CARDIOPULMONARY RESUSCITATION

1. Dr. Rahul Tiwari
Final Yr. MDS
OMFS-SIDS
CARDIOPULMONARY
RESUSCITATION

2. 9/19/2016 9:34:56 AMRT/12/CPR/88 2
• INTRODUCTION
• HISTORY
• PHYSIOLOGY
• CPR-
• BLS
• ACLS
• CONCLUSION
• REFERENCES
CONTENTS

3. •
DEFINITION
Cardiopulmonary resuscitation (CPR) is an emergency
procedure which is performed in an effort to manually
preserve intact brain function until further measures
are taken to restore spontaneous blood circulation and
breathing in a person in cardiac arrest.
9/19/2016 9:34:56 AMRT/12/CPR/88 3

4. • BLS ( Basic Life Support) .
• ACLS (Advanced Cardiovascular Life Support) .
APPROACH
Support & restore effective oxygenation, ventilation
and circulation with return of intact neurological
function.
Intermediate Goal: Return of spontaneous circulation
(ROSC)
GOAL
9/19/2016 9:34:56 AMRT/12/CPR/88 4

5. 9/19/2016 9:34:56 AMRT/12/CPR/88 5
MECHANISM

6. • It is the sudden and unexpected cessation of ventilation
and circulation.
• It may result from pulse less electrical activity, ventricular
tachycardia, ventricular fibrillation or ventricular stand
still.
• Clinical death occurs at the moment of cardiopulmonary
arrest (may be reversed if recognized promptly and
effectively managed preventing biological death).
• Biological death follows when permanent cellular damage
has occurred primarily from lack of oxygen.
CARDIAC ARREST
9/19/2016 9:34:56 AMRT/12/CPR/88 6

7. • Brain damage begins 4 - 6 minutes after cardiac
arrest.
• Brain damage becomes irreversible in 8 - 10
minutes.
CARDIAC ARREST
9/19/2016 9:34:56 AMRT/12/CPR/88 7

8. 9/19/2016 9:34:56 AMRT/12/CPR/88 8
• Absence of ventilation is detected by lack of thoracic or
abdominal movements, absence of breath sounds & absence of
air movements through nose and mouth.
• Absence of circulation is detected by lack of carotid or femoral
pulse. It is confirmed by dilated pupils, unresponsiveness &
comatose state.
RECOGNITION

9. CHAIN OF SURVIVAL
9/19/2016 9:34:56 AMRT/12/CPR/88 9

10. 10
HISTORICAL REVIEW
5000 – 3000 BC - first artificial mouth to mouth
ventilation
1780 – first attempt of newborn resuscitation by
blowing
1874 – first experimental direct cardiac massage
1901-first successful direct cardiac massage in man
1946 – first experimental indirect cardiac massage
and defibrillation
1960 – indirect cardiac massage
1980 – development of cardiopulmonary
resuscitation due to the works of Peter Safar
9/19/2016 9:34:56 AMRT/12/CPR/88

11. Cardiopulmonary
Resuscitation
A - Airway
B - Breathing
C - Circulation
D- Defibrillation
9/19/2016 9:34:56 AMRT/12/CPR/88 11

12. Effective CPR is based on the artificial delivery of
oxygenated blood to systemic circulatory beds at a
rate that are sufficient to preserve vital organ function
& at same time providing the physiologic substrate for
rapid return of spontaneous circulation.
CARDIO PULMONARY RESUSCITATION
9/19/2016 9:34:56 AMRT/12/CPR/88 12

13. 13
SEQUENCE OF OPERATIONS
 Check responsiveness
 Call for help
 Correctly place the victim and ensure the open
airway
 Check the presence of spontaneous respiration
 Check pulse
 Start external cardiac massage and artificial
ventilation
9/19/2016 9:34:56 AMRT/12/CPR/88

14. • Airway – ensure open airway by preventing the
falling back of tongue
• Breathing – start artificial respiration
• Circulation – restore the circulation by external
cardiac massage
• Differentiation, Drugs, Defibrillation – quickly
perform differential diagnosis of cardiac arrest, use
different medication and electric defibrillation in
case of ventricular fibrillation
MAIN STAGES OF RESUSCITATION
9/19/2016 9:34:56 AMRT/12/CPR/88 14

15. 9/19/2016 9:34:56 AMRT/12/CPR/88 15

16. BEFORE BLS
Assess Action
Scene safety For you and victim
Check responsiveness Tap/ shake and shout
“Are you all right?”
Activate emergency
response system and
get AED
Alone- shout for help.
Activate emergency 108
Get AED…if available
Return to victim ……start CPR
9/19/2016 9:34:56 AM RT/12/CPR/88 16

17. • CPR and defibrillation within 3-5 minutes can save over 50% of
cardiac arrest victims
• CPR followed by AED saves thousands of lives each year
• In most cases CPR helps keep victim alive until EMS or AED
arrives
CPR SAVES LIVES
9/19/2016 9:34:56 AMRT/12/CPR/88 17

18. Airway
Head tilt, Chin lift, Jaw thrust
Keeping airway open- LOOK, LISTEN, FEEL
LOOK LISTEN FEEL
CHEST MOVEMENTS BREATH SOUNDS AIR FLOW
RESP. RATE VOICE QUALITY CHEST MOVEMENTS
CYANOSIS ABNORMAL SOUNDS
TRAUMA
FLUID/BLOOD /VOMITING
NOT MORE THAN 10 SECONDS
9/19/2016 9:34:56 AMRT/12/CPR/88 18

19. A (AIRWAY) ENSURE OPEN AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 19

20. 20
A (Airway)
ensure open
airway
9/19/2016 9:34:56 AMRT/12/CPR/88

21. KEEPING THE AIRWAY OPEN, LOOK, LISTEN, AND FEEL FOR
NORMAL BREATHING. ……OPEN AIRWAY
2 EFFECTIVE RESCUE BREATHS
•TIDAL VOL. 8-10 ml/kg
•Deliver in one sec.
•Chest rise/ expand
9/19/2016 9:34:56 AMRT/12/CPR/88 21

22. 22
B (Breathing)
Tilt the head back and
listen for. If not
breathing normally,
pinch nose and cover
the mouth with yours
and blow until you see
the chest rise.
9/19/2016 9:34:56 AMRT/12/CPR/88

23. LOOK, LISTEN AND FEEL FOR NORMAL BREATHING
9/19/2016 9:34:56 AMRT/12/CPR/88 23

24. IF HE IS BREATHING NORMALLY
• TURN HIM INTO THE RECOVERY POSITION
• SEND OR GO FOR HELP, OR CALL FOR AN
AMBULANCE.
• CHECK FOR CONTINUED BREATHING.
9/19/2016 9:34:56 AM RT/12/CPR/88 24

25. IF HE IS NOT BREATHING NORMALLY
• Give 2 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
9/19/2016 9:34:56 AM RT/12/CPR/88 25

26. 26
C. Circulation
Restore the circulation, start external
cardiac massage
9/19/2016 9:34:56 AMRT/12/CPR/88

27. C. CIRCULATION
EXTERNAL CARDIAC MASSAGE
• EFFECTIVE CHEST
COMPRESSIONS
9/19/2016 9:34:56 AM RT/12/CPR/88 27

28. • Delivery of oxygenated blood during cardiac
arrest & CPR is dependent on the effectiveness
of chest compressions
• Interruption of chest compression <10 sec
except during ET insertion or defibrillation.
9/19/2016 9:34:56 AMRT/12/CPR/88 28

29. DURING CPR
• Push hard & fast(100/min)
• Compressions to relaxation
ration 50:50
• Ensure full chest recoil
9/19/2016 9:34:56 AMRT/12/CPR/88 29

30. • Patient positioning:
Firm and hard surface (ground, table/ hard bed) deflate
air/ water mattresses.
• Rescuer's position:
Level with patient, elbows vertically straight and locked,
shoulders directly above the hands, heel of one palm over
the other.
• Site :lower half of sternum in inter-mammary line 1-1 ½
inches above the xiphiod process
• Depth: 1 1/2- 2 inches.
• Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.).
• Allow complete chest recoil.
CHEST COMPRESSIONS
9/19/2016 9:34:56 AMRT/12/CPR/88 30

31. CHEST COMPRESSIONS
30 CHEST COMPRESSIONS
9/19/2016 9:34:56 AMRT/12/CPR/88 31

32. Put hand(s) in correct position for chest
compressions
9/19/2016 9:34:56 AMRT/12/CPR/88 32

33. Give 30 chest compressions at rate of
100 per minute
Then give 2 ventilations
9/19/2016 9:34:56 AMRT/12/CPR/88 33

34. CIRCULATION-CHECK THE PULSE
Check the pulse on carotid
artery using fingers of the
other hand.
In infants brachial pulse is
more easily located &
palpated than the carotid
pulse.
9/19/2016 9:34:56 AM RT/12/CPR/88 34

35. CHEST COMPRESSIONS
• Rate: 100/MIN., SITE- Sternal depression -1.5 in.-2 in.
•Universal compression-ventilation ratio (30:2) -
Recommended for all single rescuers of infant, child and
adult victims (excluding newborns)
30:2- ALL ADULTS, 15:2 – Infants and child
PURPOSE : PUSH HARD,PUSH FAST
PULSE PRESENT
CONTINUE VENTILATION TILL
SPONTANEOUS RESPIRATION
PULSE ABSENT /
NOT DETECTED
CHECK FOR SIGNS OF CIRCULATION
9/19/2016 9:34:56 AMRT/12/CPR/88 35

36. MONITORING DURING CPR
• Arterial pulse & pressure are not reliable markers of
blood flow during CPR.
• Size of the pressure pulse 50mmHg systole indicates
chest compressions were successful in promoting
systemic blood flow..
9/19/2016 9:34:56 AMRT/12/CPR/88 36

37. MONITORING DURING CPR
Pupillary size
• Pupil that are persistently contracted or initially
dilated but subsequently contracted are
associated with a greater likelihood of successful
resuscitation & neurological recovery than
persistently dilated or subsequently dilating
pupils.
9/19/2016 9:34:56 AMRT/12/CPR/88 37

38. •
HOW LONG TO RESUSCITATE
• Risk of functional impairment in any of the major
organs is directly related to the duration of the
ischemic insult.
• CPR continued for 30min if the time to onset of
CPR is <6min.
• Onset of CPR >6min CPR can be terminated
after 15min.
9/19/2016 9:34:56 AM RT/12/CPR/88 38

39. PROBLEMS AND COMPLICATIONS OF CHEST
COMPRESSIONS
1. RIB FRACTURES
2. FRACTURE STERNUM
3. RIB SEPARATION
4. PNEUMOTHORAX
5. HEMOTHORAX
6. LUNG CONTUSIONS
7. LIVER LACERATIONS
8. FAT EMBOLI
9. INFECTIONS
MANAGE ACCORDINGLY BUT CONTINUE CPR
9/19/2016 9:34:56 AMRT/12/CPR/88 39

40. Advanced, invasive assessment and management
techniques required.
Basic airway adjuncts: OPA, NPA
Advanced Airway interventions:
Combitube, LMA, Endotracheal intubation.
Advanced circulatory interventions:
Drugs to control heart rhythm and blood pressure.
ACLS
9/19/2016 9:34:56 AMRT/12/CPR/88 40

41. • It is J shaped device used in unconscious pateints when basic
procedures fail to maintain open airway.
• This device fits over the tongue to hold it and the soft
hypopharyngeal structures away from the posterior wall of
pharynx.
OROPHARYNGEAL AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 41

42. OROPHARYNGEAL AIRWAY/GUEDEL
• Different colours = different
sizes
• Neonate to large adult
SIZE COLOUR
000 Violet
OO Blue
O Black
1 White
2 Green
3 Orange
4 Red
5 Yellow9/19/2016 9:34:56 AM RT/12/CPR/88 42

43. OROPHARYNGEAL AIRWAYS
9/19/2016 9:34:56 AMRT/12/CPR/88 43

44. 9/19/2016 9:34:56 AMRT/12/CPR/88 44
•
OROPHARYNGEAL AIRWAY/GUEDEL
9/19/2016 9:34:56 AMRT/12/CARDIOPULMONARY RESUSCITATION/85 44
The size of the Guedel airway is the distance between
the center of the incisors and the angle of the jaw (on
the same side!)

45. • Clear the mouth and pharynx using pharyngeal suction tip.
• Select proper size OPA.
• Insert the OPA so that it is turned backward as it enters the
mouth.
• When the posterior wall of pharynx is approached rotate it 180
degrees into proper position.
STEPS
9/19/2016 9:34:56 AMRT/12/CPR/88 45

46. OROPHARYNGEAL AIRWAY INSERTION
9/19/2016 9:34:56 AMRT/12/CPR/88 46

47. • Indications:
To open and maintain an airway in a
patient with a depressed level of
consciousness
OROPHARYNGEAL AIRWAY/GUEDEL
9/19/2016 9:34:56 AMRT/12/CPR/88 47

48. PROBLEMS
Patient won’t accept it
Risk of vomiting & aspiration
OROPHARYNGEAL AIRWAY/GUEDEL
9/19/2016 9:34:56 AMRT/12/CPR/88 48

49. • For maintaining airway in “more awake” patients
• Sits in nasopharynx and opens airway
NASOPHARYNGEAL AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 49

50. • It is soft rubber or plastic uncuffed tube that provides
airway between nares and the pharynx.
• Can be used in concsious or semiconscious patients.
• It is used when insertion of OPA is difficult or
impossible(strong gag reflex,trismus,trauma around
mouth and wiring of jaws).
NASOPHARYNGEAL AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 50

51. Estimate by comparing to patients little
finger
Lubricate
Gently push posteriorly towards ear on same side
NASOPHARYNGEAL AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 51

52. • Contra-indications:
Base of skull fracture
Serious midline facial fractures
When definitive airway needed
NASOPHARYNGEAL AIRWAY
9/19/2016 9:34:56 AMRT/12/CPR/88 52

53. NASOPAHRYNGEAL AIRWAY SIZES
• Measure from tip of nose to
bottom of earlobe
• Also based on diameter of
patient’s nares
9/19/2016 9:34:56 AM RT/12/CPR/88 53

54. • Select proper size NPA.
• Lubricate the airway with anesthetic jelly.
• Insert the airway through nostril in a posterior
direction,if any resistence is encountered slightly
rotate or attempt placement through other nostril.
STEPS
9/19/2016 9:34:56 AMRT/12/CPR/88 54

55. NASOPHARYNGEAL AIRWAY INSERTION
9/19/2016 9:34:56 AMRT/12/CPR/88 55

56. NASOPHARYNGEAL AIRWAY INSERTION
9/19/2016 9:34:56 AMRT/12/CPR/88 56

57. • Essential component of maintaining airway.
• Prepared to perform when the airway becomes
occluded with secretions,blood or vomit.
• Portable suction devices- -80 to -120mmHg.
• Wall mounted suction devices- -300mmHg.
SUCTIONING
9/19/2016 9:34:56 AMRT/12/CPR/88 57

58. • Soft flexible used for aspiration of thin secretions
from the oropharynx and nasopharynx,intratracheal
suctioning,suctioning through NPA.
• Rigid for suctioning oropharynx,particularly if there
is thick particulate matter.
SOFT V/S RIGID CATHETERS
9/19/2016 9:34:56 AMRT/12/CPR/88 58

59. • Most basic piece of “airway” kit
• Different types - clear, black
- cushion around edge
• Won’t maintain airway by self
• Needs head tilt/chin lift or jaw thrust
• Also needs Positive Pressure Ventilation
MASK
Ventilation of the lungs single most important and
most effective step in cardiopulmonary resuscitation
of the compromised newborn
9/19/2016 9:34:56 AMRT/12/CPR/88 59

60. • Cushioned/Non-cushioned
• Round/Anatomical shaped
• Size 0 or 1
MASKS
9/19/2016 9:34:56 AMRT/12/CPR/88 60

61. CORRECT POSITION OF MASK
9/19/2016 9:34:56 AMRT/12/CPR/88 61

62. • Inserted Through Nose or Mouth
• Nasal Route Preferred in Awake Patients
• Oral Route Preferred in Coma or Uncooperative Patients
• Tracheostomy Preferred for Long Term Intubation
• Laryngoscope help
ENDOTRACHEAL INTUBATION
9/19/2016 9:34:56 AMRT/12/CPR/88 62

63. COMPLICATIONS OF INTUBATION
• Epistaxis
• Esophageal Intubation
• Nasal, Septal Necrosis
• Bacteremia
• Dental Trauma
• Occlusion from Biting on Tube
• Laryngeal Damage
9/19/2016 9:34:56 AM RT/12/CPR/88 63

64. TUBE PLACEMENT
9/19/2016 9:34:56 AM RT/12/CPR/88 64

65. • Laryngeal mask airway
• Advanced airway
• Useful alternative for “difficult intubation”
• Easy to use
• Sits on larynx - Protects lungs
LMA
9/19/2016 9:34:56 AMRT/12/CPR/88 65

66. LMA
9/19/2016 9:34:56 AMRT/12/CPR/88 66

67. • Indications:
Unconscious or anaesthetized patients
AHA Guidelines for adults:
BLS: alternative to ventilation
ACLS: Optional/alternative to ventilation, failed ETT
LMA IN EMERGENCY MEDICINE
9/19/2016 9:34:56 AMRT/12/CPR/88 67

68. • Disadvantages:
Needs adequate training
Risk of aspiration
Limited Paediatric use
Not always successful
LMA IN EMERGENCY MEDICINE
9/19/2016 9:34:56 AMRT/12/CPR/88 68

69. LMA INSERTION
9/19/2016 9:34:56 AMRT/12/CPR/88 69

70. COMBITUBE®
9/19/2016 9:34:56 AMRT/12/CPR/88 70

71. • Advantages:
Protect airway from aspiration.
Easy to use
AHA: alternative to ETT
• Disadvantages:
Trauma to soft tissues.
No availability.
COMBITUBE®
9/19/2016 9:34:56 AMRT/12/CPR/88 71

72. „Pharyngeal“
lumen No. 1
„Esophago-
tracheal“
lumen No. 2
Esophageal - tracheal
COMBITUBE
Oropharyngeal
balloon
Distal
cuff
Perforations
9/19/2016 9:34:56 AMRT/12/CPR/88 72

73. • Head neutral or slightly flexed
• Hold tongue and jaw between thumb & forefinger
and lift
• Gently insert Combitube® in a curved back and
downward movement until black markers aligned
with teeth
• Inflate (proximal) pharyngeal balloon
• Inflate (distal) tracheal balloon
• Confirm which one of #1 or #2 tube is in lungs by
using bag ventilator
COMBITUBE®
9/19/2016 9:34:56 AMRT/12/CPR/88 73

74. COMBITUBE® INSERTION
9/19/2016 9:34:56 AMRT/12/CPR/88 74

75. DEFIBRILLATION
• Treatment of choice for VT & VF
• Single most effective resuscitative measure for
improving survival in cardiac arrest
• Time elapsed from the cardiac arrest to the first
electric shock is the most important factor in
determining the survival
• Biphasic defibrillators needs lower energy than
monophasic
9/19/2016 9:34:56 AMRT/12/CPR/88 75

76. DEFIBRILLATION
• Shock should be delivered with in 3min
• CA occurs outside the hospital response time is
>5min ,a brief period of CPR followed by shock
• Chance of survival declines 7-10% for every min
without defibrillation
9/19/2016 9:34:56 AMRT/12/CPR/88 76

77. AED(AUTOMATED EXTERNAL DEFIBRILLATION)
• Technologically advanced, microprocessor-based
devices that are capable of electrocardiographic
analysis, with excellent recognition of cardiac rhythm &
VF
• Deliver impendence compensating biphasic shocks.
• One electrode is placed on the upper rt sternal border,
just below the clavicle & other lateral to the lt nipple
below the axilla.
9/19/2016 9:34:56 AMRT/12/CPR/88 77

78. AED(AUTOMATED EXTERNAL DEFIBRILLATION)
9/19/2016 9:34:56 AMRT/12/CPR/88 78

79. AED (AUTOMATED EXTERNAL DEFIBRILLATION
9/19/2016 9:34:56 AMRT/12/CPR/88 79

80. AED (AUTOMATED EXTERNAL DEFIBRILLATION
9/19/2016 9:34:56 AMRT/12/CPR/88 80

81. HOW TO USE DEFIBRILLATOR
• Turn on
defibrillator
• Select energy level
• Apply gel to pads
• Position the
paddles
• Press charge
button
• When defibrillator
fully charged state
firmly in a forceful
voice
9/19/2016 9:34:56 AM RT/12/CPR/88 81
• I am going to shock on three.
• Two you are clear
• Three every body clear
• Apply 25lb of pressure on
both paddles
• Press the 2 paddle discharge
button simultaneously

82. 9/19/2016 9:34:56 AMRT/12/CPR/88 82

83. POSITIONING OF ELECTRODES FOR AUTOMATED
EXTERNAL DEFIBRILLATOR
9/19/2016 9:34:56 AMRT/12/CPR/88 83

84. ANALYSING RHYTHM
DO NOT TOUCH VICTIM
SHOCK INDICATED
STAND CLEAR
DELIVER SHOCK
IF VICTIM STARTS TO BREATH NORMALLY PLACE IN
RECOVERY POSITION
9/19/2016 9:34:56 AMRT/12/CPR/88 84

85. • The science of cardiopulmonary resuscitation is developing rapidly.
• We as physicians and first responders must stay updated.
• We must also adjust our practice of medicine accordingly.
CONCLUSIONS
9/19/2016 9:34:56 AMRT/12/CPR/88 85

86. 1. Medical emergencies in dental office -Malamed
2. Oral and maxillofacial surgery-laskin.
3. General medicine-Davidson
4. Text book of pharmacology-Tripathi
5. Advanced cardiovascular life support-Manual of
American Heart Association
REFERENCES
9/19/2016 9:34:56 AMRT/12/CPR/88 86

87. Thank you
9/19/2016 9:34:56 AMRT/12/CPR/88 87
Take some time to learn FIRST AID & CPR.
It saves lives which is life long.
But when a heart stops every second counts.