Sudden death Sudden death

Course of First Aid for 1st year
Medical Students
Cardiopulmonary Resuscitation
(CPR)
(2 lecture)
Basic Life Support (BLS)
Advanced Life Support (ACLS)
Cardiopulmonary resuscitation (CPR). Basic life
support (BLS). Drowning. Electrocution. Hypothermia.
Hypertermia. Shock.
ERC guidelines for resuscitation 2010
Aleksander Sipria/Kadri Tamme
Clinic of Anaesthesiology and Intensive Care
Tartu University (http://www.kliinikum.ee/aikliinik)
Sudden death
Death that occurs unexpectedly and from 1 to 24 hours
after onset of symptoms, with or without known
preexisting conditions. Mosby`s Medical Dictionary, 8 th edition,
2009, Elsevier
Sudden cardiac arrest is the sudden, unexpected loss of
heart function, breathing and consciousness.
Sudden cardiac arrest is a leading cause of death in
Europe, affecting about 700 000 individuals a year
Sudden cardiac arrest is reversible in most patients if it is
treated within minutes
Sudden death
Stop of breathing
Cardiac arrest
Closure of airway
* Rhythm disturbances
Unconscious patient
- Ventricular fibrillation
Foreign body
- Pulseless electrical activity
Trauma
- Asystole
Inflammatory diseases of throat
Drowning
* Myocardial infarction
Electrical trauma
* Hypothermia
Musculature weakness
* Electrical trauma
Nervous system diseases
* Blood (fluid) loss
Drug overdoses
Gasping (agonal breathing) can be
Initially, during few minutes, pulse (heart
continued for
for 5 minutes after cardiac arrest
beating)
eating) Is preserved
Cardiac arrest can be prevented by quick
Defibrillation
Defibrillation (electric shock) is
and effective first aid (open the airway,
the treatment of ventricular fibrillation.
artificial ventilation).
AEDAED- automatic external defibrillator
•
•
•
•
-
Clinical and biological death
After cardiac arrest the brain cells are the first to
begin to die. Cells have a residual oxygen supply
and can survive for a short time (reversible damage
or clinical deathdeath- duration 44-6 minutes).
minutes). Effective
CPR may reverse clinical death and possibly restore
the patient to an undamaged state.
After 44-6 minutes brain damage become irreversible
(biological death)
death)
Signs of clinical death
Unconsciousness
Absence of breathing or agonal gasps
(may occur in the first few minutes after SCA)
Absence of movement
Absence of pulse on the large arteries
(carotid pulse in the neck, femoral pulse at
the upper thigh)
Skin color that is pale or cyanosed (blue)
(blue)
Survival from OutOut-ofof-Hospital Cardiac
Arrest (all resuscitation attempts)
Seattle and King County, Washington
1414-18% (1984)
Helsinki 17% (1996)
Göteborg 13% (1994)
Sweden 5% (1998)
Norway 66-13% (1999)
Estonia 9%, Tartu 15% (1999(1999-2008)
Determinators of survival
Additional determinators of survival
When was clinical death diagnosed? (bystander
witnessed vs unwitnessed)?
Was BLS given?
When did the emergency team arrive at the
scene?
What was the form of primary cardiac arrest? If
VF , when defibrillated?
When ALS started?
Fist aid skills of the population
Quality of work of 112
Skills and equipment of the emergency
team
Quality of hospital treatment.
Quality of rehabilitation.
How to decrease the mortality of sudden
cardiac arrest?
Out-of-hospital CPR attempts in Estonia 1999-2009.
4322 attempts (suspected cardiac arrest).
Place of CPR.
78 (2%)
299 (7%)
ERC 2010
396 (9%)
203 (5%)
2618
(60%)
AHA 2010
728 (17%)
ALS
Post-cardiac arrest care
OPALS study showed no improvement in survival to discharge rates
when ALS was added to CPR and rapid defibrillation for SCA
apartment
public place
at work
ambulance
medical facility
other
Steill IG et al. N Eng J Med 2004; 351:647-656,
ACLS Drugs Don`t Improve Cardiac Arrest Survival
Outcomes of resuscitation in out-of-hospital cardiac arrest with and without IV drug access
Olasveengen TM et al. JAMA. 2009; 302:2222-2229
First aid skills of the family members?
Out-of-hospital CPR attempts in Estonia 1999-2009.
2492 attempts (bystander-witnessed suspected cardiac arrest).
Use of BLS
Bystander witnessed out-of-hospital
cardiac arrest (cardiac aetiology) and BLS
in Estonia (1999-2009)
(52 cases unknown)
N=645 (26%)
66
151
380
N=1795
(74%)
Alive 89
(13,8%)
No CPR
Alive 137
(7,6%)
co-worker
medical professional
relative
no CPR
40%
30%
34%
32%
27% 27%
30% 29%
28%
26% 27% 27%
26%
23%
25%
P <0.01
Survival rate in all 9%
BCPR
First aid before the arrival of emergency team in
Estonia 19991999-2010
35%
645 (26%)
Survivors
89 (14%)
P<0.01
99
Bypasser
1795
(74%)
Survivors
137 (7%)
20%
15%
10%
5%
0%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
5208 victims
BLS given in 1465 cases (28%)
Non-BCPR
History of resuscitation
100 years ago effective measures of
resuscitation
1956 first defibrillation (Zoll)
1958 methods of upper airway
management and mouth to mouth
ventilation (Safar, Elam)
1960 reinvention of chest compressions
(Kowenhoven, Jude, Knickerbocker)
The quality of first aid ?!
(P.Safar 1981)
1992
1992
1992
Mistakes
Mistakes of assessing the condition of the victim:
incorrect primary assessment, incorrect
interpretation of agonal breaths, mistakes of
pulse assessment, inadequate information to the
emergency call centre
Mistakes of the emergency call centre:
inadequate assessent of the situation,
inadequate counselling.
Mistakes of chest compression: soft surface, late
start, unnecessary interruptions, inadequate
technique.
ABC or CAB?
Witnessed suspected cardiac arrest
(agonal breaths present) - CAB
Unwitnessed cardiac arrest (breathing
absent) or primary respiratory arrest ABC
If unconscious:
- Call for help without leaving the patient, or
-Consider leaving the patient to call for help??
-Open the upper airway, leaving the patient in the
same position, if possible (important in case of
trauma)
check if the victim is breathing
-If not successful, lie the victim on his/her back
and open the airway.
- Tilting the head back is dangerous when
-cervical trauma is possible.
ERC guidelines for resuscitation 2010
Universal algoritm:
Minimal interruption of chest
compressions!
BLS - adult cardiac arrest
You are alone and the victim is adult
ENSURE SAFETY
CHECK CONSCIOUSNESS
If conscious:
- Leave in the same position
-Assess general condition
-Assess repeatedly
-Call for help
If breathing is absent or abnormal
Turn the victim on his/her back, assess
consciousness, movements or coughing
Open the airway and assess breathing. Check
skin colour.
Check pulse on femoral or carotid arteries if you
are a trained helper.
Do not spend more than
10 seconds to assess the
condition of the victim.
In case of unconsciousness and
abnormal breathing
(bystander witnessed suspected cardiac arrest)
Call112
Immediately start with chest compressions
(30 compressions 100 – 120 x/min),
x/min), then
open the upper airway again
(P.Safar 1981)
zThe depth of chest compressions must be
With chest compressions systolic pressure of 60-80 mmHg is
maintained, mean arterial pressure rarely exceeds 40 mmHg
5 – 6 cm
z Time of compression and decompression
must be equal
Chest compressions are of extreme importance when
defibrillation is delayed > 5 min
The person performing chest compressions should be
changed every 2 minutes.
Continue with mouth-to-mouth breaths (B) and
chest compressions (C) 2:30
Remove visible foreign bodies (also loose dentures)
from the victim’s mouth (?)
After opening the upper airway and closing the nose,
perform 2 effective breaths of volume of 6-7mL/kg
(500-600mL) ja duration of about 1 sek per one breath
(duration of 2 breaths not more than 5 sec)
If agonal breaths continue (∼ 40% of cases), rescue
breaths are not obligatory during the first 4-6 min
(AHA)
Recommendations for trained vs untrained rescuers
Hands-Only (Compression-Only)
Cardiopulmonary Resuscitation
Circulation 2008; 117:2162-2167
American Heart Association
Chest compressioncompression-only CPR
On 31.03.2008, the American Heart Association (AHA) issued a statement
statement
recommending that bystanders who witness the sudden collapse of an adult
should give chest compressions without ventilations, soso-called ‘handshands-only’
only’
CPR.
The European Resuscitation Council (ERC) has reviewed the studies
studies
published since its guidelines were introduced in 2005, and has concluded
that there is insufficient evidence to make any changes at this time. The
Council has, therefore, issued a statement confirming its advice that CPR
should consist of alternating 30 chest compressions, of adequate force and
depth, at a rate of 100/minute, with 2 mouthmouth-toto-mouth ventilations. The
rescuer(s) should ensure that ventilations cause minimal interruption
interruption of chest
compressions. For those rescuers who are unwilling or unable to give mouthmouthtoto-mouth ventilations, chest compressioncompression-only is much more acceptable than
performing no CPR at all.
2010 American Heart Association
Both statements can be found at:
The AHA statement: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189380
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189380
The ERC statement: http://www.erc.edu/index.php/docLibrary/en/viewDoc/775/3/
Cardiac arrest and early defibrillation (aim <5
min out of hospital and <3 min in hospital)
?
ERC Resuscitation
Guidelines 2010
``Look listen and feel
for breathing`` (AHA 2010)
Early defibrillation and survival
An automated external
defibrillator, open and
ready for pads to be
attached
An AED at a railway station in
Japan. The AED box has
information on how to use it in
Japanese, English, Chinese and
Korean, and station staff are
trained to use it.
View of defibrillator
position and
placement, using the
standard hands free
electrodes.
View of defibrillator
position and
placement, using the
standard hands free
electrodes.
1
2
3
4
ERC 2010
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series1989
ERC 2010
AHA 2010
Action if sudden death is of suspected cardiac cause and bystander
witnessed. Before chest compression call for 112.
Chest comressions until the defibrillator is ready, while defibrillating, pauses in
chest compressions ≤ 5 sek !!
CPR with Entry of Second Person
Action if sudden death
is unwitnessed or primary
breathing problem is suspected
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series1989
The second person shall identify himself or herself as being trained
trained in
CPR and that they are willing to help (``I know CPR. Can I help?``
help?``))
The second person should call the local emergency number or
medical personnel for assistance if it not already been done
The person doing CPR will indicate when he or she is tired; and
should stop CPR after the next 2 full breath.
breath. Take over CPR every 2
min to prevent fatigue.
The second person should kneel next to the casualty opposite the
first person, tilt the casualty` s head back, and check for a carotid
pulse for 5 seconds??
seconds??
If there is no pulse, the second rescuer should give 2 full breath
breath and
continue CPR
The first person will monitor the effectiveness of CPR by looking
looking for
the chest to rise during rescue breathing and feeling for a carotid
carotid
pulse (artificial pulse) during chest compressions??
compressions??
Continue resuscitation until
Qualified help arrives and takes over
The victim starts breathing normally
You become exhausted
European Resuscitation Council
Guidelines 2010
2010 for Pediatric BLS
Pediatric BLS
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series
1989
Rescuers should perform 5 initial breath
followed by approximately 1 min of CPR before
they go for help
Blow steadily into the mouth over about 11-1.5 s,
watching for chest rise
Lay rescuers, who usually learn only single
rescuer techniques , should be taught to use a
ratio of 30 compressions to 2 ventilations
Two or more rescuers with a duty to respond
should learn a different ratio (15:2)
An infant is a child
under 1 year of age;
a child is between 1 year
and puberty
Drowning
Drowning accounts for approximately
450 000 death each year
Death from drowning is more common in
young males (leading cause of accidental
death in Europe in this group)
Alcohol consumption is a contributory
factor in up to 70% of drownings.
drownings.
The incidence of cervical spine injury is
about 0,5%
Pediatric basic life support algorithm (ERC 2010)
Definitions
Drowning itself is defined as a process resulting
in primary respiratory impairment from
submersion/immersion in a liquid medium
Submersion implies that the entire body,
including airway, is under the water or other fluid
Old terms: dry and wet drowning, active and
passive drowning, silent drowning, secondary
drowning and drowned versus nearnear-drowned
should no longer be used
The first aid for the drowning victim
Remove all the drowning victims from the water
by the fastest and safest means available,
without danger to rescuer and resuscitate as
quickly as possible
Despite potential spinal injury, victims who are
pulseless and apnoeic should be quickly
removed from water (even if a back support is
not available), while attempting to limit neck
flexion and extension
Do nothing if person is talking or breathing
Prehospital Emergency
Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series
1989
BLS for the drowning victim
If there is no spontaneous breathing after
opening the airway, give up to 5 rescue
breath for approximately 1 min
There is no need to clear the airway of
aspirated water
Abdominal thrust only if there are clean
signs of foreignforeign-body airway obstruction
BLS for the drowning victim
Pulse may be difficult to find in a drowning
victim, particularly if cold
If the there is no spontaneous breathing or
victim does not breathe
breathe normally,
normally, start with
chest compression (30:2)
If vomiting occurs, turn the victim` s mouth
to the side and remove the gastric content
manually or use suction
Give first aid for hypothermia if needed
Electrocution
Most electrical injuries in adults occur in the
workplace (associated generally with the high
voltage), whereas children are at risk primarily at
home
Direct effect of current on cell membranes and
vascular smooth muscle
Alternating current more dangerous (tetanic
contraction of skeletal muscle, respiratory and
cardiac arrest)
Hand to hand pathway is more likely to be fatal
Rescue and resuscitation victims of
electrocution
Hypothermia
Ensure that any power source is switched
off and do not approach the casualty until
it is safe
Start standard basic life support without
delay
Most electrical injury patients – even those
in full arrest – can be successfully
resuscitated with vigorous CPR
First aid for hypothermia
Remove the casualty from the cold environment
and insulate him against further heat loss
Handle the casualty very gently
Replace wet clothing with dry clothing
Application of direct heat, such as hothot-water
bottles or hot baths is not recommended
If the person is conscious, give warm, sweet
drinks to help maintain the blood sugar level to
provide energy
Resuscitation of hypothermia
victims
Heatstroke
If there are no signs of breathing, start
artificial respiration
Any sign of a pulse, no matter how week,
indicates that the heart is beating – do not
start CPR (decide whether or not to begin
chest compressions)
Remember that CPR , once started, must
be continued without interruption until
hand over to medical aid
Classic heatstroke occurs when the
body`s temperature control mechanism
fails; sweating ceases and body
temperature rises rapidly
Excertional heatstroke occurs as a result
of heavy physical exertion in high
temperatures; sweating continues, but
body temperature rises rapidly
Signs and symptoms of heatstroke
First aid for heatstroke
Temperature markedly elevated, reaching 42°
42°C
to 44°
44°C.
Pulse rapid and becomes weaker
Respiration noisy
Consciousness – headache, dizziness,
restlessness, convulsions, progressing to
uncosciousness and coma
Appearance – skin flushed, hot and either dry or
wet
Muscular reaction – convulsions, nausea and
vomiting
Lowering body temperature is the most urgent
first aid for heatstroke. The casualty`s life
depends on how quickly this can be done.
Remove the person to a cool, shaded place
Remove any excess clothing
Use sponge with lukewarm water, wet sheets
and fan
Medical aid is needed urgently
First aid for heatstroke
Shock
Shock is a condition of inadequate circulation to the body
tissues. It can deprive the brain and other vital organs of
oxygen and can lead to unconsciousness and death if
untreated.
Causes of shock:
- severe external or internal bleeding
- burns
- crush injuries
- cardiac emergencies
- respiratory emergencies
- spinal cord or nerve injuries
- severe allergic reaction
- infection
Signs and symptoms of shock
Pallor or blueblue-grey color of the skin, especially
the lips, fingernail beds and earlobes, indicating
lack of oxygen
Cold and clammy skin with profuse sweating
Weak and rapid pulse
Shallow and rapid breathing and, in later stages,
gasping for air
Thirst
Nausea and vomiting
Changes in the level of consciousness
Shock position
(conscious)
Unconscious
casualties or those
who show signs of
vomiting should be
placed in the
recovery position
First aid for shock
Treat the obvious causes of shock such as
severe bleeding, fractures and burns
Reassure the casualty
Handle the casualty gently to avoid causing pain
Position lying on back with legs raised and
head tilted backward
Prevent loss of body heat (cover with a blanket),
but do not overheat a person in shock
Give nothing by mouth if shock is severe.
Place an unconscious person in the recovery
position and obtain medical aid as quickly as
possible