RESUSCITATION

GUIDE LINES 2005

Aries Perdana
Department of Anesthesiology
Faculty of Medicine, University of Indonesia/
Cipto Mangunkusumo Hospital
GUIDE LINES 2005

Prevention BASIC Advanced Pediatric

Cardiac LIFE Life Life
Arrest / SUPPORT Support Support
MET

CONTROVERSIAL
NEONATAL TOPICS
RESUS. POST
RESUS.
CARE
Acute SPECIAL
BRADY & RESUS.
Coronary TACHYCARDIA SITUATIONS
Syndrome
CONTROVERSIAL TOPICS FROM THE 2005
INTERNATIONAL CONFERENCE ON CoSTR

Jerry P Nolan,Mary F H, et all

Resuscitation,2005;67:175-179

 Compression first vs shock first

 Compression – ventilation ratio
 1 vs 3- shock sequence for
defibrillation
 Shock dose
 Role of Vasopressor in treatment of
cardiac arrest
 Post resuscitation care
Compression first vs shock first

 Delaying Defibrillation to Give Basic CPR to

Patients With Out-of-Hospital VF,Randomized
Trial
 Lars Wik, MD, PhD,Trond Boye Hansen, MD et all
 Conclusions : Compared with standard care for
ventricular fibrillation, CPR first prior to
defibrillation offered no advantage in improving
outcomes for patients with ambulance response
times shorter than 5 minutes. However, the
patients with ventricular fibrillation and
ambulance response intervals longer than 5
minutes had better outcomes with CPR first
before defibrillation was at tempted.

 JAMA.2003;289:1389-1395
Compression first vs shock first

 The Cobb Study : influence of CPR prior to

defib. in patients with out-of-hospital VF
 Result:
√ All patients:
* Survival – shock first – 24%
* Survival – CPR first – 30%
√ Patients with response interval ≥ 4 minutes:
* Survival – shock first – 17%
* Survival – CPR first – 27%
√ After adjusting patient & factor differences:
* CPR first- improved survival

JAMA. 1999;281: 1182-1188

Compression first vs shock first

 Other Research
 Robinson et al. (European journal of
anesthesiology. 1998; 15:702-709) :
√ CPR first ► 2 minutes – unwitnessed VF
arrests
√ ROSC = 16 %, survival = 4%
√ Defibrillation first questioned ?
 Yakaitis rw, Ewy GA ( Critical Care Medicine.
1980;8:157-163) :
√ CPR first increases defibrillation success
rates if limited to 3 – 7.5 minutes
Compression first vs shock first

 Conclusions

 Absolute delay before Shock is critical

 Survival better with shorter response
times
 Survival improve with CPR first if
response times > 5 minutes
 CPR may provide critical cardiac
perfusion & metabolic state of
myocytes → more favorable response
to defibrillation
Compression first vs shock first

Recommendation:
 CPR is performed 1,5-3 minutes
before defibrillation on ventricular
fibrillation or pulseless ventricular
tachiccardi which occurred out of
hospital or if emergency response
time is more than 4 minutes
Compression – ventilation ratio

 Survival and Neurologic Outcome After

Cardiopulmonary Resuscitation With Four
Different Chest Compression-Ventilation
Ratios
 Arthur B. Sanders, Karl B Kern et all

 Conclusion: In this experimental model of

bystander CPR, the group receiving compressions
only for 4 minutes followed by a compression-
ventilation ratio of 100:2 achieved better
neurologic outcome than the group receiving
standard CPR and CC-CPR. Consideration of
alternative chest compression-ventilation ratios
might be appropriate.
(Ann Emerg Med. 2002;40:553-562.)
Compression – ventilation ratio

 Quality of Cardiopulmonary Resuscitation

During in-hospital Cardiac Arrest
 Benjamin S. Abella, MD, PhilJason P. Alvarado, BA,et all
 Result Analysis of the first 5 minutes of each
resuscitation by 30-second segments revealed that
chest compression rates were less than 90/min in
28.1% of segments. Compression depth was too
shallow for 37.4% of compression. Ventilation
rates were high, with 60.9% of segments
containing a rate of more than 20/min.

 (JAMA. 2005;293:305-310)
Compression – ventilation ratio .

 Conclusions : In this study of in-

hospital cardiac arrest, the quality of
multiple parameters of CPR was
inconsistent and often did not meet
published guideline recommendations
even when performed by well-trained
hospital staff.

(JAMA. 2005;293:305-310)
 Compression – ventilation ratio

Adverse Hemodynamic Effects of Interrupting Chest

Compressions for Rescue Breathing During
Cardiopulmonary Resuscitation for Ventricular
Fibrillation Cardiac Arrest
Robert A. Berg, MD; Arthur B. Sanders, MD; et all

Conclusion :
Interrupting chest compressions for rescue
breathing can adversely affect hemodynamics
during CPR for VF.
(Circulation.2001;104:2465-2470.)
Compression – ventilation ratio

Importance of Continuous Chest Compressions During

Cardiopulmonary Resuscitation Improved Outcome
During A Simulated Single Lay-Rescuer Scenario
Karl B. Kern, MD Ronald W. Hilwig, DVM, PhD et all

Conclusions ─ Mouth-to-mouth ventilation performed by

single layperson rescuers produces substantial
interruptions in chests compression–supported
circulation. Continuous chest compression CPR
produces greater neurologically normal 24-hour
survival than standard ABC CPR when performed in a
clinically realistic fashion. Any technique that minimizes
lengthy interruptions of chest compressions during the first
10 to 15 minutes of basic life support should be given
serious consideration in future efforts to improve outcome
results from cardiac arrest.
(Circulation. 2002;105:645-649.)
Compression – ventilation ratio

 Recommendation:
 Universal ratio of 30:2 for lone
rescuers of victims from infancy
(excluding newly born) through
adulthood.
 Ratio 15:2 for 2 rescuers CPR in
infants & children.
 Make rotation every 5 cycles/2
minutes
 1 vs 3- shock sequence for defibrillation

 Interruption of Cardiopulmonary Resuscitation

With the Use of the Automated External
Defibrillator in Out-Of-Hospital Cardiac Arrest
Anouk P. van Alem, MD, Rudolph W. Koster, MD, PhD et all
 Conclusion : First responders using automated
external defibrillator voice prompts provide CPR less
than half the time that the automated external
defibrillator is connected to the patient. Technical
improvements in automated external defibrillator
rhythm analysis, more efficient resuscitation
algorithms, and first-responder education could
increase CPR delivery and, perhaps, improve
outcome.
(Ann Emerg Med. 2003;42:449-457)
 1 vs 3- shock sequence for defibrillation.

Outcome of Interrupted Precordial Compression During

Automated Defibrillation
Ting Yu, MD; Max Harry Weil, MD, PhD; et all

Conclusion :
Interruptions of precordial compression for rhythm analyses that
exceed 15 second before each shock compromise the outcome of CPR
and increase the severity of post-resuscitation myocardial
dysfunction.
(Circulation 2002;106:368-372.)
1 vs 3- shock sequence for defibrillation.

 Automated eksternal defibrillator; to what

extend does the algorithm delay CPR
 Rea TD, Shah S,et all

Rhythm analysis for a 3-shock sequence

performed by commercially Available AED

resulted in delays of 29 to 37 seconds
between delivery of 1st shock and the
beginning of 1st post shock compression.

 Ann Emerg Med. 2005;46:132-141

 1 vs 3- shock sequence for defibrillation.

Recommendation :

One initial shock immediately followed

by CPR, beginning with chest
compression without initial evaluation
of cardiac rhythm or check circulation
based on pulse examination, until one
period of CPR (5 cycles or 2 minutes)
is completed.
Shock dose

 Recommendation: One shock

→ optimum shock dose needed

→ efficiency of first shock monophasic
< biphasic
 Monophasic : 360 J for initial and
subsequent shocks
 Biphasic : initially 150-200 J or 120 J
Role of Vasopressor in teatment of cardiac arrest

Vasopresin for cardiac arrest A systematic

review & meta analysis
Aung K, Htay T
No statistically significant difference between vasopresin
and epinephrine on ROSC , death within 24 hours or
death
before discharge from Hospital.
Arch Intern Med 2005:165;17-24

Recommendation:Individual resuscitation
councils will need to determine the Role
of vasopresin in their guide lines.
Post resuscitation care
ILCOR Recommendations

The Advanced Life Support Task Force of the

International Liaison Committee on Resuscitation
(ILCOR) made the following recommendations :
 Unconscious adult patients with spontaneous
circulation after out-of-hospital cardiac arrest
should be cooled to 32o C to 34o C for 12 to
24 hours when the initial rhythm was
ventricular fibrillation (VF).
 Such cooling may also be beneficial for other
rhythms or in-hospital arrest.
GUIDE LINES FOR PREVENTION OF IN- HOSPITAL
CARDIAC ARREST

 Provide care for patients who are critically ill or at risk of

clinical deterioration in appropriate areas, with the level of care
provided matched to the level of patient sickness
 Regular observations for critically ill patients; match the
frequency & type of observations to the severity of illness or
the likelihood of clinical deterioration and cardiopulmonary
arrest. Often simple vital sign observations (pulse, BP, RR) are
needed.
 Early Warning Score (EWS) to identify patients who are
critically ill and or at risk of clinical deterioration &
cardiopulmonary arrest.
 Charting system that enables the regular measurement &
recording of EWS
 Rules about clinical responses to EWS system, including rules
about medical treatment & detail responsible of the medical
staff & nurse
GUIDE LINES FOR PREVENTION OF IN- HOSPITAL
CARDIAC ARREST

 Clear identified response to critical illnes

→ resuscitation team ready for 24 hours
 Training for all staffs in nursing ward → to recognice,
monitor & take care of patients with severe disease
while waiting for more experienced team arrived
 Identification of patients on terminal state of cardiac
arrest
→ certain rules in hospitals about DNAR
 Adequate audit of every cardiac arrest incidences,
unexpected death, patients with unexpected ICU care,
& response time of emergency (code blue)
ILCOR Universal
Cardiac Arrest Algorithm

Circulation 2005; III 1-4

IN HOSPITAL RESUSCITATION
EUROPEAN RESUSCITATION COUNCIL

Collapsed/sick patient

Shout for HELP & assess patient

No Signs of life? Yes

Call Resuscitation Team Assess ABCDE

Recognize & treat
Oxygen, monitoring, iv access
CPR 30:2
With oxygen & airway adjuncts
Call Resuscitation Team
If appropriate
Apply pads/monitor
Attempt defibrillation if appropriate
Handover to Resuscitation
Team
Advanced Life Support
When Resuscitation Team arrives
Circulation 2005;
112: IV 18-34
5
ADULT ALS ALGORITHM, EUROPEAN RESUSCITATION COUNCIL

Unresponsive?

Open Airway
Look for signs of life
Call
Resuscitation Team
CPR 30 : 2
Until defibrillator/monitor attached

Assess rhythm

Shockable Non-shockable
(PEA/Asystole)
(VF/Pulseless VT)

1 Shock
150-360 J biphasic or
360 J monophasic

Immediately resume: Immediately resume:

CPR 30:2 CPR 30:2
For 2 min For 2 min
LANJUTAN

During CPR :
• Correct reversible causes *
• Check electrode position & contact
• Attempt/verify :
IV access
Airway & oxygen
• Give uninterrupted compressions when airway secure
• Give adrenaline every 3-5 mins
• Consider : amiodarone, atropine, magnesium

*Reversible Causes
Hypoxia Tension Pneumothorax
Hypovolemia Tamponade cardiac
Hypo/hyperkalaemia/Metabolic Toxins
Hypothermia Thrombosis (coronary or pulmonary)
Circulation 2005;
112: IV 57-66
4

10
 Adult Child Infant
Lay rescuer: ? 8 year Lay rescuers: 1 to 8 years Under 1 year of age
Maneuver HCP: Adolescent and older HCP: 1 year to adolescent
Airway Head tilt-chin lift (HCP: suspected trauma, use jaw thrust)
Breathing Initial 2 breaths at 1 second/breath 2 effective breaths at 1 second/breath
HCP: Rescue breathing without chest 10 to 12 breaths/min 12 to 20 breath/min (approximate)
compressions (approximate)
HCP: Rescue breaths for CPR with 8 to 10 breaths/min (approximate)
advanced airway
Foreign-body airway obstruction Abdominal thrusts Back slaps and chest thrusts
Circulation HCP: Pulse check (?10 sec) Carotid Brachial or femoral
Compression landmarks Lower half of sternum, between nipples Just below nipple line (lower half
of sternum)
Compression method Heel of one hand, other hand Heel of one hand or as for adults 2 or 3 fingers
Push hard and fast on top HCP (2 rescuers):
Allow complete recoll 2 thumb-encircling hands
Compression depth 1½ to 2 inches Approximately one third to one half the depth of the chest
Compression rate Approximately 100/min
Compression-ventilation ratio 30:2 (one or two rescuers) 30:2 (single rescuer)
HCP: 15:2 (2 rescuers)
Defibrillation AED Use adult pads Use AED after 5 cycles of CPR (out of No recommendation for
Do not use child pads hodpital). infants
Use pediatric system for child 1 to 2 years <1 year of age
if available
HCP: For sudden collaps (out of
hospital) or in-hospital arrest use AED as
soon as available.

Overview of CPR
(Circulation 2005; IV, 12-17)