• Basic life support (BLS)
• Advanced cardiac life support (ACLS)
3. Basic Life Support
• Cardiac arrest is sudden cessation of cardiac activity.
– If corrective measures are not taken rapidly, progresses to
– Most common etiology is ischemic heart disease resulting in
– The keys to survival are early recognition and treatment
(immediate initiation of excellent CPR and early defibrillation).
– Actions that make up BLS prevent or slow end organ damage
until cause of the problem corrected, until advanced care
4. Important concepts and practices for BLS
• Recognition of cardiac arrest
• Activate emergency medical services or the cardiac
• Excellent chest compressions
• Minimize interruptions
• Monitoring of chest compression quality
• Proper ventilation
• Use an automated external defibrillator as soon as one
6. Recognition of cardiac arrest
• Rapid recognition is the essential first step of successful
– Confirm unresponsiveness.
– Calls for help, activates the emergency response
system, and get AED.
– Check patient's pulse, respirations.
– Cardiac arrest: if there is absent or any abnormal
breathing and/or if a pulse cannot be readily palpated.
– Initiates excellent chest compressions.
7. Performance of excellent chest compressions
• Are the most important element of CPR.
• “Push hard and push fast on the center of the chest"
• Coronary and cerebral perfusion pressure and ROSC are
– Rate 100 to 120 compressions per minute
– Compress at least 5 cm (2 inches) with each down-stroke
– Allow chest to recoil completely after each down-stroke (remove
hands slightly but completely from the chest wall)
• An inadequate chest compression reduces likelihood of
ROSC and neurologically intact survival following SCA.
8. • Technical consideration
– Rescuer and patient must be in optimal position.
– Patient must lie on a firm surface(a backboard, floor).
– Rescuer places heel of one hand on center of chest
over lower portion of sternum and heel of other hand
atop of first.
– Rescuer's own chest should be directly above hands.
– Rescuer performing chest compressions be changed
every two minutes.
9. Minimizing interruptions
• Interruptions in chest compressions, result in
unacceptable declines in coronary and cerebral perfusion
pressure and worse patient outcomes.
• The most common reasons for prolonged interruptions
are rhythm checks, changes in clinician performing chest
compressions, tracheal intubation.
• Following any interruption, sustained chest compressions
are needed to regain pre-interruption rates of blood flow.
10. Monitoring of chest compression quality
• Chest compression should be continually reassessed, and
corrections made throughout the resuscitation
• Monitoring would improve neurologically intact survival
• Monitoring techniques
– Close observation by other clinicians
– Mechanical devices that provide real-time feedback of chest
compression rate, depth and recoil.
– End-tidal carbon dioxide (ETCO2) measurement
– Diastolic blood pressure measurement using invasive arterial
• During initial phase of SCA, importance of compressions
– Compressions-Airway-Breathing (C-A-B) approach
• In patients whose cardiac arrest is associated with
hypoxia, performance of excellent standard CPR with
• As pulselessness persists in patients with SCA, the
importance of performing ventilations increases.
12. • Proper ventilation includes
– Give two ventilations after every 30 compressions, 10 breaths
– Discontinue compressions during ventilations for patients
without an advanced airway
– Give each ventilation over no more than one second,
– Provide only enough tidal volume to observe chest rise
– Avoid excessive ventilation (rate or volume)
– Give one asynchronous ventilation every 8 to 10 seconds (6 to 8
per minute) to patients with an advanced airway in place, with
excellent compressions performed continuously.
• As soon as a defibrillator is available, providers should
assess cardiac rhythm and, when indicated, perform
defibrillation as quickly as possible.
• A single defibrillation in all shocking sequences followed
immediately by resumption of excellent chest
compressions(without pulse, rhythm check).
• Compressions should not be stopped until the
defibrillator has been fully charged.
14. • Biphasic defibrillators are preferred: lower energy levels
needed, measure impedance and adjust energy.
• Rates of first shock success: around 85 percent
• Highest available energy used (360 J for a monophasic
defibrillator and 200 J for a biphasic defibrillator).
• Cardiac rhythm analysis , Pulse checks should only be
performed during a planned interruption at the two-
minute interval (a complete cycle of CPR).
– Must not spend more than 10 seconds
21. Complications Of CPR
• Rib and sternal fractures
• Cardiac and pulmonary contusions
• Pneumo- and hemothorax
• Intra-abdominal trauma
22. Questions on BLS
1. A 65-year-old male is on a short ladder changing a light and
suddenly collapses. He is unresponsive. What is the next step?
a. Call EMS.
b. Begin CPR.
c. Begin mouth-to-mouth ventilation.
d. Check pulse.
2. What method should be used to open his airway in the case above?
b. Jaw thrust
3. CPR is initiated and the person’s pulse returns, but he is not breathing.
What ventilation rate should be used for this person?
a. 6-8 breaths per minute
b. 10-12 breaths per minute
c. 18-20 breaths per minute
d. Depends on his color 22
23. 4. You notice a bulge in the upper left chest under the skin. There is a
healed incision overlying that bulge. Which is true of AED use?
a. AED cannot be used in this person.
b. You should put a magnet over the bulge before using the AED.
c. You should place pads over the bulge.
d. You should avoid placing pads over the bulge.
5. The AED indicates “Shock.” After delivering a shock, what is the next
step in caring for this person?
a. Reassess for a pulse.
b. Do chest compressions only.
c. Resume CPR starting with chest compressions.
d. Do ventilation only.
24. Advanced Cardiac Life Support (ACLS)
• Excellent CPR
• Defibrillate VF and pulseless VT as rapidly as possible.
• Rapidly identify and treat causes of non- shockable arrest
(PEA, asystole); 5 H's and 5 T's
• Proper use of cardiovascular medications
• Immediate initiation of post cardiac arrest care after ROSC
• Resuscitation team management
29. Airway management
• The optimal approach remains uncertain
• BVM ventilation or extraglottic airway
– Are equally effective as tracheal intubation, more rapidly placed, and require
– Preferred unless one cannot ventilate patient by these means or there is high
certainty of rapid, successful placement of the tracheal tube without
interruption of chest compressions.
– Provide 100 percent oxygen during CPR.
– Oropharyngeal and nasopharyngeal airways can improve the quality of BVM
31. • Endotracheal intubation
– Can be deferred until after ROSC.
– If ventilation is inadequate using a BVM or an extraglottic,
intubation can be attempted during ongoing chest compressions
or deferred to two-minute interval.
– Continuous waveform capnography for
• Confirming and monitoring correct tracheal tube placement
• Monitoring the quality of CPR and ROSC.
34. Methods for medication administration
– Peripheral , IO, or central venous access
– When unable to obtain such access, use endotracheal tube
– Doses for tracheal administration are 2 to 2.5 times standard IV
doses, and medications should be diluted in 5 to 10 mL of sterile
water or normal saline before injection down the tracheal tube.
35. • Intra-arrest monitoring
– To optimize performance of CPR and to detect ROSC
– Assessment and immediate feedback about the rate and depth
of chest compressions, adequacy of chest recoil between
compressions, and rate and force of ventilations improve CPR.
– Arterial diastolic pressure
– Point-of-care ultrasound and echocardiography: useful for
identifying reversible causes of cardiac arrest.
37. Management of specific arrhythmias
• Pulseless VT and VF
– Non -perfusing rhythms emanating from the ventricles
– Requires excellent cardiopulmonary resuscitation (CPR) and rapid
– Treatable underlying causes should be identified and managed as quickly as
– Decreased time to defibrillation improves the likelihood of successful
conversion to a perfusing rhythm and patient survival.
– VT/VF that persists after defibrillation may be treated with amiodarone or
– Refractory pulseless VT or VF
• Coronary heart disease common causes
• May achieve ROSC after coronary revascularization.
• Veno Arterial Extra Corporeal Membrane Oxygenation (VA-ECMO) as an
adjunct to conventional CPR: Extracorporeal CPR (ECPR). 37
38. • Asystole and pulseless electrical activity
– Asystole is defined as a complete absence of electrical and
mechanical cardiac activity.
– PEA is defined as any one of organized ECG rhythms without
sufficient mechanical contraction of the heart to produce a
palpable pulse or measurable blood pressure.
– Are non-perfusing rhythms requiring immediate initiation of
excellent CPR and rapid reversal of underlying cause.
– These rhythms do not respond to defibrillation.
– Epinephrine is administered as soon as is feasible after chest
compressions are begun.
39. Arrhythmias with a pulse
– Bradycardia: HR below 60 beats per minute, Symptomatic bradycardia: HR
below 40 beats per minute.
– Intervene when Signs and symptoms of inadequate perfusion
40. • Tachycardia
– HR above 100 beats per minute, Symptomatic tachycardia: rates over 150
beats per minute.
– Management of tachyarrhythmia is governed by the presence of clinical
symptoms and signs caused by the rapid heart rate.
42. Post-resuscitation Care
• A combination of goal-oriented interventions provided by an
experienced multidisciplinary team for all cardiac arrest patients
• Objectives include:
– Optimizing cardiopulmonary function and perfusion of vital
– Managing acute coronary syndromes
– Implementing strategies to prevent and manage organ system
dysfunction and brain injury
43. Termination Of Resuscitative Efforts
• Determining when to stop resuscitation efforts in cardiac arrest
patients is difficult, and little high-quality evidence exists to guide
• Factors influencing the decision to stop resuscitative efforts include:
– Duration of resuscitative effort >30 minutes without a sustained perfusing
rhythm, a very low EtCO2: strong predictor of acute mortality.
– Unwitnessed collapse with an initial ECG rhythm of asystole
– Prolonged interval between time of collapse and initiation of CPR
– Patient age, severe comorbid disease, or prior functional dependence