CRITICAL CARE,

RESUSCITATION
& VITAL SIGNS
• VITAL SIGNS ?
 Cardio Pulmonary Resuscitation
( CPR)
Definition
Resuscitation – Latin word ‘resuscitatus’
…… to stir up again or to put in motion or to bring
back to anew….
CPR applies to that action taken to save the life of a patient
whose heart has suddenly ceased to beat.
Turk.L.H., Glen WWL
(NEJM, 251: 795-803,(1954))
 MAN’S WORK-
Story of management of sudden death
 Prophet Elysha – revived a child (The BIBLE)
 Early ages
 Respiration and circulation
1012 (IBN SENA) described disease processes.
 1288 (IBN an NAFIS) described the circulation of blood through the body.
 1530 (PARACELSUS) bellows respiration
 1543 (VESALIUS) - artificial ventilation
 1628 (WILLIAM HARVEY) – closed circulation
 1661 ( MALPHIGI) - microscopic structure
 1530-1900
 1890 (KONIG , MAAS) Intact chest Compression
 1901 (IGELSRUD) Open chest
 1904 (CRILE) drugs
 1947 (BECK) defibrillation
 1960 ( KOUWENHOVEN , G.G.KNICKERBOCKER) closed chest cardiac
massage and closed chest defibrillation
 1966 NATIONAL RESEARCH COUNCIL USA-CPR GUIDELINES
 1992-2010 A H A & EUROPEAN RESUSCITATION COUNCIL GUIDELINES
 SHOCK
Def:
A complex clinical syndrome
that results when tissue
oxygenation or nutrient
delivery are insufficient to
maintain the metabolic
needs of the cell
 COMPONENTS NECESSARY FOR ADEQUATE PERFUSION

• Composition of ambient air

• Patent Airway
• Mechanics of ventilation
• Regulation of ventilation
• Ventilation/perfusion ratio
• Transport of Oxygen,CO2, by the blood
• Blood volume
• Pump function of the myocardium
• Systemic vascular resistance
• Microcirculation
• Blood pressure
 Dynamics of Capillary Exchange

10 9

• Starling’s law of the capillaries is that the volume of fluid & solutes
reabsorbed is almost as large as the volume filtered
Tortora & Grabowski 9/e 2000 JWS 21-10
 Arterioles
• Small arteries delivering blood to
capillaries
– tunica media containing few layers
of muscle
• Metarterioles form branches into
capillary bed
– to bypass capillary bed, precapillary
sphincters close & blood flows out
of bed in thoroughfare channel
– vasomotion is intermittent
contraction & relaxation of
sphincters that allow filling of
capillary bed 5-10 times/minute

Tortora & Grabowski 9/e

21-11
 Innervation of the Heart

• Speed up the heart with sympathetic stimulation

• Slow it down with parasympathetic stimulation (X)
• Sensory information from baroreceptors (IX)
Tortora & Grabowski 9/e 2000 JWS 21-13
 Formation of Urine

Figure 15.5
Copyright © 2003 Pearson Education, Inc. publishing as Benjamin Cummings Slide
What is the Pathogenesis of Hypoperfusion ?
How do you interpret the Symptoms & Signs ?
NO
VITAL SIGNS VALUE RANGE REMARKS
1 PULSE RATE
Infants <160 bpm
Preschool <140 bpm
School <120 bpm
Adult <100 bpm 60 – 80 bpm Volume?
2 RESPIRATION Rate, TV
Infant 25 – 50 bpm
School 15 – 30 bpm
Adult 12 – 20 bpm 12 - 30 bpm <10 , >30
3 TEMPERATURE 37C >38.5C
4 GLASGOW COMA SCALE 3 - 15
5 OXYGEN SAT % > 97% <95% , <90%
6 BLOOD PRESSURE
Infant 70 mm Hg
School 80 (2 age in years)
Adult 120/80 mmHg MAP?
7 PAIN SCALE 0 - 10
 CLASSIFICATION OF HAEMORRHAGIC SHOCK
NO SIGNS CLASS I CLASS II CLASS III CLASS VI
1 Blood Loss:
Percentage < 15% 15 – 30% 30-40 %  40%
Volume < 750 ml 750 – 1500 ml 1500-2000 ml  2000 ml

2 Blood Pressure:
Systolic Unchanged Normal Reduced Very Low
Diastole Unchanged Raised Reduced Unrecordable
3 Pulse Rate 100 bpm 100-120 bpm > 120 bpm  120 bpm
 thready
4 Capillary Refill Normal Slow Slow Undetectable

5 Respiratory Rate Normal Normal > 20 /min > 20 /min

6 Urinary Flow Rate ml/h > 35 20-35 10-20 0-10

7 Extremities Normal Pale, Cool Pale, Cold Pale, Cold,

Clammy
8 Complexion Normal Pale Pale Ashen

9 Mental Status Alert Anxious Confused, Drowsy, Stupor,

Restless Aggressive Unconscious
EARLY WARNING SCORING SYSTEM
VITAL SIGN SCORE 3 2 1 0 1 2 3
SYSTOLIC BP < 70 71 - 80 81 - 100 101 - 179 180 - 199 200 - 220 > 220
(mm Hg)
HEART RATE - < 40 41 - 50 51 - 100 101 - 110 110 - 130 > 130
(beats/min)
RESPIRATORY - <8 8 - 11 12 - 20 21 - 25 26 - 30 > 30
RATE
(breaths/min)
OXYGEN SAT < 85 86 - 90 90 - 94 > 95 - - -
(%)
AVPU - - CONFUSION A V P U
URINE OUTPUT < 80 80 - 120 120 - 200 >800 - -
(Past 4 hours/mls)
TREATMENT with 60% 90 – ANY OTHER
O2 (NRFM) 94% THERAPY

SCORE 3 = ALERT # SCORE 5 = URGENT # SCORE 7 = IMMEDIATE

 OTHER SIGNS VALUE
1 SKIN Pale, Cool, Cold, Clammy, Mottled
CAPILLARY REFILL < 2 sec

2 CARDIAC RHYTHM
3 CVP / VEINS 4 – 10 cm H2O pr
4 ABG Metabolic Acidosis: <pH, n/<PaCO2, >Base def, < Bicarb.
5 URINARY OUTPUT 0.5 – 1 ml / kg / hr
6 PAWP 6 – 12 cm H2O pr
7 ARTERIAL PRESSURE
8 JUGULAR/NECK VEINS
9 PUPILS
10 CYANOSIS
11 EYE MOVEMENT
12 SPEECH
13 SPECIFIC SIGNS
 FLOW DIAGRAM FOR MANAGEMENT OF UNDIFFERENTIATED SHOCK
HISTORY THINK
1 Trauma? Haemorrhagic Sh.
Tension Pneumothorax
Cardiac Tamponade
2 GIT haemorrhage, Diarrhea, Vomiting? Volume Resus
3 Fever?Hypothermia? Sepsis syndrome
4Infection?
TFT
4 ECG / s/sACS? MI ? Cardiogenic Sh.
Pulm Embolism
5 Bradycardia / Hypotension? Drug injestion-Neg inotrops
TFT
Addisonian Crisis
6 Hypoxemia? Pulm. Embolism
7 Abdominal/Low Backpain? Volume Resus
Abd U/S
8 Wheezing / Hives? Anaphylaxis Sh.

ROSEN’S EMERGENCY MEDICINE

 RESPIRATORY DISTRESS
• Tachycardia
• Increased respiratory effort
• Inadequate respiratory effort
• Abnormal airway sounds
• Tachycardia
• Pale, cool skin (warm, red, diaphoretic)
• Agitation/Changes in level of consciousness
• Use of Abdominal muscles to assist in breathing
 RESPIRATORY FAILURE
• Marked tachypnoea
• Bradypnoea, Apnoea
• Increased/Decreased/No respiratory effort
• Poor to absent distal lung air movement
• Tachycardia (early)
• Bradycardia (late)
• Cyanosis
• Stupor/Coma (late)
 RESPIRATORY ARREST
• Absence of breathing
• Gasping <6/min, No chest movement
 Mx RESPIRATORY ARREST – BLS/ALS
• Giving supplementary Oxygen
• Opening the airway
• Providing basic ventilation-MM,MM,BVM
• Using basic airway adjuncts-OPA,NPA
• Suctioning
• Assess and Fix
 BASIC AIRWAY SKILLS
• Head tilt- Chin lift
• Jaw thrust without head extension
• Mouth-to-mouth ventilation
• Mouth-to-nose ventilation
• Mouth-to-barrier device ventilation
• Bag-mask ventilation
 ADVANCED AIRWAY DEVICE
• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal tube
• Endotracheal tube
…AND IF ANYONE SAVED A LIFE, IT WOULD BE
AS IF HE SAVED THE LIFE OF ALL MANKIND…
THE NOBLE QURAN - S: 5-32