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Rovy Pratama, MD

School of Medicine Syiah Kuala University


Four Core Healthcare Development and Innovation Center
Resuscitation
Banda Aceh, Indonesia Overview of Advance Life Support

Presented in:
The 1st Sumatera Anesthesiology Update – April 2019
Objective

1 Airway Management 4 Volume Assessment

2 Ventilation Technique 5 Shock

3 Cardiac Arrest Management 6 Fluid Resuscitation


Decision to Resuscitation

1. At the request of person with capacity


2. Person who is terminally ill from an advanced and irreversible disease
3. Continues to deteriorate despite all appropriate treatment or suffered catastrophic event
4. People recognized by healthcare professionals as the end of their lives

Joy Tomkins, who at aged 81 tattooed her chest with the


words “do not resuscitate” to avoid “wasting away in a
hospital bed”

Source: Resuscitation Council (UK). "Prevention of Cardiac Arrest and Decisions about CPR." (2015).
Chain of Survival
Chain of Prevention

Source: Smith GB, Prytherch DR, Psirides AJ. An Overview of the Afferent Limb. In: DeVita MA, Hillman K, Bellomo R, editors. Textbook of Rapid Response Systems 2ed. Switzerland:
Springer International; 2017. p. 159-72.
Airway Obstruction & Respiratory Failure

1. Decreased level of consciousness


2. Trauma
3. Burns
4. Foreign bodies
5. Infection
6. Inflammation
7. Shock
8. Tumor
9. Generalized weakness
10. Congenital anomalies in children
Source: Alford J, Berry M, Gaudry P, Finckh A. Securing the airway, ventilation and procedural sedation. In: Fulde GW, Fulde S, editors. Emergency Medicine. Australia:
Churchill Livingstone; 2014. p. 13-37.
Airway Management

Oropharyngeal Airway Nasopharyngeal Airway


Basic Airway Maneuvers

Correct OPA Size Incorrect OPA Size


Airway Adjuncts
Source: Quinlan M, Jekich BM. Resuscitation. In: Blok BK, Cheung DS, Platts-Mills TF, editors. First Aid For The Emergency Medicine Board. New York: Mc Graw Hill; 2016. p. 1-69.
Definitive Airway (Intubation)

Decision to intubation
1. Failure to maintain a patent airway
2. Loss of protective reflexes
3. Failure to adequately oxygenate or ventilation
4. Anticipated clinical deterioration

Difficult laryngoscopy and intubation


General appearance Look externally
Obstruction Evaluate 3:3:2
Oral opening Mallampati Score
Superior larynx Obstruction
Extension Neck immobility
Source: Quinlan M, Jekich BM. Resuscitation. In: Blok BK, Cheung DS, Platts-Mills TF, editors. First Aid For The Emergency Medicine Board. New York: Mc Graw Hill; 2016. p. 1-69.
Ventilation Technique

Difficult Mask Ventilation


Beard
Obesity
No teeth
Elderly
Stiffness

Hypoxia after intubation


Displacement
Obstruction
Pneumothorax
Equipment Failure
Rigidity of Chest Wall

Thomas V, Abraham S. Adding an" R" in the" DOPE" Mnemonic for ventilator troubleshooting. Indian Journal of Critical Care Medicine. 2018 May 1;22(5).
Cardiac Arrest Management

Source: Fulde GW, Preisz P, Berry MJ. Cardiopulmonary resuscitation. In: Fulde GW, Fulde S, editors. Emergency Medicine. Australia: Churchill Livingstone; 2014. p. 1-12.
Chest Compression

• Ensure high quality CPR Reversible Cause


• Minimize interruption when compression Hypovolemia
Hypoxia
• Give oxygen
Hydrogen ion
• Continuous compression when advance Hypo/hyperkalemia
airway in place Hypoglycemia
Toxin
• Vascular access
Tamponade
• Give adrenaline every 3 – 5 minutes Tension pneumothorax
• Give amiodarone after 3 shock Thrombosis
Trauma

Source: Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’neil BJ, Paxton JH, Silvers SM, White RD. Part 7: adult advanced cardiovascular life support:
2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015 Nov 3;132(18_suppl_2):S444-64.
Advanced Cardiac Life Support Algorithm
CPR
START Shockable
(VF/Pulseless VT)

CPR

Assess rhythm ROSC

CPR

Non-shockable
(PEA/Asystole)

Source: Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O’neil BJ, Paxton JH, Silvers SM, White RD. Part 7: adult advanced cardiovascular life support:
2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015 Nov 3;132(18_suppl_2):S444-64.
Post Cardiac Arrest Care
Cardiovascular Care Glucose Control
1. Acute cardiovascular intervention
2. Hemodynamics goal Seizure Management
Treatment of Pulmonary Embolism
Targeted Temperature Management
1. Hypothermia induction Sedation and Analgesic
2. Avoidance of hyperthermia
System of Care
Respiratory Care
1. Ventilation
2. Oxygenation

Source: Callaway CW, Donnino MW, Fink EL, Geocadin RG, Golan E, Kern KB, Leary M, Meurer WJ, Peberdy MA, Thompson TM, Zimmerman JL. Part 8: post–cardiac arrest care:
2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015 Nov 3;132(18_suppl_2):S465-82.
Oxygen Delivery

DO2 = CO x CaO2

SV x HR Hb x SPO2 x 1.34

Preload Contractility Afterload


Source: Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European
Society of Intensive Care Medicine. Intensive care medicine. 2014;40(12):1795-815.
Shock

Shock is best defined as a life-threatening,


3 Clinical Window
generalized form of acute circulatory
Superficial
failure associated with inadequate oxygen Visceral
utilization by the cell. Neurologist

Cellular Disfunction

MULTIPLE ORGAN FAILURE


Source: Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European
Society of Intensive Care Medicine. Intensive care medicine. 2014;40(12):1795-815.
Fluid Resuscitation Problem

Source: Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured
patients: a systematic review with suggestions for clinical practice. Anaesthesiology intensive therapy. 2014;46(5):361-80.
Impact of Fluid Overload
Excess volume expansion results in organ dysfunction

Negative fluid balance correlates with improved survival


Source: Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured
patients: a systematic review with suggestions for clinical practice. Anaesthesiology intensive therapy. 2014;46(5):361-80.
Rational Fluid Therapy

ROSE Concept
Resuscitation
Optimization
Stabilization
Evacuation

Principle of Fluid Therapy


1. Life saving
2. Organ rescue
3. Organ support
Optimization Evacuation 4. Organ recovery
Resuscitation Stabilization
Source: Malbrain ML, Marik PE, Witters I, Cordemans C, Kirkpatrick AW, Roberts DJ, Van Regenmortel N. Fluid overload, de-resuscitation, and outcomes in critically ill or injured
patients: a systematic review with suggestions for clinical practice. Anaesthesiology intensive therapy. 2014;46(5):361-80.
Resuscitation Endpoints
When resuscitation is completed? Basic clinical sign  Patient response
1. O2 debt is repaid
2. Tissue acidosis is eliminated
3. Aerobic metabolism is restored INADEQUATE urine output
mean
“Listen what Cell Say” INADEQUATE resuscitation

Resuscitation Endpoint
1. Hemodynamic endpoint  MAP, CVP, PAC, ScVO2, IVC
2. Metabolic endpoint  lactate, BE, pH, ETCO2
3. Regional endpoint  Gastric tonometry, gastric PCO2, gastric intramucosal pH
Source: Connelly CR, Schreiber MA. Endpoints in resuscitation. Current opinion in critical care. 2015 Dec 1;21(6):512-9.
Take Home Message

1. The goal of resuscitation is to maximize survival and minimize morbidity

2. Adequate resuscitation is no longer judge by presence of normal vital sign

3. Resuscitate with appropriate fluid, in appropriate amount, at appropriate time


Thank You

Together We Can Create System of Care

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