CPCR

Cardiopulmonary
cerebral resuscitation
(CPCR)
• Cardiopulmonary resuscitation (CPR)is
required when the supply of oxygen to the
brain is in-sufficient to maintain function.
Oxygen delivery is dependent upon cardiac
output, haemoglobin with oxygen, which
depends predominantly on respiratory
function.
• CPR is required most commonly after
cardiac arrest, respiratory arrest or a
combination of the two.
 Cerebral hypoxia
• The brain is more sensitive to hypoxia than any other
organ, including the heart. It has a limited facility for
anaerobic metabolism and cannot store oxygen.
Hypoxaemia is tolerated remarkably well in the normal
individual, as cerebral blood flow (CBF) increases
substantially to compensate for reduced oxygen carriage in
blood.In contrast, ischaemia (e.g. circulatory arrest )or
hypoxaemia in a patient unable to increase CBF (e.g.
cerebrovascular atherosclerosis or a low cardiac output
state )results in the rapid onset of anaerobic metabolism
 The cerebral cortex is damaged permanently by
ischaemia of more than 3-4min duration. Thus
,although a patient may survive an episode of
circulatory arrest, permanent impairment of
cerebral function may result if cerebral oxygen
delivery is not restored within 3-4 min of the
initial cessation of blood flow. The commonest
cause of brain damage after cardiac arrest is delay
in starting resuscitation. Therefore,when
circulatory arrest has occurred, it is essential to
start CPR as rapidly as possible.
SIGNS OF CARDIAC ARREST

These are shown in Figure 43.1.During

surgery it may be difficult to distinguish
between profound hypotension and
circulatory arrest. If neither surgeon nor
anesthetist can find a pulse, external cardiac
massage must be instituted.
• .
 Guidelines to guide the performance of cardio-
pulmonary resuscitation have been developed by
the European Resuscitation Council (1992)and the
American Heart Association (1986).These
guidelines are based on the concept of the ‘chain
of survival ’.The chain of survival requires that
following an initial clinical assessment of the
patient’s condition ,a telephone call for help is
made before starting basic life support.
 This early call for help decreases the
time to the first defibrillation, shortens the
time to the delivery of advanced life
support, decreases the length of time of
performance of basic life support and
improves survival form the initial
resuscitation event.
 ASSESSMENT

Approach the patient ensuring that there

is no further danger form the surrounding
environment.Assess the level of
responsiveness by gently shaking the
patient and shouting ‘Are you all right?’.
 Airway

In the unresponsive patient ,open the

airway by tilting the head back and lifting
the jaw forwards (Fig.43.2).
 Breathing

• Look--to see if the chest wall is moving or if the

abdominal wall is indicating an obstructed airway
by a see--saw movement.
• Listen--over the mouth for sounds of air move--
ment or for sounds indicating an obstructed
airway.
• Feel--over the mouth with the side of the face for
sign of air movement indicating effective
breathing.
 Circulation

Check the rate and rhythm of the carotid

pulse.
 Call for help

It is essential to telephone for help as

soon as the assessment has been completed.
 BASIC LIFE SUPPORT

• Air way
• Breathing
• Circulation
 Cardiac arrest

If breathing and pulse are absent

commence basic life support, which is a
combination of chest compressions and
ventilation.
 Chest compressions
Chest compressions are performed on the lower
third of the sternum ,two fingers breadth above the
xiphisternum. The overlapping heels of both hands
are used to compress the chest by depressing the
sternum approximately 4-5 cm at a rate of 80
compressions per minute (range 60-
100compressions per minute). After 15
compressions open the airway by tilting the head
and lifting the chin and give two expired air
breaths.
 Breathing
This is achieved by expired air ventilation.
With the airway held open ,pinch the nostrils
closed .Take a full breath and seal your lips over
the patient’s mouth .Blow steadily into the
patient’s mouth, watching the chest rise as if the
patient was taking a deep breath. Each breath
should take approximately 2 s for a full inflation.
Maintaining the airway, take your mouth off the
patient and allow the chest to fall in expiration
.Repeat this manoeuvre to give two ventilations.
 Continue basic life support ,15 chest
compressions with two expired air
ventilations, until advanced life support
arrives. Do not interrupt basic life support
to perform further assessments of the
patient unless the patient shows signs of
recovery.
 Respiratory arrest
• If the patient is not breathing but has a
pulse, perform 10 expired air breaths before
leaving the patient to telephone for help. On
returning to the patient recheck the
breathing and the pulse. If a pulse is present
continue expired air breathing at a rate of
10 breaths per minute but recheck the pulse
after every 10 breaths .Commence full basic
life support if the pulse stops.
ADVANCED LIFE SUPPORT
 By following the chain of survival, the
early telephone call for help will result in
the prompt arrival of the equipment and
personnel needed to perform advanced use
of a defibrillator in ventricular fibrillation
has a definitive effect on eventual survival.
• There are four underlying disorders of
cardiac rhythm associated with cardiac
arrest:
• 1.Ventricular fibrillation
• 2.Ventricular tachycardia
• 3.Asystole
• 4.Electromechanical dissociation (pulseless
electrical activity).
 ALKALINIZING AGENTS

In prolonged resuscitation the patient

may become increasingly acidotic. This is
especially so when initial basic life support
has been delayed ,ventilation had not been
performed effectively (respiratory acidosis)
or chest compressions have not been
successful in achieving a satisfactory flow
of blood (metabolic acidosis).
 AFTERCARE

For every ten in-hospital resuscitation

events, three patients survive the initial
resuscitation procedures, two survive the
next 24 h, 1.5 survive to discharge from
hospital and one patient lives for 1 year
after the initial event.
 Cardiovascular system

• Cardiac output may remain unsatisfactory

as a result of cardiogenic shock and may be
so poor that unconsciousness persists. A
low cardiac output may result from:
• 1.Poor myocardial contractility
• 2.Hypovolaemia
• 3.Arrhythmias
 Respiratory system
• Lung dysfunction is produced during resuscitation for
reasons which may include inhalation of vomit ,lung
contusion, fractured ribs and pneumothorax. Pulmonary
oedema may occur in the presence of heart failure and after
head injury, drowning or smoke inhalation. Oxygen therapy
for 24 h should follow any episode of circulatory arrest. If
overt respiratory failure supervenes, more intensive
treatment is required ,including possibly a period of
artificial ventilation. All patients should have a chest X-ray
and blood gas analysis after resuscitation.
 Central nervous system

• Patients may fail to recover consciousness

for the following reasons:
• Low cardiac output
• Brain damage, which may be present if
resuscitation was delayed or if the
circulatory arrest was precipitated by
hypoxaemia.
 MANAGEMENT OF BRAIN
DAMAGE

The aim of treatment is to provide

optimal conditions for recovery of cerebral
cells and prevention of secondary neuronal
damage.
 General measures

Airway obstruction occurs readily in the

unconscious patient and leads to hypoxaemia and
hypercapnia ,which aggravate cerebral damage. In
addition, cough and swallowing reflexes are
depressed. Continued tracheal intubation protects
the lungs ,secures the airway and renders it easy to
institute mechanical ventilation if respiration
becomes inadequate.
 Specialized treatment

PREVENTION OF CARDIAC ARREST

Good recovery has taken place after 1-2 h
of continuous CPR.
Thank you !

Good bye !