Resuscitation in Adults (Paramedic)

00:01 Hello. In this presentation, we will look at prehospital adult resuscitation. To do this, we must first d efine w ho is considered an adult.

00:14 Based on the current adult resuscitation guidelines, any patient showing visible signs of puberty may be considered adults.

00:25 Before we get too deep into the topic, let's take a look at a few epidemiological aspects regarding resuscitation.

00:33 In adults. The most common cause of cardiovascular arrest is heart disease.

00:40 We have approximately 67 to 140 out-of-hospital cardiac arrests per 100,000 population in Europe and 50 to 80 per 100,000 in Germany.

00:52 In general, this data is difficult to gather, primarily because it is preclinical data being provided by emergency rescue.

00:59 Preclinical data is not collected uniformly, so the numbers are not very reliable.

01:05 The first thing we should ask ourselves is why should we bother performing resuscitation? The goal of resuscitation is to end cardiovascular arrest, restoring blood flow a nd ultimately achieving spontaneous circulation with the heart beating independently. This return of spontaneous circulation is called ROSC, or "Return of Spontaneous Circulation." Various ECG rhythms are possible in the context of cardiovascular arrest. For treatment, the most important distinction is between those that can be defibrillated and those that cannot.

01:46 Ventricular fibrillation and pulse-less ventricular tachycardia, which includes the special form torsads, are phenomena that absolutely require defibrillation.

02:05 In contrast, rhythms that cannot be defibrillated include as asystole and pulseless electrical activity, which can be seen in almost any ECG trace.

02:16 If there is PEA, there is no heart ejection taking place.

02:19 Resuscitation can now be performed in two ways, depending on the personnel deployed and the equipment available.

02:25 First, Basic Life Support is used for basic resuscitation of the patient.

02:32 When more resources and more staff are available, Advanced Live Support takes advantage of medications and involves intubation, ventilation, and airway management.

02:47 Next, we will look at what actions occur during this resuscitation.

02:52 When resuscitation is performed, there is a clear order of priorities.

03:01 First and foremost is the initiation of high-quality chest compression.

03:06 To maintain quality, the provider must be rotated every two minutes, as quality chest compressions are very labor intensive, even for a skilled provider.

03:18 If this does not happen, the quality of chest compression will begin to drop significantly, and the patient's chances of survival will decrease.

03:26 It is therefore neither appropriate to play the hero yourself, nor force the intern to do compressions for half an hour as a hazing ritual.

03:34 So please rotate every 2 minutes of chest compressions to maintain quality and the best outcome for the patient.

03:44 Another treatment focus is around early rhythm analysis, and if necessary, defibrillation if needed.

03:54 Analysis must be assessed as early as possible, and defibrillation should follow immediately, if appropriate.

04:03 Next is sufficient ventilation, which ensures that oxygen is distributed throughout the body via the blood being circulated by the chest compressions.

04:13 Medications also play a major role in Advanced Life Support resuscitation. I will explain the two main drugs in a moment and then present the methods for identifying and correcting potentially reversible causes.

04:29 We will now return to high-quality chest compression and look at the three criteria we aim to meet.

04:38 The first is the compression location.

04:41 The correct point is on the lower half of the sternum, at the level of the line drawn between the two nipples.

04:48 If the pressure point moves, there is a reduction in the depth of pressure and efficiency of chest compression, so the provider must pay particular attention to the compression location.

04:59 The second important aspect is the compression depth.

05:02 The optimal is 5 to 6 centimeters during each compression.

05:06 Non-medical individuals usually suspect much less, and ultimately do not achieve the pressure depth actually required to sufficiently compress the heart, resulting in significantly worse circulation.

05:17 In addition to the compression depth, h owever, full rebound of the chest wall is also important.

05:23 As you probably know, the actual blood flow to the heart takes place during diastole, the phase when the heart is relaxed.

05:30 If it is not completely relaxed during resuscitation, the blood flow to the coronary vessels is limited, thus lowering the likelihood of the heart receiving sufficient oxygen and or being able to restart spontaneous circulation.

05:45 So with the depth of compression, pay attention to fully releasing the pressure so that the heart can fill up again.

05:51 The third criterion is the compression frequency.

05:56 It ranges from 100 to 120 chest compressions per minute.

06:02 Now, let us move on to discuss defibrillation.

06:04 The goal in adult sudden cardiac arrest is to perform rhythm analysis as early as possible and defibrillate if necessary.

06:12 As a rule of thumb, every minute a patient with a defibrillatable rhythm is not shocked, their chance of survival drops by about 10%. That is why there are now many projects aimed at establishing early defibrillation for the layperson in the form of AEDs or automatic external defibrillators.

06:34 From this they can see that bystander resuscitation is also playing an increasingly important role.

06:40 If you are performing defibrillation, you must of course know what values should be set on the defibrillator.

06:48 With biphasic pulse shape deliver the first shock with an energy of at least 150 joules.

06:55 With pulsed biphasic pulse shape, deliver the first shock at 120 to 150 joules.

07:04 In recurrent or refractory ventricular fibrillation, the delivered energy should be increased. Most devices automatically adjust the energy after the first shock. Alternatively, try changing the positions of the electrodes so that they are placed on the chest and back.

07:23 This is called anterior-posterior pad placement.

07:27 Ventilation is performed between chest compressions.

07:31 The target tidal volume is 400 to 600 milliliters.

07:36 Thus, during ventilation, the thorax should not be overloaded with air, but only the slight lifting of the thorax is needed to achieve adequate ventilation.

07:45 Whenever possible, ventilate with 100% oxygen.

07:49 Also be sure to protect the patient's airway if possible.

07:54 Effective tools are now available for this purpose.

07:57 They are less invasive and can be used relatively quickly even by non-anesthesiologists.

08:09 The laryngeal tube or laryngeal mask, which I will discuss in more detail in another presentation, are both examples of this.

08:18 The advantage of these devices is that they can be used during resuscitation.

08:22 After successful intubation, chest compressions must not be interrupted.

08:28 Be sure to ventilate after every tenth compression.

08:32 This will then achieve a respiratory rate of about 10 to 12 per minute with the heart compression rate remaining at 100 to 120.

08:43 If intubation has not occurred, resuscitation is performed at a 30-to-2 ratio, starting with chest compressions.

08:54 As I mentioned at the beginning, we will now discuss the drugs that are commonly used during resuscitation.

09:00 Three drugs are particularly important, because they are useful in the return of spontaneous circulation.

09:08 You've probably heard the first one before, and that is epinephrine.

09:12 Epinephrine is dosed at 1 milligram.

09:15 It can be administered pure with an infusion solution or applied diluted to ten milliliters with saline, depending on the algorithm being used by the team. Epinephrine causes peripheral vasoconstriction, increasing blood flow to the coronary vessels and improving blood flow to the heart. It also increases the chance that the heart will regain a spontaneous rhythm on its own and start beating.

09:45 Amiodarone, the next drug, is dosed at 300 milligrams and given with glucose. As a channel blocker, it increases the likelihood of successful defibrillation.

09:57 Usually, it is not used before the third unsuccessful defibrillation for rhythms requiring defibrillation, and even then only in combination with epinephrine.

10:09 If the patient has a rhythm that cannot be defibrillated, then epinephrine is administered intravenously as early as possible and amiodarone is omitted. If amiodarone is not available or the decision is made by the team, lidocaine may be given as an alternative.

10:27 Lidocaine blocks a different type of ion channel and, like amiodarone, improves the likelihood of successful defibrillation.

10:36 It is also applied after the third and fifth unsuccessful shocks with a dose of 100 and subsequent 50 milligrams.

10:46 Now that we have turned to the measures that restore circulatory arrest, let us conclude with its reversible causes.

10:55 How can you identify the triggers of cardiac arrest? For this question, the schemes of H's and HITS are common.

11:04 All of these are causes, as they are often identified and usually reversible.

11:10 But let's look at the H's first.

11:13 The first cause is hypoxia, which means lack of oxygen.

11:17 This occurs, for example, when the airway is blocked by food components.

11:23 The second point, hypvolemia, refers to the reduction of blood volume, and can occur due to traumatic blood loss.

11:33 Hypo- or hyperkalemia means electrolyte shifts and also includes glucose shifts.

11:40 Patients with renal insufficiency are often affected by hypo- or hyperkalemia. Finally, hypothermia forms the final h.

11:50 It occurs, for example, in intoxicated patients who fall asleep in the snow.

11:57 The second scheme is the "HITTS".

12:01 This stands for pericardial tamponade, intoxication, thromboembolism, or tension pneumothorax.

12:10 Here, too, it makes sense to look for the causes and intervene accordingly, particularly in the case of thromboembolism, for example, by medical intervention or in the case of tension pneumothorax by needle decompression.

12:23 If the cause of the cardiac arrest can be eliminated, the patient's chances of survival significantly improve.

12:29 Let us now take a look at how resuscitation should ideally proceed and what the provider should pay attention to in each case.

12:45 A young man suddenly loses consciousness.

12:53 The eyewitness immediately calls for help! The first responder addresses the young man and turns him onto his back.

13:09 Meanwhile, the eyewitness dials the emergency number, 911.

13:16 Meanwhile, by shaking the shoulders, the first responder tries to wake the patient.

13:21 There is no reaction to this maneuver.

13:25 While the emergency control center gives further instructions to the helpers on site, t he ambulance is alerted and makes its way to the scene.

13:46 Meanwhile, the paramedic checks the patient's breathing by listing, looking and feeling for a maximum of ten-seconds with the head extended.

14:00 He notes no breathing, and immediately begins chest compressions, with a rate of 100 to 120 per minute and a depth of 5 to 6 centimeters. First responders will then receive assistance from the rescue coordination center.

14:51 Emergency medical services arrive at the emergency scene while the first responder continues to resuscitate the patient.

14:59 He is directly prompted to continue chest compressions.

15:10 The chest is stripped so that the electrodes of the defibrillator can be glued on.

15:16 The first electrode is positioned to the right of the sternum below the clavicle, t he second is placed on the left axilla approximately at the level of the fifth intercostal space.

15:29 Immediately after application of the electrodes, the rhythm analysis is performed.

15:33 Ventricular fibrillation is identified, a shockable rhythm, so defibrillation follows immediately.

15:41 During the charging phase of the defibrillator, cardiac compressions continue and should only be interrupted for the delivery of the shock.

15:49 Resuscitation is performed at a ratio of 30 chest compressions to two bag-mask ventilations.

16:10 The airway is secured early here with a laryngeal tube.

16:18 The tube is locked into place and ventilation with capnography is connected.

16:40 After airway protection is successful, resuscitation is continued at a 10-to-1 ratio with chest compressions uninterrupted by ventilation.

16:59 After 2 minutes, the next rhythm analysis takes place.

17:03 Since a shockable rhythm is still shown, it is delivered again.

17:12 After delivery of the shock, chest compressions are continued by another team member. Meanwhile, intravenous access is established and an IV is connected.

17:27 After a further 2 minutes and continued ventricular fibrillation, the patient is shocked a third time.

17:34 After the third unsuccessful shock, the patient receives the drugs epinephrine and amiodarone intravenously.

17:42 As the process continues, the team begins to search for potentially irreversible causes of circulatory arrest.

17:49 It makes use of the four H's and HITS for this purpose.

17:56 Let's look at a similar process again, but taking place in the clinical setting.

18:00 The patient call button is triggered.

18:04 Alerted by the patient alarm, the first attending arrives and determines that the patient is not conscious.

18:11 He extends the head and checks for breathing for a maximum of 10 seconds.

18:16 He determines that breathing is not preserved and calls in direct assistance.

18:28 More help arrives.

18:35 For the compression to be effective, the patient should lie on a hard surface.

18:52 The defibrillation pads should be placed below the clavicle on the right parasternum, and on the left axilla at the level of the fifth intercostal space.

19:06 Once the defibrillator is connected, chest compressions are briefly interrupted to perform the rhythm analysis.

19:13 When a shockable rhythm is evident, the shock is triggered . Then chest compression is continued immediately.

19:23 Interruptions should be avoided and possible breaks should be planned well in advance.

19:33 The rescuers now continue to resuscitate the patient at a ratio of 30 chest compressions to two ventilations.

19:45 After two minutes, the next rhythm analysis is performed.

19:49 Again as a shockable rhythm is seen, the defibrillator is charged.

19:53 While it is charging, chest compressions continue and are only interrupted for shock delivery. If one team member is exhausted, another should continue chest compressions.

20:07 Airway protection is now performed.

20:11 While the patient continues to be resuscitated, a team member inserts the laryngeal tube.

20:22 If this is successful, resuscitation is continued at a ratio of 10 to 1.

20:27 Cardiac compression is now no longer interrupted for ventilation.

20:32 The capnography is monitored constantly.

20:45 This patient already has intravenous access.

20:48 The team can prepare the resuscitation, drugs, epinephrine and amiodarone.

20:54 They are usually administered after the third unsuccessful shock.

21:03 Two minutes later, the team again analyzes the rhythm.

21:07 And if this one is shockable, the third shock is delivered.

21:19 After the shock, another attending continues chest compressions while medications are delivered.

21:44 This is followed by an examination for potentially reversible causes.

21:49 Now the four H and HITS schemes are used again.

21:52 If rhythm analysis reveals images that may indicate an existing pulse, palpate centrally in the carotid artery area for the pulse.

22:02 If it can be felt, chest compressions are not continued, and the post-resuscitation phase follows.

22:15 To recap, in adulthood, cardiac arrhythmias are among the leading causes of cardiovascular arrest.

22:23 To ensure that spontaneous circulation returns quickly, it is important to perform high-quality chest compressions as early as possible.

22:31 This should be interrupted as little as possible.

22:33 You should also wait to use defibrillation and rhythm analysis.

22:38 The airway is secured and chest compressions are not interrupted for ventilation after intubation.

22:44 The main drugs used in resuscitation are epinephrine, amiodarone and lidocaine. Irreversible causes of circulatory arrest are actively checked and corrected if necessary.