose Comments adenosine Initially 6 mg, then 12 mg × 2 Initially 0.1 mg / kg, then 0.2 mg / kg x 2 A fast i.v. Push by a flush (maximum single dose 12 mg) is followed. Amiodarone for VF and pulseless VT: 300 mg for VF and pulseless VT: 5 mg / kg for VF and pulseless VT: Gabe as an i.v. Push over 2 min For slowed VT: initial dose of 150 mg infusion (drip): 1 mg / min x 6 h, then 0.5 mg / min × 24 h for slowed VT: 5 mg / kg over 20-60 min, repeated up to a maximum of 15 mg / kg / day For slowed VT: loading dose as an iv Push over 10 min. Amrinone initial dose: 0.75 mg / kg over 2-3 min infusion (drip): 5-10 mcg / kg / min dose: 0.75-1 mg / kg over 5 min (can be repeated up to 3 mg / kg be) infusion: 5-10 mcg / kg / min 500 mg in 250 ml of 0.9% saline solution is 2 mg / ml. Atropine 0.5-1 mg 0.02 mg / kg repeatedly every 3-5 min or the total dose of 0.04 mg / kg (minimum dose 0.1 mg). Calcium chloride 1 g of 20 mg / kg 10% solution containing 100 mg / ml. Kalziumluzeptat 0.66 g N / A 22% solution containing 220 mg / ml. Calcium gluconate 0.6 g 60-100 mg / kg 10% solution containing 100 mg / ml. Dobutamine 2-20 mcg / kg / min (from 2-5 mcg / kg / min) No difference from the adult dose 500 mg in 250 ml of 5% D / W results in 2000 mcg / ml. Dopamine 2-20 mcg / kg / min (from 2-5 mcg / kg / min) No difference from the adult dose 400 mg in 250 ml of 5% D / W results in 1600 mcg / ml. Adrenalin bolus 1 mg Infusion: 2-10 mcg / min bolus: 0.01 mg / kg infusion: 0.1-1.0 mcg / kg / min every 3-5 min repeatedly as needed. 8 mg in 250 ml of 5% D / W results in 32 mcg / ml. Glucose 25 g 50% D / W 0.5-1 g / kg High concentrations in infants and small children should be avoided. 5% D / W: Dose 10-20 ml / kg. 10% D / W: dose 5-10 ml / kg. 25% D / W: Dose 2-4 ml / kg. For older children, a large vein is taken. Magnesium sulfate 1-2 g 25-50 mg / kg up to a maximum of 2 g dose over 2-5 min. Milrinone initial dose: 50 mcg / kg infusion over 10 minutes: 0.5 mcg / kg / min Initaldosis: 50-75 mcg / kg over 10 min infusion: 0.5-0.75 mcg / kg / min 50 mg in 250 ml 5% D / W results 200 mcg / ml. 2 mg naloxone 0.1 mg / kg for patients <20 kg or <5 years Repeat as required. Norepinephrine infusion: 2-16 mcg / min infusion: Starting with 0.05-0.1 mcg / kg / min (maximum dose 2 mcg / kg / min) 8 mg in 250 ml of 5% D / W results in 32 mcg / ml , Phenylephrine infusion: 0.1-1.5 mcg / kg / min infusion: 0.1-0.5 mcg / kg / min 10 mg in 250 ml of 5% D / W results in 40 mcg / ml. Procainamide 30 mg / min for the effect or a maximum of 17 mg / kg No difference from the adult dose procainamide is not recommended in cases of pulse Wi cardiac arrest in children. Sodium bicarbonate (NaHCO3) 50 mmol 1 mmol / kg a slow infusion, and then only if a sufficient ventilation. 4.2% containing 0.5 mmol / ml; 8.4% containing 1 mmol / ml. Vasopressin 40 units × 1 Not recommended vasopressin as a single dose. * For instructions and use, s. Text. † iv or intraosseous VF = ventricular fibrillation; VT = ventricular tachycardia. If an intravenous access is available, after medication administration in each case a fluid bolus administered ( "once untwist" in adults in young children should satisfy 3-5 ml) to thus einzuschwemmen the substance rapidly into the central circulation. If a patient is neither an intravenous nor intraosseous access route, so atropine and epinephrine can (adrenaline) - also be given via endotracheal tube - if indicated. In this case, however, the dose to 2 to 2.5 times must be raised. During the administration of a drug through an endotracheal tube, the compression should be stopped short. Drugs of first choice drugs of choice are adrenaline or epinephrine, vasopressin was the main agent for the treatment of cardiac arrest, even if its benefits, as noted earlier, is being questioned more and more frequently. It can be administered at intervals of 3-5 min. Epinephrine has a combined ?- and ?-adrenergic effect. The ?-adrenergic effect leads to an increase of the coronary diastolic pressure. Thus, an improved subendocardial perfusion is achieved for the duration of chest compression. Epinephrine additionally promotes the likelihood of successful defibrillation. Nevertheless, ?-adrenergic effects may also take negative influence because they (especially the heart) provide for increasing the O2 requirement occasion and also cause vasodilation. Intracardiac administration of epinephrine is not recommended. There is a danger of pneumothorax, injury of the coronary vessels as well as the pericardial tamponade in addition to the interruption of the compression. The single dose of 40 units of vasopressin is an alternative to epinephrine (only for adults); it advantages over epinephrine are not yet proven. Vasopressin has a duration of 40 minutes at 40 units. 300 mg amiodarone can be used with vasopressin in unsuccessful defibrillation by prior administration of epinephrine or alternately, followed by a dose of 150 mg. It can also be useful when it came to re-insert a ventricular tachycardia or ventricular fibrillation after previously successful defibrillation. Over 10 minutes a lower dose is given, which may be followed by continuous administration via infusion then. There is no confirmed evidence that it is the survival to hospital discharge erhöht.Weitere medications A number of additional drugs may be useful in special cases. Atropine is a vaglolytischer active ingredient for the increase in heart rate and signal conduction in AV node. It is given in symptomatic bradyarrhythmias and AV nodal block high degree. However, it is no longer recommended for asystole or pulseless electrical activity. Calcium chloride is used in hyperkalemia, hypermagnesemia, hypocalcemia or calcium channel blocker intoxication. In other cases, the intracellular calcium is already increased so that the additional calcium administration would have more adverse effect. In dialysis patients, cardiac arrest is often accompanied by hyperkalemia. Therefore, these patients may benefit from calcium administration; especially when an immediate determination of potassium is not available. but must also be particularly noted that the administration of calcium increases the toxicity of digitalis and can even be the cause of cardiac arrest. Magnesium sulfate has not demonstrated in randomized clinical trials that it can contribute to improved results. Still, there may be as helpful as suspected magnesium deficiency (z. B. with alcoholism or longstanding diarrhea) in cases of "torsades de pointes". Procainamide is not a substance of choice for the treatment of a refractory ventricular fibrillation or ventricular tachycardia. In cases of pulse Wi cardiac arrest in children procainamide is anyway not recommended. Phenytoin could be used in individual cases of ventricular fibrillation or ventricular tachycardia, but only if this situation occurred due to digitalis intoxication, and also is refractory to all other substances. A dose of 50 mg / min will be given up to improve the rhythm situation. The total dose is 18 mg / kg. NaHCO3 (sodium bicarbonate) is only recommended if occurred cardiac arrest by hyperkalemia, hypermagnesemia or overdosage of tricyclic antidepressants and associated with complex ventricular arrhythmias. In children comes NaHCO3 only be considered if the cardiac arrest for some time (> 10 min) stops. Even then it is given without sufficient ventilation situation. With the use of NaHCO3, the arterial blood pH should regularly before and after administration of 50 mmol (1-2 mmol / kg in children) are determined. Lidocaine and bretylium are no longer recommended for the treatment of cardiac arrest. Treatment of arrhythmias VF or pulseless VT is treated with an electronic impulse sliding, preferably in the biphasic waveform as soon as possible after the cardiac arrest, and after 2 minutes of cardiac massage, which as little as possible is to be interrupted. 150-200 Joule are recommended for the use of a biphasic pulse, monophasic signal at 360 joules. If this is not successful, 1 mg epinephrine is given intravenously and repeated at intervals of 3-5 minutes. Older

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