basic life support

1. Cardiopulmonary Resuscitation
Dr. Rajkumarr
Anesthesiologist
Care Hospital
Nagpur

2. “No initial intervention
can be delivered to the
victim of cardiac arrest
unless bystanders are
ready, willing, and able to
act”
2

3. Bad News Time Flies
Good News You are the Pilot
You take care of the Seconds
We take care of the Minutes
3

4. Cardiac Arrest
Cardiac arrest is the cessation of all cardiac
mechanical activity. It’s clinical diagnosis is
confirmed by
Unresponsiveness
Absence of detectable pulse
Apnea (or agonal respirations )

5. The Cardiac Arrest Rhythms
The four cardiac arrest rhythms are
 Asystole
 PEA ( Pulseless Electrical Activity )
 Pulseless Ventricular Tachcardia (VT)
 Ventricular Fibrillation (VF)

6. D. Differential Diagnosis
Review the most frequent causes
( the 6 H’s and 6 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Tamponade - cardiac
Hydrogen ions – acidosis Tension pneumothorax
Hyper / hypokalemia Thrombosis - coronary
Hypothermia Trauma
Hypoglycemia Thrombosis - pulmonary

7. Cardio Pulmonary Cerebral Resuscitation
 BLS : Basic life support
 ACLS : Advance cardiac life support
 Better chance of survival
 Brain damage starts in 4-6 minutes
 Brain damage is certain after 10 minutes
without CPR
What is treatment of cardiac arrest….?

8. How to do It- Chain of Survival
Early Recognition
(Sudden Cardiac Arrest))
Early Activation
(Emergency Medical Service)
Early Chest Compression
(Push Hard &Push Fast)
Early Shock
(Automated External
Defibrillator
Early Advanced care

9. Chain Of Survival – 4 links
Early Activation
of EMS
Early CPR
Early Defibrillation
Early Advanced
Care
BLS

10. International Guidelines for CPR
2005…..????

11. Chain of survival
2005
2010

14. International Guidelines for BLS 2010

15. BLS Algorithm
Step 1. Assess Responsiveness
Step 2. Activate the EMS and call for the defibrillator(AED)
Step 3. check for pulse in 10 sec.
Step 4. Start chest Compressions (30:2), minimize interruption
Beginning with 30 compressions rather than 2 ventilations l/t shorter
delays.
Step 5. Open airway
Step 6. Check breathing
Step 7. Give rescue breaths, avoid excessive ventilations
As soon as a AED is available attach and fallow
instructions

16. WORKSHOP
Ready for hands on……?

18. 1. Check Responsiveness

19. 2. Call for help with AED defibrillator

20. 3. Check for Pulse (carotid pulse )

21. 4.Start Chest Compressions
Site for chest compressions

22. Place hand 2 finger spaces above the
xiphoid process

23. Place other hand over hand on sternum

24. Hand Position for Chest
Compression

25. “Push hard and Push fast”
Minimise interruption of chest compression
• >100 /min.
• 30:2 ratio ( C:V )
• 5 cycles (2 minutes)
• 50% : 50 % ( C/R )
• minimum 5 cm sternal depression
• Arms Straight, elbows locked,
shoulder over hands
• Complete recoil of chest

26. • Rescuer fatigue may lead to inadequate
compression rates or depth.
• When 2 or more rescuers are available it is
reasonable to switch chest compressors
approximately every 2 minutes (or after
about 5 cycles of compressions and
ventilations at a ratio of 30:2) to prevent
decreases in the quality of compressions .
• Every effort should be made to accomplish
this switch in 5 seconds.

27. 5. Open the Airway
Head Tilt –Chin Lift Maneuver

28. Open The Airway
Jaw Thrust Maneuver

29. 6. Check for Breathing

30. 7. Ventilation over 1 sec.
(The Chest Must Rise)
 Mouth to mouth breathing
 Bag and mask ventilations

31. Bag and mask ventilations

32. Ventilation With Bag and Mask
• Rescuers can provide bag-mask ventilation
with room air or oxygen.
• This amount is usually sufficient to produce
visible chest rise and maintain oxygenation
and normocarbia in apneic patients (Class
IIa).
• If the airway is open and a good, tight seal is
established between face and mask.
• Avoid excessive ventilation (30:2 for bag &
mask and 8-10 breaths/min after intubation)

33.  As long as the patient does not have an
advanced airway in place, the rescuers
should deliver cycles of 30 compressions and
2 breaths during CPR.
 The rescuer delivers ventilations during
pauses in compressions and delivers each
breath over 1 second (Class IIa).
 The healthcare provider should use
supplementary oxygen (O2 concentration
40%, at a minimum flow rate of 10 to 12
L/min) when available.

34. Ventilation With an Advanced Airway
 When an advanced airway (ie, endotracheal
tube, Combitube, or laryngeal mask airway
[LMA]) is in place during 2-person CPR, give
1 breath every 6 to 8 seconds without
attempting to synchronize breaths between
compressions (this will result in delivery of 8
to 10 breaths/minute).
 There should be no pause in chest
compressions for delivery of ventilations
(Class IIb).

35. Attach defibrillator(AED) as soon as
available and shock if indicated

36. D – Early Defibrillation
Automated External Defibrillator (AED)
 Single greatest advance in CPR
 The survival rate is 90% if
the patient is defibrillated
within 1 min. and only 10%
if it is delayed till 10mins
(Circulation 1984;69:943-8.)
 Survival rate after cardiac
arrest has been reported to
go up from 30% to 49%
(Ann Emerg Med 1996;28:480-5.)

39. International Guidelines for CPR
2010 vs 2005

Team work

No look, listen, feel

ABC -CAB sequence Beginning with 30
compressions rather than 2 ventilations .

Chest compressions – >5 cm

Rescuer specific cpr strategy

Untrained: Hands only cpr

Pulse checks are only undertaken where
there are signs suggestive of ROSC.

40. 
<10 sec. for intubation

Waveform capnography (Etco2 >10 mmhg)

Intra-arterial diastolic pressure >20 mmhg

Atropine no longer recommended in PEA /Asystole
and it remains for peri-arrest management.

Chronotrophic drug infusions used as alternative to
pacing.

Advanced airway: includes supraglottic airway
devices, capnography.

Interruption is allowed for only 5 sec.e.g.
Defibrillation, change over

The tracheal route of drug administration is not
recommended except in neonates following the
widespread introductionof intraosseous devices.

41. THANK YOU

43. Biphasic vs Monophasic Defibrillation
 Advantages
- greater efficacy
- low energy produces same effect
- less myocardial damage
- less incidence of S-T changes
( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )
 Energy
- Monophasic 360 J
- Biphasic 150/200 J
 All AEDs are Biphasic
 High first shock success of
Biphasic defibrillation (84%-95%)

44. ADVANCED
LIFE SUPPORT

45. A - Airway
 Definitive airway should be secured as soon as possible
 Tracheal intubation using cricoid pressure (by trained
personnel only)
 Laryngeal Mask Airway (LMA) and Esophageal–tracheal
Combitube are accepted alternatives for others
 Cricothyrotomy to be performed in an emergency

46. B. Breathing - Confirm device placement
 Primary Confirmation
 Direct Visualisation of ETT passing through cords
 Chest expansion
 5 point auscultation - L and R anterior,
- L and R mid-axillary
- Over stomach
 Still in doubt –repeat laryngoscopy
 Further confirmation - Exhaled CO2 detector (ETCO2)
- Oesophageal detector device
 Inflate cuff and secure the tube

47. B. Breathing –
Confirm effective oxygenation and ventilation
 No synchrony between ventilation and chest
compressions once definitive airway is secured
 No longer 30 : 2 compression ventilation cycles
COMPRESSION @100/min
VENTILATION @ 6 – 8 breaths/min

48. C. Circulation
 Identify the rhythm
 Defibrillation /Pacing
 Secure IV line-large easily accessible peripheral veins
 Give rhythm appropriate medication

49. Recognition of Rhythm
Cardiac Arrest (lethal rhythms)
Shockable-VF,Pulseless VT
Non Shockable – Asystole.PEA
Non Cardiac Arrest (non lethal rhythm)
Rate too fast - >120/min
Rate too slow- <60/min

50. Defibrillation
 For shockable rhythms – VF / Pulseless VT
 Monophasic or Biphasic defibrillators (Biphasic preferred)
Monophasic 360 J ~ Biphasic 200 J
 Steps of Defibrillation
- Mains plugged in or on battery, On Defib mode
- ECG size/gain maximum
- Set on leads: Only set on paddles if no leads
- Select joules (200,300 & all others 360)
- Charge, (“all clear”chant to count of 3 before discharge)
- Discharge

51. Pacing
 Disappointing results for asystole, PEA
 No benefit in post shock asystole
 May be indicated for cardiac arrest with
narrow QRS complexes
 Not useful during terminal wide complex
agonal rhythms
 Extensive use in pre-arrest bradyarrhythmias
 Transcutaneous or transvenous

52. C-Circulation
IV Access
 Wide bore peripheral upper limb vein
 Push each bolus with 20cc fluid
 Raise extremity
 Urgent central/femoral line only if peripheral
access impossible or difficult & taking a long time
to cannulate

53. C-Circulation
Other Drug Delivery Routes
 Tracheal
- 2-3 times IV dose
- Dilute in 10 ml saline
- Preferably inject down a suction catheter which
is wedged deep into the bronchus
- Rapid bagging
 Intracardiac route
- Not recommended
- Dangerous
can result in refractory VF or convert to
nonshockable rhythm

54. C - Circulation
Rhythm appropriate medications
Epinephrine
 Indicated in all cardiac arrest rhythms
i.e. VF, Pulse less VT, Asystole and PEA
 IV dose is 1mg administered every 3-5 minutes
followed by 20 ml IV saline flush
 Adrenaline causes intense cardio-cerebral sparing
vasoconstriction CPR generates CO 25% of normal
 Beneficial effects outweigh negative effects on the myocardium

55. Vasopressin
 Antidiuretic hormone and a powerful vasoconstrictor
when used in the higher doses.
 Positive effects of epinephrine with lesser adverse
effects . Effect lasts for 20 minutes
 Dose - 40 IU
 Drug of choice for all 4 rhythms
Pulseless VT , VF, Asystole and PEA
 One dose of vasopressin may replace either the first
or the second dose of epinephrine

56. Atropine
 First drug of choice in symptomatic bradycardia (class I )
 Second drug after epinephrine for asystole and
bradycardic PEA ( class II b ).
 Dose is 1mg IV push, repeat every 3-5 minutes up to a
maximum dose of 0.04 mg /kg .

57. Amiodarone
 Persistent or recurrent VF or VT ( class II b )
 Dose is 300 mg IV push (150 mg may be repeated after
3-5 minutes ) may be followed by a 24 hour infusion of
1mg / minute for 6 hours and then 0.5 mg/minute for the
remaining 18 hours.
 Amiodarone preferred over Lignocaine (class
indeterminate ) in the treatment of persistent or
recurrent VF /VT.

58. Sodium Bicarbonate
Specific indications are as follows
 class I if known pre-existing hyperkalemia
 class II a if known bicarbonate responsive acidosis -
TCA overdose
 class II b after prolonged resuscitation with
effective ventilation
 class III hypercarbic acidosis
The dose is 1 meq/kg bolus, repeat half this dose every
10 minutes thereafter

59. Calcium
Detrimental effect on ischaemic myocardium
Impairs cerebral recovery
NOT TO BE USED ROUTINELY
Indicated in PEA due to
 Hyperkalaemia
 Hypocalcaemia
 Ca channel blocker overdose

60. Magnesium sulphate
 Shock refractory ventricular fibrillation in
pr of possible hypomagnesemia
 Torsades de pointes
 VT in pr of possible hypomagnesemia
Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2
min,can be repeated after 10 –15 min

61. D. Differential Diagnosis
Review the most frequent causes
( the 5 H’s and 5 T’s )
Hypovolemia Tablets ( Toxins)
Hypoxia Tamponade - cardiac
Hydrogen ions – acidosis Tension pneumothorax
Hyper / hypokalemia Thrombosis - coronary
Hypothermia trauma
hypoglycemia Thrombosis - pulmonary

62. ACLS - Secondary ABCD
Survey
A Airway : place airway device as soon as possible
B Breathing : confirm airway device placement
by examination plus confirmation device
B Breathing : secure airway device
B Breathing : confirm effective oxygenation & ventilation
C Circulation : identify rhythm – monitor
C Circulation : Defibrillation/Pacing
C Circulation : establish IV access
C Circulation : give medications appropriate for rhythm and
condition
D Differential Diagnosis : search for and treat identified reversible
causes

63. Monitoring the Victim -
To assess effectiveness of rescue efforts
 Monitor for signs of circulation and breathing
 Check pulse during compression to assess
effectiveness of compression
 To determine ROSC after 2 minutes of chest
compression check for pulse
 ETCO2

65. Termination of cpr ALS

66. THANK YOU