MASURI DE PRIM AJUTOR

CURS 1/2010

Sef lucrari dr.Ioana GhitescuUMF Tg.Mures, Disciplina A.T.I.

S.C.J.U. Mures, Clinica A.T.I.

PLAN Definitie, Obiective, Principii EVIDENCE BASED MEDICINE-medicina

bazata pe dovezi Aspecte etico-medico-legale si

epidemiologice ale CPR si primului ajutor Notiuni elementare de anatomie si

fiziologie CPR: definitie Lantul supravietuirii BLS la adult

INTRODUCERE Proceduri de ingrijire medicala simple, de

urgenta aplicabile de catre neprofesionisti pana la sosirea personalului medical de specialitate.

Se face referinta atat la “laici”, cat si la personalul de pe ambulante sau alti “first responders”.

NU INLOCUIESTE UN TRATAMENT MEDICAL COMPETENT

PRIM AJUTOR Masuri de ingrijire si tratament de urgenta

aplicate unui bolnav sau unei persoane traumatizate INAINTEA sosirii/defeririii catre servicii medicale.

MASURILE DE PRIM AJUTOR NU SUNT APLICATE CU SCOPUL DE A INLOCUI DIAGNOSTICAREA SI TERAPIA CORECTA MEDICALA

ofera asistenta temporara pana la sosirea personalului medical calificat

PRIM AJUTORScop: Salvarea vietii Prevenirea producerii in continuare a leziunilor Reducerea la minimum/prevenirea infectiilor Cei trei “P” P - Preserve Life.

P - Prevent the condition worsening.

P - Promote RecoveryFace diferenta dintre: Leziune temporara/permanenta Vindecare rapida/ infirmitate permanenta Viata/moarte

Medicina bazata pe dovezi (EBM) EBM are ca scop utilizarea celor mai bune dovezi

disponibile provenite din metode stiintifice pentru a conduce la decizii medicale

urmareste sa stabileasca calitatea dovezilor ce stabilesc riscurile si beneficiile tratamentelor (inclusiv absenta acestora).

EBM recunoaste ca multe aspecte ale medicinii depind de factori individuali cum ar fi calitatea si “rationament al valorii vietii” ce sunt doar partial supuse cercetarilor stiintifice.

sa aplice aceste metode in practica medicala cu scopul de a asigura cea mai buna predictie asupra prognosticului ad vitam, chiar daca persista inca controversele legate de tipul prognosticului de urmarit.

Masuratori statistice “Evidence-based medicine” incearca sa

exprime beneficiile clinice ale testelor si tratamentelor utilizand metode statistice

EBM- stadializarea nivelurilor de evidenta Evidence-based medicine categorizes different

types of clinical evidence and ranks them according to the strength of their freedom from the various biases that beset medical research.

The strongest evidence for therapeutic interventions is provided by systematic review of randomized, double-blind, placebo-controlled trials involving a homogeneous patient population and medical condition.

Little value as proof: patient testimonials, case reports, and even expert opinion – the placebo effect, the biases inherent in observation and reporting of

cases, difficulties in ascertaining who is an expert, etc.

Nivel de evidentaSystems to stratify evidence by quality have been developed,

such as this one by the U.S. Preventive Services Task Force for ranking evidence about the effectiveness of treatments or screening:

Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Level II-1: Evidence obtained from well-designed controlled trials without randomization.

Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.

Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Categorii de recomandariIn guidelines and other publications, recommendation for a clinical service is

classified by the balance of risk versus benefit of the service and the level of evidence on which this information is based. The U.S. Preventive Services Task Force uses:

Level A: Good scientific evidence suggests that the benefits of the clinical service substantially outweighs the potential risks. Clinicians should discuss the service with eligible patients.

Level B: At least fair scientific evidence suggests that the benefits of the clinical service outweighs the potential risks. Clinicians should discuss the service with eligible patients.

Level C: At least fair scientific evidence suggests that there are benefits provided by the clinical service, but the balance between benefits and risks are too close for making general recommendations. Clinicians need not offer it unless there are individual considerations.

Level D: At least fair scientific evidence suggests that the risks of the clinical service outweighs potential benefits. Clinicians should not routinely offer the service to asymptomatic patients.

Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service.

Ghiduri Un ghid medical (denumit si ghid clinic,

protocol clinic, ghid de practica medicala) este un document destinat orientarii deciziilor si criteriilor de:

diagnostic conduita tratament intr-un domeniu specific

medical

De ce ghiduri?

PRIM AJUTOR- Obiective

A. – Airway: Mentinerea permeabilitatii cailor aeriene

B. – Breathing: Mentinerea respiratiilor C. – Circulation: Mentinerea circulatiei

+ Oprirea hemoragiilor Prevenirea/ reducerea socului

PRIM AJUTOREvaluare initiala Inspectia rapida a zonei

Pericole (curent electric, foc, apa, “haz mats”, obiecte instabile, ascutite, animale)

Trafic Violenta Conditii de relief si clima Situatii speciale

Preluarea controlului calm, rapid si eficient

PRIM AJUTORSe vor evalua:1. SIGURANTA proprie si a pacientului2. MECANISMUL DE PRODUCERE A LEZIUNII Constient Inconstient3. INFORMATII TRANSMISE PE CAI SPECIALE- Medalion, bratara cu simboluri - card cu informatii

PRIM AJUTOR4. NUMARUL VICTIMELOR Cand sunt mai multe- evaluarea

A,B,sangerare si C5. MARTORI Pot furniza informatii, ajutor chiar daca

sunt nepregatiti prin: apel de urgenta, suport moral victimei, impiedicarea imixtiunii altor persoane

6. PREZENTATI-VA ca persoane calificate in prim ajutor; consimtamant cerut celor constienti, prezumat pentru cei inconstienti

Aspecte etico-legale Datoria de a interveni(desemnata, serviciu sau

responsabilitate preexistaenta fata de victima) Standard: cat si pentru ce aveti calificare Consimtamant= acord, permisiune

Pacient constient/inconstient Minor/major Bolnavi cu afectiuni psihiatrice Exprimat/prezumat

Confidentialitatea Legea Bunului Samaritean (urgenta, cu bune intentii, fara

compensatii, fara a produce daune/leziuni) Abandon Neglijenta (datorie, nerespectarea datoriei sau

substandard, producere de leziun/daune, nerespectarea limitelor)

Aspecte etico-legaleSecventa”logica”: Obtineti consimtamantul victimei INAINTE de A O

ATINGE Urmati ghidurile si protocoalele pentru care ati

fost instruiti, fara a va depasi nivelul de competenta

Explicati victimei fiecare lucru pe care urmeaza sa-l faceti

Odata ce ati demarat asistarea victimei, nu o parasiti pana nu o deferiti unei persoane cel putin la fel de calificata ca dumneavoastra!

Aspecte etice OUT OF HOSPITAL SETTINGS

To initiate resuscitation Not to initiate resuscitation To terminate resuscitation

IN HOSPITAL RESUSCITATION To initiate resuscitation Not to initiate resuscitation To terminate resuscitation To withdraw life support

PRIM AJUTOR-REGULI DE BAZA1. Mentineti pacientul in decubit dorsal, capul la

acelasi nivel cu corpul, pana la evaluarea gravitatii situatiei.

Identificati exceptiile la aceasta regula: Varsaturi sau hemoragii in zona cavitatii bucale-

pozitie laterala de siguranta ! la leziunile suspectate de coloana cervico-dorsala (2% explozii, 6% traumatism facial sau GCS<8)

Dispnee- pozitie sezanda sau semi Socul- membrele superioare ridicate (!?) doar

daca nu se suspecteaza leziuni de coloana2. Nu mobilizati pacientul mai mult decat necesar.

Indepartati hainele cu efect restrictiv, asigurati comfortul termic

PRIM AJUTOR-REGULI DE BAZA3. Asigurati confort psihic pacientului4. Nu atingeti rani, arsuri decat daca e absolut

necesar. Folositi obiecte sterile. Folositi bariere. Spalati maini!

5. Nu oferiti apa sau alimente din primul moment6. Imobilizati orice zona suspectata a fi fracturata.

Nu incercati sa reduceti fractura. Nu mobilizati decat daca e strict necesar

7. Mentineti temperatura normala a corpului

PRIM AJUTOR-aspecte epidemiologiceTransmitere de boli infectioase HIV Virusul hepatitei B, C TuberculozaMasuri de protectie universala- orice pacient trebuie

considerat potential purtator de agenti cu transmitere sanguina

Purtati manusi sau folositi alta bariera Spalati-va mainile cu apa calda si sapun:

La venire/plecare Inainte/dupa examinare, procedura Dupa scoaterea manusii, mastii Dupa folosirea batistei, toaletei, trecere prin par, activitati

administrative/gospodaresti Bariera pentru respiratii artificiale, protectie oculara

NOTIUNI ELEMENTARE DE ANATOMIE SI FIZIOLOGIE

Notiuni elementare

OXIGEN PLAMANI SANGE

CELULEGLUCIDE

LIPIDE

PROTEINE

Ce se intampla daca… Se opreste respiratia…. Se opresc bataile cardiace?

Sudden Cardiac Arrest

• 300,000 victims of out-of-hospital cardiac arrest each year in the U.S.• Less than 8% of people who suffer cardiac arrest outside the hospital survive.• Sudden cardiac arrest can happen to anyone at any time. Many victims appear healthy with no known heart disease or other risk factors.• Sudden cardiac arrest ≠a heart attack.

Sudden cardiac arrest: electrical impulses in the heart become rapid or chaotic, which causes the heart to suddenly stop beating.

A heart attack: when the blood supply to part of the heart muscle is blocked. A heart attack may cause cardiac arrest

SUDDEN CARDIAC ARREST

Approximativ 700,000 stopuri cardiace pe an in Europa

Supravietuirea la externare de aprox 5-10%

CPR efectuat de martori: interventie vitala inaintea sosirii echipajelor de urgenta – dubleaza sau tripleaza supravietuirea dupa SCR

Resuscitarea precoce si defibrilarea prompta (in decurs de 1-2 minute) poate duce la supravietuiri de >60%.

CPR: Ghiduri The International Liaison Committee on

Resuscitation (ILCOR) American Heart Association (AHA) International Guidelines 2000 for

Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (2005 Consensus Conference).

CPR Cardiopulmonary resuscitation (CPR) is an emergency

medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest. CPR is performed in hospitals, or in the community by laypersons or by emergency response professionals.

CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the blood, called artificial respiration,

CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage

Istoric 1740   The Paris Academy of Sciences officially recommended mouth-to-mouth

resuscitation for drowning victims. 1767   The Society for the Recovery of Drowned Persons became the first organized effort to deal with sudden and unexpected death. 1891   Dr. Friedrich Maass performed the first equivocally documented chest compression in humans. 1903   Dr. George Crile reported the first successful use of external chest compressions in human resuscitation. 1904   The first American case of closed-chest cardiac massage was performed by Dr. George Crile. 1954   James Elam was the first to prove that expired air was sufficient to maintain adequate oxygenation. 1956   Peter Safar and James Elam invented mouth-to-mouth resuscitation. 1957   The United States military adopted the mouth-to-mouth resuscitation method  to revive unresponsive victims. 1960   Cardiopulmonary resuscitation (CPR) was developed. The American Heart Association started a program to acquaint physicians with close-chest cardiac resuscitation and became the forerunner of CPR training for the general public. 1963   Cardiologist Leonard Scherlis started the American Heart Association's CPR Committee, and the same year, the American Heart Association formally endorsed CPR. 1966   The National Research Council of the National Academy of Sciences convened an ad hoc conference on cardiopulmonary resuscitation.  The conference was the direct result of requests from the American National Red Cross and other agencies to establish standardized training and performance standards for CPR. 1972   Leonard Cobb held the world's first mass citizen training in CPR in Seattle, Washington called Medic 2.  He helped train over 100,000 people the first two years of the programs. 1981   A program to provide telephone instructions in CPR began in King County, Washington.  The program used emergency dispatchers to give instant directions while the fire department and EMT personnel were en route to the scene.  Dispatcher-assisted CPR  is now standard care for dispatcher centers throughout the United States.

SCA 40% din victimele SCA: FV Deteriorare in asistolie-

sanse reduse de resuscitare

Tratament optim pentru SCR cu FV este: CPR de catre martori+

defibrilare

Tratamentul optim pentru SCR cauzat de asfixie (inec, trauma, droguri, copii): rescue breaths vitale

Lantul supravietuirii

CHAIN OF SURVIVAL

LANTUL SUPRAVIETUIRII Recunoastera precoce si activarea

sistemului de urgenta: poate preveni SCR Early CPR:dubleaza/tripleaza

supravietuirea din fv Fiecare minut fara CPR scade supravietuirea cu

7-10% Defibrilarea precoce:CPR + defib in 3-5

min: supravietuire de 49-75% Fiecare minut intarziere- reduce sansele de

externare cu 10-15%

BASIC LIFE SUPPORT secventa de proceduri efectuate pentru a

restabili circulatia sangelui oxigenat dupa un SC/R

Compresii sternale si ventilatie pulmonara efectuate de oricine care stie cum sa o faca, oriunde, imediat, fara alt echipament.

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

APPROACH SAFELY!

Scene

Rescuer

Victim

Bystanders

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

Factori de risc legati de scena actiunii Mediu

Trafic cladiri Electricitate Apa, foc Toxice

Victima Boli infectioase Intoxicatii

Tehnici Defibrilatoare Instrumente taioase sau ascutite

Training- manechin

Risk factors Infection tramsmissions Accidents with needles Rescuers having wound on their mouth, hands Case reports of tuberculosis, SARS, but no case

report of HIV transmission Mannequins: of the estimated 40 mil. in the USA

and perhaps 150 mil worldwide that have been taught mouth to mouth rescue breathing on mannequins in the last 25 years, there has never been a documented case of transmission of bacterial, fungal or viral disease by a CPR training mannequin

CHECK RESPONSE

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

Shake shoulders gently

Ask “Are you all right?”

If he responds

• Leave as you find him.

• Find out what is wrong.

• Reassess regularly.

CHECK RESPONSE

SHOUT FOR HELP

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

OPEN AIRWAY

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

OPEN AIRWAY

Head tilt and chin lift- lay rescuers- non-healthcare rescuers

No need for finger sweep unless solid material can be

seen in the airway

OPEN AIRWAY

Head tilt, chin lift + jaw thrust- healthcare professionals

AIRWAY OPENING BY NECK EXTENSION

Cam

pbel

l

CHECK BREATHING

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

CHECK BREATHING

Look, listen and feel for NORMAL breathing

Do not confuse agonal breathing with NORMAL breathing

Respiratii agonice

Apar la scurt timp dupa oprirea cordului in aproximativ 40% din stopurile cardiace

Descrise ca respiratii “grele”, dificile. Zgomotoase, “gasping”

Recunoscute ca semn de stop cardiacErroneous information can result in withholding CPR from cardiac arrest victim

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

Obstructia cailor aeriene cu corp starin (FBAO)

Approximativ 16 000 adulti si copii sunt tratati annual in UK pentru obstruictie de cai aeriene cu corpi straini

SEMNE OBSTRUCIE MODERATA

OBSTRUCIE SEVERA

“Te ineci?” “Da” Incapabil sa vorbeasca, poate incuviinta

Alte semne Poate tusi, respira, vorbeste

Nu poate respira/ respiratie cu Wheezing/silentiu/incearca sa tuseasca/ inconstienta

ADULT FBAO TREATMENT

ABDOMINAL THRUSTS

30 CHEST COMPRESSIONS

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

Place the heel of one hand in the centre of the chest

Place other hand on top Interlock fingers Compress the chest

Rate 100 min-1

Depth 4-5 cm Equal compression : relaxation

When possible change CPR operator every 2 min

CHEST COMPRESSIONS

• The most effective rate for chest compressions is 100 compressions per minute – the same rhythm as the beat of the BeeGee’s song, “Stayin’ Alive.”

http://www.dailymotion.com/video/x1afd7_bee-gees-staying-alive_music

RESCUE BREATHS

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

RESCUE BREATHS

Pinch the nose Take a normal breath Place lips over mouth Blow until the chest

rises Take about 1 second Allow chest to fall Repeat

RESCUE BREATHS

RECOMMENDATIONS:- Tidal volume 500 – 600 ml

- Respiratory rate give each breaths over about 1s with enough volume to make the victim’s chest rise

- Chest-compression-only

continuously at a rate of 100 min

CONTINUE CPR

30 2

Video Demonstration of CPR for Adults.flv

Hands-only CPR

DEFIBRILLATION

Call 112

Approach safely

Check response

Shout for help

Open airway

Check breathing

Attach AED

Follow voice prompts

AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

Some AEDs will automatically switch themselves on when the lid is opened

ATTACH PADS TO CASUALTY’S BARE CHEST

ANALYSING RHYTHM DO NOT TOUCH VICTIM

SHOCK INDICATED

Stand clear Deliver shock

SHOCK DELIVEREDFOLLOW AED INSTRUCTIONS

30 2

NO SHOCK ADVISEDFOLLOW AED INSTRUCTIONS

30 2

http://www.youtube.com/watch?v=O9T25SMyz3A

IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN RECOVERY POSITION

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths

Approach safely

Check response

Shout for help

Open airway

Check breathing

Call 112

Attach AED

Follow voice prompts

CONTINUE RESUSCITATION UNTIL

Qualified help arrives and takes over

The victim starts breathing normally

Rescuer becomes exhausted