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Executive Summary of CPR

2010

Henti Jantung Mendadak


(Sudden Cardiac Arrest)
Eropa (ESC)
700.000
kematian/tahun
40% Fibrilasi ventrikel

Amerika (CDC)
kematian CAD/thn
330.000 di luar RS / UGD
250.000 di luar RS
Insidens
0,55 kematian/1000 pop/thn
Indonesia (Depkes)
Penyebab kematian utama
sistem sirkulasi (26,4%)

Penyakit Penyebab
Kematian Umum di
Indonesia
26,4%

18,9%
Sistim sirkulasi
= henti jantung
16%

rofil Kesehatan Indonesia 2001 Depkes RI 2002

Courtesy of Arif Mansjoer

History of Modern
CPR
1950
1960

1974

1993

SAFAR
Pengendalian jalan napas
& Pernapasan buatan

KOUWENHOVEN
Kompresi jantung tertutup

American Heart Association


Cardiopulmonary Resuscitation (CPR)

International Liaison
Committee on Resuscitation
(ILCOR)

ILCOR = International Liaison


Comittee on Resuscitation
1. American Heart Association AHA
2. European Resuscitation Council ERC
3. Heart and Stroke Foundation of Canada

HSFC

4. Resuscitation Councils of Southern Africa

RCSA

5. Australian Resuscitation Council ARC


6. Resuscitation Councils of Latin America CLAR
7. New Zealand Resuscitation Council NZRC

International Guidelines 2000


Conference on Cardio-pulmonary
Resuscitation and Emergency
Cardiovascular Care

Circulation 102, 2000

Resuscitation 46, 2000

BACKGROUND
Data2 tentang angka survival sewaktu

keluar RS terhadap korban2 henti


jantung karena VF di luar RS yg
disaksikan sangat rendah yaitu hanya
6% selruh dunia. Dengan catatan hanya
sedikit perbaikan setelah guideline thn
2000 di keluarkan. Data2 ini dibuat
hanya bberapa waktu sebelum
dimulainya konferensi CPR ILCOR2005.
Ada 2 penelitian yg dipublukasi
sebelum konferensi 2005 menunjukkan

Perubahan2 utama pada CPR 2005

Check and assess hands-off time =


time without chest
compression reduce
survival

100 per
menit
Ratio 15:2

Hands-off time = time


without chest
compression
Repeatedly assessing the patient
Interruption for ventilation
Operator delay for CVP, intubation, changing

rescuer
Time taker by AED for analysis
A fall in coronary perfusion pressure
A deterioration in waveform of VF
A decrease of successful outcome after DC shock

Remove check
breath and
assess
circulation
RATIO 30:2
(less
ventilation)

AED

Why 30:2 or less ventilation?


In VF SCA, ventilation NOT AS important as

compressions
VQ mismatch (need less Vt)
Increases intrathoracic pressure
Decreases venous return
Prevents adequate filling
DECREASES CARDIAC OUTPUT

Gastric insufflation

Hyperventilation is bad.

Aufderheide TP, Sigurdsson


G, Pirrallo R, Yannopoulos D,
McKnite S, von-Briesen C, et
al Hyperventilation-induced
hypotension during CPR
Circulation. 2004;109:1960-5

Percobaan 3 kelompok hewan hiperventil


Tekanan intra toraks rata-rata

Tekanan perfusi koroner

Observasi pada penolong terlatih


dalam memberikan pernapasan buatan

Kelompok pasien
yang ditolong

Kecepatan ventilasi
(napas/menit)

Kelompok 1 (n=7)

37 + 4*

Kelompok 2 (n=6)

22 + 3*

Kelompok 3 (n=13)

30 + 3.2

Tidak ada korban yang selamat


Penolong profesional pemberian ventilasi berlebih pada tindakan RJP.
Hiperventilasi (pada hewan) tekanan intratorakal meningkat,
tekanan perfusi koroner menurun, dan angka ketahanan hidup
menurun

Why AED?
Witnessed vs Unwitnessed
Witnessed Collapse//Cardiac Arrest
AED first

Unwitnessed arrest
CPR first (2 minutes or 5 cycles), then AED

Etiology of sudden cardiac


arrest
Etiologi
Cardiac (primary)
Heart attack (MCI)
Kelaianan jantung lain
Non-Cardiac (secondary)
Internal
Pneumonia

berat, syok, dll

Eksternal
Trauma,

keracunana dll

Nolan J. ERC Guidelines for Resuscitation 2005-introduction. Resuscitation. 2005; 67


(suppl 1):S3-S6

Etiology of sudden cardiac


arrest
Etiologi

Nolan J. ERC Guidelines for


Resuscitation 2005introduction.
Resuscitation. 2005; 67
(suppl 1):S3-S6

Henti Jantung

Saat di EKG:
asistol

100%
?%
40%

Henti
jantung/par
u

Henti
jantung
VT/VF

Saat di EKG:
VT/VF

Fase Henti Jantung


(Weisfeldt & Becker)

Electrical phase
AED first
VF early defibrillation (class I)
Each passing minute decreased survival

by 8-10%

Circulation 1997

Survival rate approaching 50%


Chicago airport study
AED 10/18 VF case survival
NEJM 2002

Chicago Airport
AED within 1 minute anywhere in the

airport
Survival approaching 50% (10/18) for VF

Outcome of Rapid Defibrillation by


Security Officer After Cardiac Arrest
in Casinos
Prospective study for sudden

cardiac arrest in casinos n=105


Survival to discharge 53%
90 patients (86%) witnessed
Collapse to AED 3.5+2.9
Collapse to defibrillation 4.4 + 2.9 min

Collapse
Survival
Collapse
Survival

to defibrillation 3 min
to discharge 74%

to defibrillation 3 min
to discharge 49%
NEJM 2000

Tripling Survival From Sudden


Cardiac Arrest via Early Defibrillation
Without
Traditional Education in
Result ;
Cardiopulmonary
Resuscitation
354 sudden cardiac arrest in Italy

Circulation 2002;106

Circulatory phase
CPR first
First provide oxygen delivery (chest

compression/ventilation) followed by
defibrillation

Immediate vs. delayed counter shock

Survival

24%

30%
JAMA 1999;281

4%

22%
JAMA 2002;289

Delaying Defibrillation to Give Basic


CPR to Patients With Out-of-Hospital VF
Randomized trial, n=200
Defibrillation at once (group A) vs. 3 min of

CPR before defibrillation (group B)


A(n=96)

B(n=104

46%

56%

0.1

ROSC

Response time < 5 min (n=81)


No difference between group A and B
Response time > 5 in (n=119)
A(n=64)

B(n=55)

P-value

ROSC

38%

58%

P<0.03

Survival to discharge

4%

22%

P<0.003

1-yr survival

4%

20%

P<0.003

JAMA 2003

The Science of resuscitation era..

Background
There is a striking disparity in survival outcomes

from cardiac arrest across systems of care, with


some systems reporting 5-fold higher survival rates
than others.
Although technology, such as that incorporated in
automated external defibrillators (AEDs), has
contributed to increased survival from cardiac arrest,
no initial intervention can be delivered to the victim
of cardiac arrest unless bystanders are ready,
willing, and able to act.
Moreover, to be successful, the actions of bystanders
and other care providers must occur within a system
that coordi- nates and integrates each facet of
care into a comprehensive whole, focusing on
survival to discharge from the hospital

Why change CPR?


New data has proven strong CPR in the field

has improved patient outcomes.


Documentation since 2005 has shown that
lay rescuer primarily perform CPR with
chest compressions only, and that they
have similar outcomes to CPR with
rescue breathing.
Minimizing intervals between chest
compressions and delivering a shock,
improves chances of shock success and
improved patient survival.

Conclusion: Bystander-initiated cardiac-only


resuscitaion and conventional CPR are similarly
effective for most adult out-of-hospital cardiac
arrest. For very prolong cardiac arrest, the
addition of rescue breathing may be of some
help

Meta-analysis

Conclusion: Available evidence strongly support the superiority of bystander


compression-only CPR. Reasons for the best efficacy of chest compressiononly CPR include a better willingness to start CPR by bystanders, the low
quality of mouth-to-mouth ventilation and a detrimental effect of too long
interruptions of chest compressions during ventilation. Based on our
findings, compression-only CPR should be recommended as the
preferred CPR technique performed by untrained bystander.

Conclusion: Among patients with out-of-hospital cardiac arrest, layperson


compression-only CPR was associated with increased survival compared
with conventional CPR and no bystander CPR in this setting with public
endorsement of chest compressiononly CPR.

So???.

The old (2005) algorithm

Remove open
airway and
rescue breath
time
consuming

AED
AUTOMATED EXTERNAL DEFIBRILATOR

Universal Algorithm CPR 2010

Rescuer Proficiency

Chain of Survival

0
0
0
2
Early
Access

Early
CPR

Early
Defibrillation

5
0
0
2

Early
Advanced
Care

0
1
0
2
Call for help

Chest
Defibrillation Advanced
Compression
Life Support

Post-Cardiac
arrest Care

New Sequence for 2010


Chest compressions, Airway, Breathing

(CAB) is the new order of operations from


American Heart Association.
This applies for adults, pediatrics and
infants, excluding newborns. Newborn
arrest are most likely respiratory and
should use the ABC sequence.
Adult Chain of Survival.

Rationale of changes 2010


A large number of witnessed cardiac arrest

are patients going into a ventricular


fibrillation, or pulseless ventricular
tachycardia. Early chest compressions
and defibrillation are key components to
the patients survival.
The CAB method allows the responder to
save time, and provide blood flow to the
heart muscle quickly.
A lay person is more likely to give CPR if
chest compressions are the priority.

Basic Life Support


Hands-Only (Compressions only) CPR for the

untrained lay person. Can be guided by


dispatcher on the phone.
Start chest compression before opening the
airway. CAB.
Allowing the chest to recoil between compressions
with a depth of 2 inches. Rate of 100/min.

BLS Adult Algorithm

Cardiopulmonary Resuscitation and


Emergency Cardiovascular Care
Any unnecessary interruptions in chest

compressions, decreases the effectiveness of


the CPR. CPR should be continued until return
of spontaneous circulation (ROSC) or termination
of resuscitative efforts.
Healthcare providers should take no longer
than a 10 second pulse check to determine if
pulses are present.
Chest compression and rescue breathing at a
rate of 30:2.

Role of the Lay Person


Rescuer
Initial recognition of the victim is imperative to

quick treatment. A patient having a cardiac


arrest may have gasping respirations or
even have seizure like activity. The rescuer
should learn through training these are
atypical presentations of a cardiac arrest and
alert responders to these findings.
Lay persons should call EMS when finding
unconscious victim and should not attempt
to check for a pulse. The lay person should
assume that the victim is in a cardiac arrest;
1. suddenly collapses, 2. person is
unresponsive, and 3. not breathing normally
or not at all.

CPR Devices and Techniques


No device other than the defibrillator has

proven to have long-term survival from in


the field cardiac arrest.
Electrical Therapies-Pacing in bradycardia,
cardioversion and defibrillation for
symptomatic tachycardia are all proven
methods to help the chain of survival. No
precordial thump.
CPR prior to defibrillation improves
outcomes in cardiac arrest.

Capnography
Capnography is recommended for

intubated patients.
This tool is used as an additional indicator
of proper tube placement, monitoring CPR
quality and detecting ROSC.

Advanced Cardiac Life


Support
New fifth link in the chain of survival is post

cardiac care.
Hypothermia treatment studies are showing
improvement with neurological, hemodynamic
and metabolic function in the ROSC patients.
Transportation to most appropriate hospital
with comprehensive post-cardiac arrest
treatment.
Post cardiac care should include prevention,
treatment of possible multiple organ
dysfunction.

ACLS Algorithm
Call for
help!
Start CPR give
02 -Attach
monitor/
defibrillator.

ROS
C

Post-Cardiac Care

Drug Therapy
Advanced
Airway
Treat
Reversible
Causes

ST Elevation Myocardial
Infarction

Prehospital 12 Lead electrocardiogram, with

interpretation by EMS providers and


information relayed to Base Station.
Advanced notification to the receiving
hospital are key elements of the treatment
and care of a patient having a STEMI.

Pediatric Basic Life Support


American Heart Association reports that 5%

to 15% of pediatric cardiac arrest are


related to ventricular fibrillation.
Studies have also shown that resuscitation
from asphyxia benefit from combination of
chest compression and ventilations. The
CAB method is to be used.
Compression only CPR is to be used with
bystanders who have not been trained with
giving ventilations or do not feel
comfortable doing so.

Pediatric Advanced Life


Support
Use of the AED with children and infants

from ages 1 to 8 years.


Rescuer needs peds-dose attenuator
system.

Neonatal Resuscitation
No changes in sequence with the neonates.
ABCs, unless known cardiac etiology.
3:1 compression to ventilation ration.
Post resuscitation therapeutic hypothermia.
Delay in cord clamping.

Adult Stroke
Stroke is the third leading cause of death in

the United States.


Public education about signs and symptoms
of stroke, calling 911, are key to the lay
person to recognize, in the early hours of
the stroke happening.
Prehospital programs, and a stroke hospital
system are in progress with ICEMA at this
time.

Education and Team


Approach
Encouraging continuing education with

healthcare provider and the lay public.


Hands only CPR should be taught to lay
persons fearful or unwilling to perform
conventional CPR.
The AED does not require formal training,
but training will enhance the students
performance.
ACLS training should reinforce the team
approach in the code situation.

Terima kasih

Resources/References
American Heart Association,

http://www.heart.org.
Inland Counties Emergency Medical
Agency, http://www.sbcounty.gov/icema.
American Stroke Association,
http://www.strokeassociation.org.
Any questions please contact Patty Eickholt
RN, BSN, PHN, MICN, CEN at ICEMA. 909388-5823.

AHA

ERC

Check response

Shout for help

Open airway

30 chest compressions

Check breathing

2 rescue breaths

DEFIBRILASI

Attach AED

SWITCH ON AED

ATTACH PADS TO CASUALTYS BARE CHEST

30
ANALYSING RHYTHM
DO NOT TOUCH VICTIM

SHOCK INDICATED

SHOCK DELIVERED FOLLOW AED INSTRUCTIONS

POSISI RECOVERY

CPR IN CHILDREN
Teknik CPR dewasa

dapat digunakan
pada anak
Kompresi cukup 1/3

tebal dada

AED PADA ANAK


Umur > 8 thn
Gunakan AED dewasa
Umur 1-8 thn
Gunakan pads
anak/jika terdapat
setting utkanak (jika
tidak ada gunakan
mode dewasa
Umur < 1 thn
Gunakan jika instruksi
dari pabriknya
menindikasikan aman

Hands-off time = time


without chest compression
Repeatedly assessing the patient
Interruption for ventilation
Operator delay for CVP, intubation, changing

rescuer
Time taker by AED for analysis
A fall in coronary perfusion pressure
A deterioration in waveform of VF
A decrease of successful outcome after DC

shock

Active Compression-Decompression (ACD)

Ann Emerg Med 1994;24:895-906

Impedance
Threshold Valve

Anesth
Analg 2001

Active Compression-Decompression CPR


combined with Impedance Threshold
Device vs. Standard CPR for Out-of-Hospital
ACD +Arrest
Cardiac
ITD CPR improve vital organ blood flow
(>3-fold increased) during cardiac arrest
Prospective, randomized controlled trial, n=210

Circulation 2003;108:2201

Circulation 2000

Triphasic Shocks are Superior to


Biphasic Shocks for Transthoracic
Defibrillation

Biphasic (7.2/7.2 ms) vs Triphasic

(4.8/4.8/4.8 ms)
Adult, Swine (18-28 kg), VF model
Results

Shock-induced VT and Asystole occurred less

often after triphasic shocks

JACC 2003

Summary
Criticall point in Basic Life Support
Place greater emphasis on chest

compression
Avoid hyperventilation
Time-sensitive model
More sophisticated CPR device
AED

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