1. CARDIO PULMONARY
RESUSCITATION(CPR)
K.KRISHNA LOHITHA
1ST PG STUDENT

2. CONTENTS
RESUSCITATION
CARDIOULMONARY RESUSCITATION
BACKGROUND
PATHOPHYSIOLOGY OF CPR
STEPS IN CPR
BASIC LIFE SUPPORT
CRITICAL CONCEPTS
ADULT CHAIN OF SURVIVAL
RESCUE BREATHING
CHOKING
CPR WITH ADVANCED AIRWAY
CPR IN MAXILLOFACIAL TRAUMA

3. RESUSCITATION:
Resuscitation is the process of correcting physiological disorders( such
as lack of breathing or heart beat) in an acutely unwell patient.

4. cardiopulmonary resuscitation (CPR) is a procedure to support and
maintain breathing and circulation for a person who has stopped breathing
(respiratory arrest) and / or whose heart has stopped( cardiac arrest)
CPR is an emergency procedure that combines chest compressions often
with artificial ventilation in an effort to manually preserve intact brain function
until further measures are taken to restore spontaneous blood circulation and
breathing in a person who is in a cardiac arrest

5. BACKGROUND:
The American Heart Association(AHA) estimates that about 3,50,000 people die of
cardyiac arrest each year
Approximately 4280 out of evary1 lakh people die every year from sudden cardiac
arrest (SCA) in India alone
About 74-80% of all sudden cardiac arrests happen at home; so being trained in CPR
can mean the difference between life and death for a member of a family
Approximately 10% of SCA events occur among people less than 40 years of age
Effective btstander CPR, provided immediately after sudden cardiac arrest, can double
the victims chance of survival
The survival rates for performing basic life support alone are reported between 0% and
6%
CPR cannot ‘restart’ the heart, but it can keep blood and oxygen moving through the
victim’s body until medical help arrives

6. PATHOPHYSIOLOGY OF CPR:
The goal of CPR was to compress and release the ventricles between the
sternum and thoracic spine
CARDIAC PUMP MECHANISM/ TRADITIONAL THEORY:
Depress the sternum 1.5 to 2 inches
- Squeezes the heart b/w sternum and spine
- Increase in ventricular pressure
- Mitral and tricuspid valve closure

7. Opening of semilunar valves
Blood expelled into arteries
Anterograde left and right heart emptying
(artificial systole)
During decompression
Reduces the ventricular volume
Diastole/relaxation
Mitral, tricuspid valve opening
Ventricular filling from lungs and body

8. THORACIC PUMP MECHANISM:
discovered in 1980’s by Criley’s clinical observation of cough CPR
mechanism:
when thoracic pump is operative,
during chest compressions
large antero posterior diameter of chest
generalised increase in intrathoracic pressure
both mitral valve and aortic valve open simultaneously
causes increase in pressure gradient in all heart chambers
left heart acts as a conduit(collective pulmonary vasculature
constitutes main pumping chamber)

9. NEW STUDIES SHOW THAT:
Both mechanisms function simultaneously during CPR( hybrid pump)
In adults, hybrid pump is thoracic pump
In children, hybrid pump is cardiac pump
differences in compression force, location, force, chest wall characteristics, and
volume status account for operating ,mechanisms of CPR

10. STEPS IN CPR
BASIC LIFE SUPPORT(BLS)
ADVANCED LIFE SUPPORT( ALS)
PROLONGED LIFE SUPPORT(PLS)

11. BASIC LIFE SUPPORT( BLS)
Basic life support is the provision and maintainence of an airway , and the
support of ventilation and circulation without the use of any equipment
other than simple airway devices or protective shields.
STEP A – AIRWAY CONTROL
STEP B – BREATHING SUPPORT
STEP C – CIRCULATION SUPPORT

12. CHANGE IN SEQUENCE: C-A-B, not A-B-C
the 2010 AHA guidelines for CPR and ECC recommend a change in BLS
sequence of steps from A- B- C to C- A- B for adults, infants and children. This
change is likely to improve survival
in the A- B- C ( Airway- Breathing- Chest compressions sequence), chest
compressions were often delayed while the rescuer opened the airway to give
mouth to mouth breathes, retrieved a barrier device or gathered and assembles
ventilation equipment
by changing the sequence to C-A-B ( Chest compressions- Airway-
Breathing),rescuers can start chest compressions sooner, and the delay in giving
breaths should be minimal

13. ADVANCED LIFE SUPPORT ( ALS)
- STEP D – DRUGS AND FLUIDS
EPINEPHRINE
BLOOD VOL REPLACEMENT
- STEP E – ELECTROCARDIOGRAPHY
- STEP F – FIBRILLATION TREATMENT
- open chest
- closed chest defibrillation

14. Reason for basic life support
Speed of initiation may be more important than the absolute quality
BLS should be started
-unresponsive
-not breathing (apnoeic) or have an absent major pulse, or both.

15. ON FINDINGA COLLAPSED PATIENT
Shout for help
Approach with care
Free from danger
Evaluate ABC

18. Causesof airway obstruction
Hypopharyngeal obstruction
Presence of foreign matter – vomitus/blood
Laryngospasm
Lower airway obstruction
- spasm
- bronchial secretions
- mucosal edema
- inhaled gastric contents
- foreign matter

19. AIRWAY OBSTRUCTION
Complete
partial
Complete Asphyxia, apnea
Cardiac arrest
(within 5-10 min

20. Partial:
Hypoxic brain damage
Cerebral, pulmonary
edema
Exhaustion
Secondary apnea
Cardiac arrest

21. Recognition of airway obstruction
Hear or feel’ air flow
Complete – nil
Partial – Noisy (Crowing, Gurgling,
Wheezing)

22. CHAIN OF SURVIVAL:
The term chain of survival provides a useful metaphor for the elements of the ECC
systems concept. The 5 links in the Adult Chain of Survival are
Immediate recognition of cardiac arrest and activation of the emergency response
system
Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions
Rapid defibrillation
effective advanced life support
Integrated post cardiac arrest care

23. MAJOR GUIDELINE CHANGES
The following changes have recently been made in the 2010 BLS guidelines
•Refinements have been made to recommondations for immediate
recognition and activation of emergency response system based on signs of
unresponsiveness, as well as initiation with no breathing or normal
breathing(gasping)
•Rescuers must place their hands in the center of the chest, in the lower half
of sternum, rather than to spend more time using ‘rib margin’ method
•“look,listen, feel” for breathing has been removed from the algorithm
•Use of cricoid pressure in cardiac arrest is not recommended
•Emphasis on high quality CPR
•Change in sequence to C- A- B, circulation is more important than airway

25. Critical concepts:
high quality cpr improves persons chance of survival:
•Start compressions within 10 seconds of recognition of cardiacarrest
•Push hard, push fast: compressions at a rate of 100-120 minute
- atleast 5cm / 2 inches for adults
- at least 1/3 rd depth of the chest, about 5cm for children
- atleast 1/3 rdthe depth of the chest, about 4 cm for infants
•Allow complete chest recoil after each compression
•Minimise interruptions in compressions(interruptions should be limitedfor < 10
secs)
•Give effective breaths that make the chest rise
•Avoid excessive ventilation

26. INITIAL BLS STEPS FOR ADULTS:
STEP ACTION
1 Assess the victim for a response and look for a normal or abnormal breathing. If
there is no response and no breathing or no normal breathing (i.e, only gasping),
shout for help
2 if you are alone, activate the emergency response system and get an AED (or
defibrillation) if available and return to the victim
3 check the victim’s pulse (take atleast 5 but no more than 10 seconds)
4 If you definitely do not feel a pulse within 10 seconds, perform 5 cycles pf
compressions and breaths( 30: 2 ratio), starting with compressions( C-A-B)
sequences

27. STEP 1: ASSESSMENT AND SCENE SAFETY
the first rescuer who arrives at the side of the victim must quickly be
sure that the scene is safe. The rescuer should then check the victim foe a
response:
STEP ACTION
1 Make sure the scene is safe for you and the victim. You do not want to become
a victim for yourself
2 Tap the victim’s shoulder and shout, “ are you alright?”
3 Check to see if the victim is breathing. If a victim is not breathing or not
breathing normally( ie, only gasping), you must activate the emergency
response system.

28. CAUTION:
• agonal gasps are not normal breathing. They may be present in the first minutes
after sudden cardiac arrest
•A person who gasps usually looks like he is drawing air in very quickly .
•The mouth may be open and the jaw, head or neck may move with gasps.
•Gasps may appear forceful or weak, and some time may pass between gasps
because they usually happen at a slow rate
•The gasp may sound like a snort, snore, or groan.
•Gasping is a sign of cardiac arrest in someone who doesn’t respond

29. STEP 2: ACTIVATE THE EMERGENCY RESPONSE SYSTEM AND GET AN AED
if you are alone and find an unresponsive victim not breathing, shout for help.
If no one responds, activate the emergency response system, get an AED(or
defibrillator) if available, and then return to the victim to check the pulse and begin
CPR(C-A-B) sequence

30. STEP 3: PULSE CHECK
Healthcare providers should take no more than 10 second to check for a pulse
Locating the carotid artery pulse
Follow these steps to locate , carotid artery pulse:
STEP ACTION
1 Locate the trachea, using 2 or 3 fingers
2 Slide these 2 or 3 fingers into the groove between the trachea and muscles
at the side of the neck, where you can feel the carotid pulse
3 Feel for a pulse for atleast 5 but no more than 10 secs. If u do not definitely
feel a pulse, begin CPR, starting with chest compressions( C-A-B sequence)

32. STEP 4: BEGIN CYCLES OF 30 CHEST COMPRESSIONS AND 2 BREATHS(CPR)
The lone rescuer should use the compression- ventilation ratio of 30 compressions to 2
breaths when giving CPR to victims of any age

33. STEP
ACTION
1
Position yourself at the victim’s side
2
Make sure victim is lying faceup on a firm, flat surface.if the victim is lying facedown, carefully roll him face up.
3
Put the heel of one hand on the center of the victim’s chest on the lower half of the breast bone
4
Put the heel of the other hand on top of the first hand
5
Straighten your arms and position your shoulders directly over your hands
6
Push hard and fast
press down at least 5cm(2 inches) with each compression. For each chest compression, make sure you push straight down on the
victim’s breastbone
deliver compressions in a smooth fashion at a rate of atleast 100/min
7
at the end of each compression, make sure you allow the chest to recoil completely. Chest recoil allows blood to flow into the heart and is
necessary for chest compressions to create blood flow. Incomplete chest recoil is harmful because it reduces blood flow created by chest
compressions. Chest compressions and relaxation times should be approximately equal
8
Minimize interruptions

34. ALTERNATIVE TECHNIQUE FOR CHEST COMPRESSIONS:
If one has difficulty pushing deeply during compressions, put one hand on the
breastbone to push on the chest. Grasp the wrist of that hand to support the first hand as it
pushes the chest. This technique is helpful for rescuers with arthritis

35. OPENING THEAIRWAY FOR BREATHS
Two methods:
head tilt- chin lift
jaw thrust
Use a jaw thrust only if head or neck injury is suspected
Switch to head tilt – chin lift if the jaw thrust doesnot open the airway
STEP ACTION
1 Place one hand on victims forehead and push with your palm to tilt the head
back
2 Place the fingers of the other hand under the bony part of lower jaw near the
chin
3 Lift the jaw to bring chin forward

37. Jaw thrust: if the victim has neck or spine injury, jaw thrust should be performed by 2
rescuers.
STEP ACTION
1 place one hand on each side of the victim’s head,resting your elbows on the surface on which victim’s
lying
2 place your fingers under the angles of the victims lower jaw and lift with both hands, displacing the
jaw forward
3 If the lips close, push the lower lip with your thumb to open the lips

39. Adult mouth –to-barrier- device breathing:
standard precautions include use of barrier devices, such as face mask or a bag mask
device,when giving breaths
in 1- rescuer CPR , the person performing CPR uses the mouth to mask breaths
at a compression ventilation ratio of 30:2 i.e, after giving 15 compressions, ventilation
is given by the lone rescuer from the victim’s side
In 2- rescuer CPR, rescuer at the victim’s side, gives the compressions in the same
ratio, and the rescuer at the head side gives ventilation
Switch duties with the second rescuer every 5 cycles or about 2 minutes, taking
less than 5 seconds to switch

40. DIRECT MOUTH TO MOUTH / BAG VLVE MASK
MOUTH TO NOSE BREATHING

44. •Once the AED team arrives, place it at victims side who will operate it
•When ventricular fibrillation is present, heart muscle quiver and donot
contract together to pump blood
•A defibrillator delivers an electric shock to stop quivering of heart fibres
•This allows the muscle fibres of the heart to reset so that they begin to
contract at the same time
•Once the organised rythm occurs, the heart muscle begins to contract
effectively and begin to generate a pulse(Return of spontaneous circulation)

45. 4 universal steps for operating AED
first 2 steps should be performed within 30 seconds after AED arrives

47. Modification of cpr in children
Use the heel of one hand for chest compressions
Press the sternum down 1 to 1.5 inches
Give 1 full breath followed by 5 chest compressions
If you are alone with the child give one minute of CPR before calling
for help

50. THE PEDIATRIC BLS ALGORITHM

52. CHOKING
foreign bodies may cause range of mild to severe airway obstruction
Mild airway obstruction Severe airway obstruction
Signs:
good air exchange
Can cough forcefully
May wheeze between coughs
Signs:
Poor or no air exchange
Weak,ineffective cough
High pitched noise while inhaling or no noise
at all
Increased respiratory difficulty
Cyanosis
Unable to seak
Clutching the neck with thumb and fingers
Rescuer actions Rescuer actions
Good air exchange- encourage spontaneoys
coughing and breathing efforts
If mild airway obstruction ersists, activate
Emergenc response system
ask victim if he/ she is choking. If the
victimnods yes and cannot talk, you must try
to telieve the obstruction

53. choking
Heimlich maneuver : abdominal thrusts should be given
make a fist with one hand
place the thumb of your fist against thevictims abdomen. In the midline, slightly
above the patients navel and below the breastbone
grasp your fist with the other hand and press your fist in to abdomen with a
quick, foreceful upward thrust
Complications :
- Gastric rupture
- Injury to the liver
- Danger of provoking regurgitation

54. Choking in infants< 1 year

55. CHOKING IN CONSCIOUSADULTAND CHILDREN( 1- 8 YRS OF
AGE

56. HEMILICH MANEUR IN PREGNANT PATIENTS

58. Rescue breathing
•When the adult ,child or infant has a pulse but is not breathing effectively, rescuers should give breaths
without chest comprssions
•It is done in respiratory arrest,to prevent hypoxic injury tobrain and other organs
give each breath 1 sec
each breath should result in visible chest rise
check the pulse for every 2 minutes
Rescue breathing for adults Rescue breathing for infants and
children
Give 1 breath every 5-6 seconds(about
10-12 breaths per minute
Give 1 breath every 3- 5 seconds( about
12- 20 breaths per minute)

59. CPR WITHANADVANCEDAIRWAY
Ventilation technique Compression to breaths
( adult)
Compression to
breaths(child and infant)
No advanced airway
(mouth to mouth, mouth
to mask, bag mask)
30 compressions to 2
breaths
Compression rateof
atleast 100/min
15 comressions to 2
breaths
Compression rate of
atleast 100min
Advanced airway
(endotracheal intubation,
laryngeal mask airway,
supraglottic)
Compression rate of
atleast 100/min without
pauses for breaths
1 breath every 6—8
secs(8-10 breaths per
minute
Compression rate of
atleast 100/min without
pauses for breaths
1 breath every 6—8
secs(8-10 breaths per
minute

60. CPR INMAXILLOFACIAL TRAUMA
Severe injuries to the maxillofacial region can complicate early management of
atrauma patient owing to its proximity to brain , cervical spine and airway
The usual A-B- C are often supplemental with other methods in maxilla facial injuries
Situation is complicated by presence of broken teeth, dentures, foreign bodies, avulsed
tissues, multiple mandibular fractures, massive edema of glottis which cause direct
threat to airway
Alcohal , drugs and pooled blood also trigger nausea and vomiting
If patient has multiple fractures, the displacement of maxilla or mandible decreases
airway patency

61. MANAGEMENT OF AIRWAY
Airway should be tailored according to a particular situation in trauma depending on
the typr of injury and magnitude of injury
Look listen feel helps to figure out airway obstruction and anticipated airway
complications
High velocity trauma involving mandible, swallowing mechanism is altered due to pain
and ineffective protective reflex modulation results in difficulty to keep airway clear
Most common cause of airway obstruction is falling back of tongue
To prevent airway blockage and to initiate CPR , tongue should be pulled out with a
safety pin , blood should be finger sweeped , check for any obstructions like foreign
body, vomitus, bleeding should be checked and airway adjuncts to be used to provide
airway

62. Other devices can be used are:
Indications for Suctioning
A patient needs to be suctioned immediately when a gurgling
sound is heard with artificial ventilation
Remove blood, other liquids, and food particles
from the airway

63. Types of suction devices:
Mounted suction devices:
fixed on board the ambulance
portable suction device:
electric battery powered
oxygen powered
hand powered

64. Special considerations
Secretions that cannot be removed, log roll and finger sweep
Patient producing frothy secretions as rapidly as suctioning
can remove them
◦ Suction 15 seconds
◦ Positive pressure with supplemental oxygen for 2 minutes
◦ then suction again and repeat the process
Residual air removed from lungs, monitor pulse and heart rate

65. Advanced airway maintenance
Oropharyngeal airways
Nasopharyngeal airways
Esophageal tracheal combitube
Laryngeal mask airway
Endotracheal intubation
Laryngoscoe
Needle cricothyrotomy
Retrograde intubation
tracheostomy

66. OROPHARYNGEAL AIRWAY
Used to maintain a patent airway only on
deeply unresponsive patients
No gag reflex
Designed to allow suctioning while in place
Must have the proper size
If patient becomes responsive and starts to
fight the OPA, remove it ...

67. Select the proper size (corner of the mouth to tip of the ear)
Open the patient’s mouth
Insert the OPA with the tip facing the roof of the mouth
Advance while rotating 180°
Continue until flange rests on the teeth
Infants and children insertion

68. NASOPHARYNGEAL AIRWAY
Used on patients who are unable to tolerate an OPA or
is not fully responsive
Do not use on suspected basilar skull fracture
Still need to maintain head-tilt chin lift or jaw thrust when inserted
Must select the proper size
Made to go into right nare or nostril

69. INSERTING NASOPHARYNGEAL AIRWAY
Select the proper size in length and diameter
Lubricate
Insert into right nostril with bevel always toward the septum
Continue inserting until flange rests against the nostril
Insertion into left nostril

70. CRICOID PRESSURE

71. ESOPHAGEAL TRACHEAL COMBITUBE

72. COMBITUBE IN THE TRACHEAL POSITION

73. LARYNGEAL MASK AIRWAY
wide bore tube,
-connector at its proximal end, elliptical cuff at its distal end.
When inflated, the elliptical cuff forms a low pressure seal
around the entrance into the larynx.
variety of pediatric and adult sizes and successful insertion
requires appropriate size selection.
•Used
•When endotracheal intubation is not desired
•During emergency situations in which mask ventilation is not
possible or intubation and/or ventilation fails

74. LARYNGOSCOPE
•Consists of a handle containing batteries and
interchangeable blades of various shapes and sizes
containing a bulb or fiberoptic light.
• The laryngoscope is used to lift the tongue, mandible,
and epiglottis and visualize the glottis opening, both for
removing foreign bodies and inserting endotracheal tubes.
• Blades commonly are available in 5 sizes, from 0 for
infants to 4 for large adults

75. ENDOTRACHEAL TUBE•Made from poly vinyl chloride, with a radiopaque line from
top to bottom, standard size connectors
•Tubes come in a number of sizes, usually designated in
millimeters of internal diameter.
•The choice of ETT size is always a compromise between
choosing the largest size to maximize flow and the smallest size
to minimize airway trauma
•Once a view of the larynx is obtained via laryngoscopy, the
ETT is introduced with the dominant hand through the right
side of the mouth. Directly observe the tip of the tube passing
into the larynx, between the abducted cords. Pass the tube 1
cm through the cords.

76. COMPLICATIONS OF INTUBATION
•Trauma- tooth damage
- lip/tongue/mucosal laceration
- sore throat
- dislocated mandible
- Mucosal inflammation and ulceration.
•Tube malfunction.
•Malpositioning of the endotracheal tube can result in esophageal intubation and unintentional
extubation.

77. RETROGRADE TRANSCRICOID INTUBATION
INDICATIONS:
1.VISUALISATION OF VOCAL CORDS DIFFICULT
2.STABLE,CO-OPERATIVE COMATOSE PATIENTS IN WHOM ACCESS TO POST.OROPHARYNX IS EASY.
SEVERE MAXILOFACIAL TRAUMA.
CONTRAINDICATIONS
PATIENTS REQUIRING IMMEDIATE INTUBATION AS THE PROCEDURE MAY LAST 3-5 MINUTES.

78. 1. PLASTIC CATHETER IS FED
THROUGH THE NEEDLE AND INTO THE
PHARYNX
. ENDOTRACHEAL TUBE
IS BEING PASSED DOWN
THE CATHETER GUIDE

79. “TO DO NO HARM “
SURGICAL AIRWAY TECHNIQUES:
cricothyrotomy: needle
surgical
Tracheostomy: it is an elective procedure once patient is stabilised by
cricothyrotomy

80. BREATHING SUPPORT
Emergency artificial ventilation
-Exhaled air
-Air
-oxygen

81. Mouth to Mask
Direct mouth to mouth /mouth to nose ventilation

82. Automatic oxygen powered ventilators
For prolonged artificial ventilation of the intubated/ tracheomatized patient

83. conclusion
The development of modern CPR has given every person the ability to
challenge death anywhere.
Resuscitation medicine and its science, reanimatology, if pursued with
historic perspective, wisdom and compassion, can become a positive force
in human evolution.

84. THANK YOU