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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