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Cardiac/circulatory arrest

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In December 2005, the ERC (European Resuscitation Council) published new guidelines.
The following are the main differences to the previous recommendations:
  • Cardiopulmonary resuscitation (CPR) is to be initiated as soon as the patient stops reacting and breathing normally.
    It is thus no longer necessary to look for signs of circulatory function, or of missing circulatory function prior to initiation of CPR.
  • Place your hands in the middle of the patient's breast; unnecessary loss of time while looking for the optimal pressure point should be avoided.
  • The compression/ventilation ratio has been doubled to 30:2, regardless of the number of rescuers.
  • The 2 initial resuscitation breaths are no longer considered necessary; the thorax is compressed 30 times immediately after the patient has stopped reacting and breathing normally.
  • The time for one resuscitation breath should no longer be 2 seconds but rather only 1 second.
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Diagnosis – Phase of assessment

  • Unconsciousness (after 10-15 sec)
    • Patient does not respond to verbal stimuli
    • No response upon gently shaking shoulders
    • No response upon painful stimulus (pinching at nasal root)
  • Respiratory arrest (after 30-60 sec)
    • No visible breathing movements
    • No hearable breathing sounds
    • Breathing cannot be felt, or
    • Gasping breathing (final diaphragmatic contractions without ventilation)
    In case of doubt, respiratory arrest or insufficiency of the emergency patient should be assumed.

    Note!
    • Do not look for general signs of circulatory function
    • Start cardiopulmonary resuscitation immediately when patient does not respond to verbal stimuli and their respiration is insufficient or has stopped altogether

Phase of reaction – Cardiopulmonary resuscitation

  1. The first aid team calls for emergency service with emergency physician and ambulance (European emergency telephone number 112; in US and Canada: 911).
  2. Lay the patient on a hard flat surface (floor).
  3. At the same time, start documentation (record the time of standstill)
  4. Basic life support
The ABC rule is no longer valid, as of now the CAB rule applies!
(ERC guidelines of December 2005)

C) Circulation (chest compressions)

A prerequisite for external cardiac massage (ECM) is that the patient is positioned on a hard surface since only this guarantees that the applied pressure has an effect on the intrathoracic space. Furthermore, the patient should be placed flat on their back, with their head not higher then the heart since otherwise cerebral perfusion would be reduced. The patient's chest must be uncovered so that the rescuer can locate the compression site. The rescuers should remove the patient's clothing within only a few seconds.

Place the patient on a hard surface for ECM and press down on the chest 4—5 cm.

Procedure:
(ERC guidelines of December 2005)
  • Kneel by the side of the patient
  • Place the heel of one hand in the centre of the patient's chest
  • Place the heel of your other hand on top of the first hand
  • Interlock the fingers of your hands
  • Ensure that your hands are on the central part of the sternum, and not over the patient's ribs #pic#
  • Only place the heel of your hand on the patient's chest
    #pic#
    #pic#
  • Apply pressure with your arms straight, horizontally from above, by bending in the hip.
  • For cardiac compression, put the weight of the upper part of your body on your straight arms and press down on the sternum 4—5 cm towards the spinal column.
    #pic#
  • The ventilation/compression ratio is always (until intubation) 2:30, regardless of the number of rescuers.
    Note!
    The compression/ventilation ratio is 30:2,
    regardless of the number of rescuers
  • Two-rescuer CPR should be the method of choice.
  • The frequency of cardiac massage should be 100/min so that the effective nummber of compressions (ie after subtraction of resuscitation breaths) is approx. 70 compressions/min.
    A higher frequency is not recommendable due to the shorter diastolic phase and thus insufficient ventricular filling.
Note!
Frequency of cardiac massage: 100/min
  • Later on, the emergency physician continues CPR

A) Airways – Clear and keep open

Remove dentures/dental appliances, tilt the head back so that the neck is extended, raise the chin and depress lower jaw.
#pic#
#pic#

Tilting back the head raises the relaxed tongue of the deeply unconscious patient from the posterior pharyngeal wall and lifts the epiglottis from the laryngeal opening.

Technique:
Grasp the patient’s forehead at the hairline with one hand.
Grasp and lift the chin with the other hand. Use both hands to turn the patient’s head to the side.

B) Resuscitation breathing

  • Pinch the soft part of the patient's nose closed, using the index finger and thumb of your hand on their forehead.
  • Open the mouth with the chin lifted.
  • Allow the mouth to open, but maintain chin lift.
  • Take a normal breath and place your lips around the patient's mouth, making sure that you have a good seal.
  • Blow steadily into the mouth while watching for the chest to rise.
Ventilate slowly and regularly for one second, watching for the chest lifting and falling as a sign for sufficient ventilation. Maintain head tilt and chin lift between resuscitation breaths.
Do not start the second inspiration before the patient has completely exhaled.

After two resuscitation breaths, give a further 30 chest compressions.
#pic#
#pic#

Mask ventilation

A prerequisite for sufficient mask ventilation is a secure C-grip.
For the C-grip, thumb and index finger press the mask tightly on mouth and nose while the remaining fingers grasp the jaw angle, tilting the head and lifting the mandible.
Risks:
  • Insufficient tightening of the mask and tilting of the head may cause hypoventilation.
  • Insufficient tilting of the head may lead to ventilation of the stomach with the risk of reflux of food/chyme from the stomach with subsequent aspiration.

D) Drugs

Only if A to C are interrupted no longer than 15 sec.

Adrenaline is the substance of choice for cardiac/respiratory arrest.

1 mg adrenaline is drawn up with 0.9 ml saline solution (0.9 %) and administered intravenously.

Typical mistakes and complications of cardiac massage

  • Abrupt compression and release movements with non-extended elbows and an excessive break during the release phase;
    Consequence: Risk of rib fracture; insufficient cardiac output
    Better: Steadily count out loud, “one and two and ...”, etc. Apply pressure to the chest saying “and” and release saying numbers; compression and release periods should have the same duration. Do not interrupt chest compressions for more than 5 seconds.
  • Exhalation is incomplete because the rescuer’s hands lightly rest on the patient’s chest;
    Consequence: Low cardiac filling and output in addition to risk of reduced coronary artery and myocardial perfusion!
    Better: Kneel as close to the patient as possible and ensure that your upper body is completely supported by your back muscles! Do not support your weight on the patient during exhalation!
  • Patient has not been placed on a hard surface
    Consequence: insufficient increase in chest pressure
  • Compressions are not given in horizontal direction
    Consequence: insufficient increase in chest pressure
Since in elderly patients the chest is not as elastic any more, the risk of rib fractures is increased and in approx. 50 % of cases inevitable. This is not a reason to stop resuscitation and will not have legal consequences for the physician or lay rescuer.

Emergency trainiging in practice

  • Control contents of first-aid case after every case of emergency, and every 3 months
  • Write a protocol of any emergency treatment
  • Training every 6 months
  • First-aid course for the practice team every 2 years
Dentist Assistant
Positioning Provide first aid case,
Emergency call
Instructions Preparation of instruments
Injections Check blood pressure and pulse
Give resuscitation breaths Chest compressions, drawing up of injections
  • Any staff member must know where the first-aid case is kept.
  • The emergency phone number should be in reach of the telephone.
  • The emergency call should include:
    Where did it happen?
    What happened?
    When did it happen?
    How many people are involved?
    Who is calling?


sources

  • Handley AJ, Koster R, Monsieurs K, Perkins GD, Davies S, Bossaert L; European Resuscitation Council (2005)   European Resuscitation Council guidelines for resuscitation 2005. Section 2. Adult basic life support and use of automated