CARDIOPULMONARY RESUSCITATION (CPR)

 CARDIOPULMONARY RESUSCITATION (CPR)

OUTSIDE HOSPITAL CPR

PRE- CPR PROCEDURE:

1. First, check the scene for factors that could put you in danger, such as traffic, fire, or falling masonry.

2. Next, check the person. Tap their shoulder and shout, "Are you OK?”. If they are not responding, call for help and call 108. If available, ask a near-by person to bring AED machine.

3. 
   

Remove any obstruction (food or vomitus) seen, only if it is loose. 

(If it is not loose, trying to grasp it may push it farther into the airway.)

• Check for breathing and feel for pulse (Brachial artery in infant, Carotid or femoral in a child and Carotid in adults) within 10 seconds:

  
  

  

  
  

1. No breathing, or occasional gasps + No pulse           Begin CPR

2. No breathing or occasional gasps + Pulse felt         Give 10-12 breaths/ minute

3. Unconscious but still breathing, do not perform CPR. Instead, place them in:

Keep monitoring the patient. Start CPR if the person stops breathing.

CPR

4. Perform chest compressions at the rate of 100-120/ min:

5. Open airway using triple maneuver: 

6. Give rescue breaths:

Pinch the nose while giving a breath mouth-to-mouth and look for chest rise.

If their chest does not rise with the first breath, tilt their head.

If their chest still does not rise with a second breath, the person might be choking. 

7. Try to synchronize the breaths with any voluntary breathing activity of the patient that might be present.

8. Repeat the cycle of 30 chest compressions and two rescue breaths until the person starts breathing or help arrives. If an AED arrives, carry on performing CPR until the machine is set up and ready to use. 

FOR CHILDREN (STEPS AS ABOVE WITH FOLLOWING MODIFICATIONS)

For children, give compressions using one hand only, between the nipples and press down around 2 inches.

For infants, give compressions using both the thumbs or index and middle fingers and press down approximately 1.5 inches.

If two rescuers present, try give 15 compressions followed by 2 rescue breaths and so on.

INSIDE HOSPITAL CPR

1. Recognize cardiac arrest and activate emergency team.

2. Start CPR as above (except that now, the person administering CPR should stand by the side of patient). 

3. Instead of using mouth-to-mouth for rescue breaths (may not feasible in case of infectious diseases), bag and mask ventilation is done and the patient is ventilated with a compression to ventilation ratio of 30:2

For Bag and mask ventilation, tilt the head of patient backwards.

Then, form a tight seal with the mask around the nose and mouth of patient forming letters E by fingers and thumb of one hand and C by the other.

Squeeze the AMBU bag and look for chest rise.

4. Airway may be secured by following methods while making sure that this process doesn’t compromise on the chest compressions.

• Combitube

• Laryngeal Mask Airway

• Endo-tracheal intubation (See document titled ‘ENDOTRACHEAL INTUBATION’)

Once advanced airway is secured give 1 breath every 6 seconds.

ADULT ALGORITH FOR MANAGEMENT OF CARDIAC ARREST

In brief:

• Shockable rhythm - ALWAYS Shock 

• Non- shockable rhythm – CPR with epinephrine (keeping approximately 4-minute interval between 2 epinephrine injections)

• Shock 🡪 CPR gain i.v. access + Inject Epinephrine 🡪Shock 🡪 CPR + Inject Amiodarone 🡪 Shock 🡪 CPR + Epinephrine 🡪 and so on...

• Time between 2 assessments/ 2 shocks/ time for which CPR is performed while injecting drugs = 2 mins

DEFIBRILLATION

For pediatric patients:

1st shock: 2-4 J/kg 

Subsequent 4J/kg (but not more than 10 J)

For adults:

Biphasic defibrillators: 100-120 J 

Monophasic defibrillators: 360 J

Placement of leads:

EPINEPHRINE:

1 mg 1:10000 i.v./ i.o. every 3-5 mins 

AMIODARONE:

1st Dose: 300 mg bolus dilute in 20-30 ml

2nd Dose: 150 mg bolus

VIDEO LINK:

ADVANCED CARDIAC LIFE SUPPORT (ACLS) ADULTS:

(2) ACLS Megacode - YouTube

Written by our guest authors - Hemant Kadam, Jignesh Bhadarka, Anveshi Nayan 

Illustrations by Anveshi Nayan and Devi Bavishi

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Diffusion-Weighted Image (DWI) and Fluid-Attenuated Inversion Recovery Image (FLAIR) Mismatch on MRI can be used as a surrogate for the time of stroke onset for unclear-onset strokes or "wake up" (nocturnal) strokes.

Why?

Cystinuria VS Cystinosis - know the difference!

 Hi!

Cystinuria is an AR disorder that is characterized by defective absorption of cysteine and other di-basic amino acids from PCT and intestinal lumen.

Cystinosis, on the other hand, is a lysosomal storage disease characterized by accumulation of amino acid cystine.

Note :

Cysteine + Cysteine = Cystine.

Fact :

Cystinosis is one of the most common cause of Fanconi's syndrome in pediatric age group.

Also, check hexagonal crystals seen in

That's all

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All frequently asked questions are highlighted with (FAQ)
How to approach each question is explained below it
Disclaimer: All these questions are compiled from different sources and personal experiences.

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Hello Awesomites! 

1.Genomic imprinting IOC = methylation specific MLPA 

2.Trinucleotide repeat disorder = IOC is Trinucleotide primed PCR 

3.Fragile X Syndrome is XLR (mendelian inheritance) but once inherited during gametogenesis what happens is non - mendelian inheritance.

Confusing but thats the beauty. 

Can you tell me about Huntington disease what does mendelian and non mendelian inheritance mean? 

4.Angelman  that undergo whatever you learn (like maternal deletion and unipaternal disomy) involve chromosome 15 but gene is UBE3 ubiquitin protein. 

And praderwilli whatever you learn happens at chromosome 15 but gene is Sn RPN (small nuclear ribonucleoprotein polypeptide N)

 Hope it broadens your horizon.

-Dr.Upasana Y. 

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 NEXUS criteria for Cervical Spine imaging 

Any 1 of the following is an indication : 

Mnemonic =  “NSAID”

Riley- Day Syndrome mnemonic

 

Shy-Drager syndrome mnemonic

 

Weber & Rinne test mnemonic / trick

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Ear Syringing

EAR IRRIGATION (SYRINGING)

REQUIREMENTS:   Water (temperature being as close to body temperature as possible), kidney tray, Simpson’s aural syringe/ 50 ml syringe attached to 16-18 gauze needle or pulsating water device, towel (if available)

PROCEDURE: 

• Examine the ear. 

(Do not irrigate if there is: severe pain, recent trauma or surgery or a dry perforation of tympanic membrane, inability of patient to sit upright, organic foreign body in the ear, opening into mastoid, severe otitis externa, history of middle ear disease, ear surgery, inner ear problems [vertigo] or radiation in the area) 

• Ask patient to sit upright. 

• Hold the pinna backwards and upwards in adults and backwards in children to straighten the ear canal.

• Keep a towel on the shoulder. 

• Use a kidney dish to catch solution.

• While irrigating direct the syringe towards the ear canal, postero-superiorly.  

  
  
  
  

• Apply firm and constant pressure to the syringe.

• Dry mop the ear and check it again to see if everything is out.  

  

Written by our guest author - Abhineet Desai

Illustration by Devi Bavishi

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Contraception

 CONTRACEPTION 

Cu-T INSERTION 

REQUIREMENTS:  

Written Informed consent, IUD, Povidone Iodine, Spirit and drapes, Sims’s speculum, Allis forceps, Uterine Sound 

 

PROCEDURE: 

• Begin with the history and clinical examination to rule out contraindications. 

• Before inserting the IUD, always do UPT to rule out pregnancy. 

• The patient is taken up in the OT (but can be done in OPD or labour ward immediately post-partum). An anaesthetist should be present if in case perforation occurs. 

• POSITION: Standard lithotomy position with legs in stirrups. 

• Scrubbing, painting, and draping should be done. 

• Bimanual examination to check for uterine size, position, version, and adnexal pathology. 

• Depress posterior vaginal wall with Sim’s speculum and hold the anterior lip of cervix using Allis forceps. 

• Using uterine sound, measure utero-cervix length and the accordingly adjust the bobbin. 

• The technique used is “No Touch/ Withdrawal technique”. 

• CuT is self-loaded. Remove the whole thing without touching CuT. 

• Plunger should not touch the vaginal wall. Reach upto the uterine fundus. Pull the ring behind on the plunger. CuT is unfolded. 

• Slowly remove the loader so as not to disturb the CuT. 

• Cut the tail (2.5-3 cm). The patient should be made to feel the tail. 

• Observe for about half an hour for uterine cramps (since foreign body inserted so uterus tries to expel it)  

Managed by giving Drotaverine/Dicyclomine. 

 

• Record the date of insertion. Document it on CuT card and mention the date of expiry. Give it to the patient. 

• Counsel the patient regarding all the possible complications and also regarding the follow-ups. 

 

ANTARA 

Injectable Contraceptive DMPA (Under ANTARA programme) given as i.m. injection on outer upper quadrant of buttock. 

Dose: 150 mg every 3 months  

Written by our guest author - Ayushi Gupta

Illustration by Devi Bavishi

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Central Venous Catheterisation

CENTRAL VENOUS CATHETERISATION

 

Internal jugular vein approach (Seldinger's technique)

Position of patient 

Patient should be in head low position with head turned to face the left.

Procedure 

1. Skin is cleaned with antiseptic. Neck can be extended by keeping a rolled towel or normal saline bag under shoulder.

2. Local anaesthesia may be infiltered but that causes a wheal production which may hide the puncture site.

3. Right internal carotid artery is palpated lateral to cricoid cartilage. 

4. Triangle formed by two heads of sternocleidomastoid muscle and clavicle is located.  

5. The heparinised needle with the syringe attached is inserted starting at the apex of the triangle keeping fingers gently over the internal carotid artery just lateral the pulsations at an angle 30 to 40 degree to the skin and advancing it downward in the direction of nipple on same side. 

Another way to gain access to IJV is to go behind the posterior head of sternocleidomastoid. 

6. Blood is aspirated to confirm that needle is in the lumen of vein.

7. The guide wire is threaded through needle into vein with J shaped end first.

8. Needle is then removed.

9. Dilator is passed over guide wire in the twisting motion to dilate the site of skin puncture. A small incision in the skin may be necessary to introduce the dilator.
   
   
   

10. Dilator is removed and catheter is passed over guide wire.  

11. Guide wire is removed. 

    

12. After confirming blood can be aspirated freely the catheter is flushed properly with heparinised saline.

    

13. The catheter is secured in place with suture and sterile dressing is given. 

 

    •     Post procedure X ray Chest is taken for confirming the position of the central line 

For accurate CVP measurement, the tip of the central venous catheter (CVC) should lie within the superior vein cava (SVC), above its junction with the right atrium and parallel to the vessel walls.

Other Sites  

1. Subclavian Vein 

2. Antecubital Vein 

3. Femoral Vein 

Written by our guest author - Akash Davhale

Illustrations by Devi Bavishi

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