Adult Resuscitation

Shenyang medical college affiliated second hospital

 PERSPECTIVE
Epidemiology

It is estimated that 236,000 to 325,000 patients are treated

for out-of-hospital cardiac arrest each year in the United
states.
The proportion of EMS-treated cardiac arrest patients has
declined over time to1/3 or less in recent U.S. studies.
Tremendous variability in survival to hospital discharge after
EMS-treated cardiac arrest.
Of patients surviving to hospital discharge,1/3 have persistent
neurologic deficits, less than half return to prearrest function.
Favorable outcome has been reported in approximately 50%
cardiac of comatose cardiac arrest survivors treated with
hypothermia.

2 Emergency Department:
 PRINCIPLES OF DISEASE

Understanding the cause of cardiac arrest helps direct ther

apy and diagnostic testing during resuscitation and in the imme
Etiolgy

diate post-cardiac arrest period.

Autopsy studies showed a 75% incidence of previous MI a
nd 20%-30% incidence of AMI. And SCD caused by Vf or VT in
clude myocardial hypertrophy, cardiomyopathy ,and specific str
uctural abnormalities.
PEA and asystole are less common presenting rhythms in
patients with a cardiac cause of arrest

3 Emergency Department:
 common cause of nontraumatic cardiac arrest

GENERAL SPECIFIC DISEASE OR AGENT

Cardiac CAD Cardiomyopathy Structural ab

normalities Valve dysfunction
Respiratory Hypoventilation CNS dysfunction
Neuromuscular disease Toxic and
metabolic Encephalopathies
Upper airway CNS dysfunction Foreign body Infectio
obstruction n Trauma Neoplasm
Pulmonary dysfunction Asthma COPD Pulmonary edema Pul
monary embolus Pneumonia

Circulatory Mechanical obstruction Tension pneumothorax Pericardial tam

ponade Pulmonary embolus
Hypovolemia Hemorrhage
Vascular tone Sepsis Neurogenic

Metabolic Eletrolyte abnormalities Hypokalemia hyperkalemia Hypermag

nesemia Hypomagnesemia hypocalce
mia

Toxic Prescription mediations Antidysrhythmics Digitalis beta-blocker

s CCB Tricyclic Antidepressants
Drugs of abuse Cocaine Heroin
Toxins Carbon monoxide Cyanide

Environmental Lightning Electrocution Hypothermia

Drowning or near drowning
4 Emergency Department:
 CLINICAL FEATURES AND MANAGEMENT

1 Most cardiac arrest cases managed in the ED

2 An increasing number of first responders, traditional providers

and public venues are being equipped with AED, Dramatic
resuscitation rate have been achieved

3 Quality of CPR and time of defibrillation are two most important

determinants of outcomes.

5 Emergency Department:
 History and Physical Examination

Historical information from the patients family,

bystanders and EMS personnel provides key
information regarding causes and prognosis.
Includes whether the arrest was witnessed ,the time
of arrest, what patient was doing ,the possibility of drug
ingestion, time of initial CPR, initial ECG rhythm ,and
intervention by EMS providers, important past medical
history.
If possible the patients current medications and
allergies should also be obtained.

6 Emergency Department:
 History and Physical Examination

Physical examination focused on a few key goals.

ensure adequacy of airway maintenance and
ventilation.
confirm the diagnosis of cardiac arrest .
find evidence of the cause
monitor for complications of therapeutic interventions

7 Emergency Department:
 History and Physical Examination

Cardiopulmonary arrest is defined by the triad of unconscio

usness ,apnea, and pulselessness.
The pulse is palpated in large artery (carotid and femoral).
With sudden onset of cardiac arrest ,as in Vf, loss of conscious
ness occurs within 15 s, but agonal gasping respirations persist
for several minutes.
Pupils dilate within 1 minute but constrict if CPR is initiated
immediately and performed effectively .
Dependent lividity and rigor moris develop after hours of cardia
c arrest.
Temperature is an unreliable predictor of duration of cardia
c arrest because it does not decrease significantly during the fir
st hour of arrest.

8 Emergency Department:
 History and Physical Examination

Physical examination findings indicating potential cause of cardiac arrest and

complications of therapy
Physical examination Abnormalities Potential causes
General Pallor Hemorrhage
Cold Hypothermia
Airway Secretions, vomitus ,blood Aspiration, Airway obstruction
Resistance to PPV( positive-pre Tension pneumothorax, Airway
ssure ventilation) obstruction Bronchospasm,

Neck Jugular venous distention Tension pneumothorax, cardiac tam

ponade, pulmonary embolus
Tracheal deviation Tension pneumothorax,

Chest Median sternotomy scar Underlying cardiac disease

Lung Unilateral breath sounds Tension pneumothorax ,Right main
stem intubation ,Aspiration Esopha
geal intubation, Airway obstruction ,
Distant or no breath sounds or on che
st explansion Severe bronchospasm
Wheezing Aspiration, Bronchospasm Pulmona
ry edema
Apiration ,Pulmonary edema, Pneu
Rales monia ,

9 Emergency Department:
 History and Physical Examination

Physical examination findings indicating potential cause of cardiac arrest and

complications of therapy

Physical examination Abnormalities Potential cause

Heart Audible heart tones Hypovolemia Cardia

c tamponade Tension pneu
mothorax Pulmonary embolus

Abdomen Distended and dull Ruptured AAA (abdominal aortic aneur

ysm) Ruptured ecto
pic pregnancy
Distended and tympanitic Esophageal intubation
Gastric insufflation

Rectal Blood, melena Gastrointestinal hemorrhage

Extremities Asymmetrical pulses Aortic dissection

Arteriovenous shunt or fistula Hyperkalemia

Skin Needle tracks or abscesses Intravenous drug abuse

Burns Smoke inhalation
Electrocution

10 Emergency Department:
 Monitoring

Traditional monitoring during CPR relies on evaluati

on of the ECG in one or more leads and palpation of car
otid or femoral artery pulse.
Myocardial blood flow depend on the CPP.
ECG monitoring during cardiac arrest indicates the
presence or absence of electrical but not the mechanical
activity.
A brief overview of CPP, ETco2 and ScvO2 monitorin
g can detect inadequate CPR with high specificity.

11 Emergency Department:
 Monitoring
Indicators of inadequate blood flow during
cardiopulmonary resuscitation
MONITORING TECHNIQUE INDICATOR
Carotid or femoral pulse Not palpable

CPP <15mm Hg

Arterial relaxation (diastolic) pressure <40mm Hg

End-tidal co2 partial pressure PETco2 <10mm Hg (before vasopressor)

ScvO2 <40%

12 Emergency Department:
 Resuscitation

Restoration of adequate cardiac function is the defining

factor of ROSC.
Restoration of normal brain function is the defining factor of
successful resuscitation.
Important quality performance measures include:
compression rate (100-120 per minute), compression
depth (5-6cm), duty cycle full relaxation ,and minimum pauses,
avoid hyperventilation,30:2 compression-to-ventilation ratio,
Once the airway has been secured, provide six to eight
ventilations every time ,and CPR should be performed
continuously without pausing.

13 Emergency Department:
 Resuscitation

14 Emergency Department:
 Post-cardiac arrest

Resuscitation of a cardiac arrest victim does not end with

ROSC.
Management includes Rapid diagnosis, treatment of the d
isorders which cause the arrest and the complications of prolon
ged global ischemia.
Simultaneous management of these entities makes carin
g for a post-cardiac arrest patient particularly.

15 Emergency Department:
 Review and Summarize

CPR quality is critical to successful

resuscitation from cardiac arrest .
Restoration of adequate cardiac function is the
defining factor of ROCS.
Restoration of normal brain function is the defining
factor of successful resuscitation.
Rapid diagnosis ,proper management of pathologic
conditions and goal-directed hemodynamic
management can improve the outcome.
Induced prolonged hypothermia can improve survival
and functional outcome of comatose cardiac arrest
survivors.

16 Emergency Department:
 Video of CPR

17 Emergency Department:
Thank You

18 Emergency Department: