BLS(BASIC LIFE SUPPORT) &
ACLS(ADVANCED CARE LIFE
SUPPORT)
PRESENTER-
DR SHAILENDRA
DR VINOD
CO-ORDINATOR-
DR DEVANAND PAWAR

WHAT IS CARDIAC ARREST
• Cessation of normal circulation of blood due to failure of
heart to contract effectively.
• It is sudden cessation of mechanical activity of heart with
some or no electrical activity.

OHCA & IHCA
• IHCA is in hospital cardiac arrest
While
• OHCA is out of hospital cardiac arrest

HOW IT WORKS?

Cardiac Arrest
• Can be classified on the basis of ECG rhythm into-
a. Shockable-
1. Ventricular fibrillation (VF)
2. Pulseless ventricular tachycardia (pulseless VT)
a. Non-shockable-
1. Asystole
2. Pulseless electrical activity (PEA)

Cardiac Arrest
• Treatable causes of cardiac arrest-
5H’s 5T’s
Hypoxia Thrombosis(coronary)
Hypothermia Cardiac tamponade
H+ less(acidosis) Tension pneumothorax
Hyperkalemia Toxins
Hypovolemia Thrombosis(pulmonary)

Cardiac Arrest
• Signs and symptoms-
1. No response
2. No breathing
3. No pulse

Cardiac Arrest
• Lack of carotid pulse is gold standard for diagnosis
• Patient may present like unresponsive to tactile verbal stimuli
with no or abnormal breathing or agonal gasps and absence
of carotid pulsation.

Rhythms In cardiac arrest
ECG rhythms that can be seen in cardiac arrest are-
• Ventricular fibrillation
• Pulseless ventricular tachycardia
• Pulseless electrical activity
• asystole

Ventricular fibrillation
• Most important shockable cardiac arrest rhythm

Ventricular fibrillation
• Prolonged VF leads to decreasing amplitude of waveform,
from initial coarse VF to fine VF progressively leading to
asystole due to decreased myocardial energy stores

Ventricular fibrillation
• ECG findings-
1. Chaotic irregular deflections of varying amplitudes
2. NO identifiable P waves, QRS complexes OR T waves
3. Rate-150 to 500/min
4. Amplitude decreases with duration.

Pulseless VT
• ECG findings-
o Very broad QRS (>160ms)
o AV dissociation
o Extreme axis deviation “northwest”, so QRS positive in Avr
and negative in 1 and Avf

PEA
• Cardiac arrest in which ECG shows heart rhythm that should
produce a pulse bt it does not.
• Lack of palpable pulse in presence of organised cardiac
electrical activity
• Also known as “electromechanical dissociation”.

Asystole
• There is no discernible electrical activity on ECG monitor.
• May get confused with flat line.

CA management cont..
These can be achieved by-
• CPR (Cardiopulmonary resuscitation)
• Defibrillation
• Medications
• Therapeutic hypothermia

What is BLS?
• A level of medical care which is used for victims of life-
threatening illnesses or injuries until they can be given full
medical care at a hospital. It can be provided by trained
medical personnel, including emergency medical technicians,
paramedics, and by qualified bystanders.

WHAT IS ACLS?
• A set of clinical interventions for the urgent
treatment of cardiac arrest, stroke and other
life-threatening medical emergencies, as well
as the knowledge and skills to deploy those
interventions.

What is CPR?
• Cardiopulmonary Resuscitation
• An emergency procedure which is series of actions performed
until further measures are taken to restore Return of
spontaneous blood circulation (ROSC) and breathing in a
person having cardiac arrest.

Pathophysiology
CARDIAC ARREST
No blood or tissue oxygenation
Brain sustain damage for 4 min and after 7 min irreversible damage occurs
After 1-2 hrs, cells of body die
CPR
Causes blood to circulate to brain and heart
Enough blood to brain delaying brain death and allows heart to remain responsive till defibrillation

Steps
After recognition of arrest
C Compressions
A Managing airway
B Rescue breathing

Recognition Of Arrest

RECOGNITION OF ARREST
• First step is to Ensure scene safety
• Check for response
• Shout for help/activate resuscitation team at the time or after
checking pulse and breathing
• Activation of AED/emergency equipments either by lone rescuer or
person sent by rescuer must occur as soon as possible after checking
pulse and breathing (ideally should be done simultanously)
• Immediately begin CPR and use AED/defib when available

Check breathing?
• Inspecting the chest rise of patient while palpating carotid
pulse (saves time)
• OR Lay rescuer can check by keeping our fingers in front of
nostrils/keeping ears close to nose to check if any blow of
expired air is present or not.
• Agonal gasps or abnormal breathing patterns may get
confused with normal respiration by lay man rescuer.

Carotid Artery

C P R
• Start CPR immediately after checking and observing there is
no
1. RESPONSIVENESS
2. BREATHING
3. PULSE

Chest Compressions

Chest Compressions
• Technique-
o Position yourself at patient’s side
o firm, flat surface and
o remove all the clothings
o Put the heel of one hand on the centre of chest (sternum) at
the level of nipples and put your other hand on the top of that
hand.

Chest Compression
• Technique-
o Lock all joints ; movement is allowed only at hip joint
o Push hard and fast (100 - 120 times / min)
o At the end of each compression, chest is allowed to recoil
completely
o Avoid excessive ventilation
o Then give next compression immediately
o This cycle should be repeated until patient revives or any EMS
arrives.

Chest Compressions
• Rate- 100 to 120/min
• Depth- 5 cms to 6 cms (2 inches to 2.4 inches)
• While giving chest compression only resuscitation (COLS) by
lay or untrained rescuer give chest compressions only
• Ratio – 30:2
• Minimum/no interruptions

Chest Compressions

Mechanisms
• Cardiac Pump –
1. Blood pumping is assured by compression of heart between
sternum and spine
2. Between compressions, thoracic cage expands and heart gets
filled with blood.

Mechanisms
• Thoracic pump –
1. Blood circulation restored due to changes in intra-thoracic
pressure and jugular and subclavian vein valves.
2. During chest compressions,blood is directed from
pulmonary circulation to systemic circulation.

Thoracic Pump

AIRWAY

Head tilt-Chin lift

Jaw Thrust

Rescue Breath

Rescue Breath
• Each rescue breath over 1 second
• Visible chest rise
• 30 compression: 2 breaths (no advanced aiway)
• Advanced airway-
o Give 1 breath every 6 to 8 seconds without attempting to
synchronise breaths between compressions
o 8-10 breaths per min

Types
• Mouth to mouth breathing
• Mouth to barrier device breathing
• Mouth to nose and mouth to stoma ventilation
• Ventilation with bag and mask
• Ventilation with supraglottic airway
• Ventilation with advanced airway

Mouth-To-Mouth breath

Mouth-To-Nose breath
• Given when mouth cant be open
• Good seal cant be made
• Severe injury present over area of mouth

Mouth-To-Barrier device

Bag and Mask ventilation
• Position yourself directly above patient’s head
• E_C clamp technique followed
o Perform head tilt
o Make “C” with thumb and index finger of one hand
o When we use 3 fingers, it forms “E”
o Chest rise is checked while squeezing the bag to give breaths
to the patient.

Bag And Mask Ventilation

CPR cont..
• Access airway and if patient is on ventilator or intubated and
being ventilated with bag then give 1 breath every 6 seconds
• There is no use of giving any extra breaths
• ETCO2 monitoring – Can be used as a guide to monitor when
ROSC occurs or is unlikely to occur. Successful outcome is
unlikely if end tidal co2 is not higher than 10-15mmhg after 20
mins of CPR
• ETCO2 monitoring should not be considered for ROSC access
in non-intubated patients

Defibrillation

Defibrillation
• Important in saving patient of cardiac arrest
• Mechanism-
A defibrillation shock must be strong enough to stun or excite
a large majority of the cardiac tissue. If a sufficient portion of
the cardiac tissue were made temporarily unexcitable by a
shock, the uncoordinated wavefronts of excitation that
perpetuate VF would be extinguished, and would allow
normal cardiac excitation and contraction to resume.

When to defibrillate?
• Indications –
o Ventricular fibrillation
o Pulseless ventricular tachyardia
• Contra-indications –
o If the patient is having pulse (accidental shock during this phase
may lead to arrhythmias )
o Unsafe situations for rescuer
o Asystole
o Pulseless Electrical Activity

Types
MONOPHASIC BIPHASIC
Delivers current in one direction Delivers current in two direction
Requires more energy upto 360J Requires less energy upto 200J
Cuases more chest burn Cuases less chest burn
More trauma Less trauma
More myocardial damage Less myocardial damage
First shock survival rate is around 60% First shock survival rate is around 90%
Outcome is good Outcome is better than monophasic
defibrillator

Other types
• Manual External Defibrillator
• Manual Internal Defibrillator
• Automated External Defibrillator
• Semi-automated External Defibrillator
• Implantable cardioverter-defibrillator
• Wearable Cardiac Defibrillator

• Continue Chest compresssions until defibrillator is available
• Once the defibrillator is available, ask your assistant to attach paddles- Paddles may
be
1. Handheld paddles :
 Larger paddles size decrease transthoracic resistance increasing the energy
delivery
 Apply gel pads to help minimise burns and enhance proper contact
 Pressure applied to chest with paddles decreases impedance and potentially
improves efficacy of countershock
 Pressure applied should be 25-30lbs or 11-12 kgs
 Place paddles atleast 2 cms away from electrodes and 10cms away from
pacemaker generator

Defibrillation
 Paddle placement :
 Antero-Lateral
Anterior pad on the right infraclavicular chest and lateral pad
lateral to left chest at the level of nipple in midaxillary line
 Antero-posterior
Anterior pad on the right infraclavicular chest and posterior
pad at left lower scapula (More preferred in atrial arrhythmias
and in patients with implanted devices)

Defibrillation
2. Self Adhesive Pads -
 More common
 Easy to use
 Equally effective as handheld paddles
 No gel required for contacts
 Minimizes risk to providers as less contact with bed and
patient during shock delivery

• Once the paddles are attached , set the desired charge to be delivered
usually 200 j in biphasic defibrillators.
• Ensure there is no contact with metal on bed and all rescue personnel
are away from the bed. Call “ALL CLEAR”.
• Keeping paddles firm in positions press charge and deliver shock
• Start CPR immediately after delivering shock, keeping pads in place to
minimise time delay for next shock.
• No delay is allowable
• Check for any signs of revival after completion of one cycle of CPR
• Stop if pulsations are felt/ sinus rhythm achieved/pt moves his or her
limbs or starts to breath

What is AED?
• Automated External Defibrillator
• A portable electronic device that automatically diagnose the
life-threatening cardiac arrhythmias of ventricular
defibrillation and pulseless VT and is able to treat them
through defibrillation.
• Possible for more people to respond to medical emergency
where defibrillation is required
• Can be used by lay-rescuer trained in CPR

AEDs
• Made part of emergency response program
• Gives simple audio and visual commands,making its use easy
• Should be available at public places like stations, stadiums,
airports, malls etc.
• Can’t be overriden manually and takes upto 10-20 sec to
detect arrhythmias
• Now a part of BLS program because early defibrillation is
found to increase survival rate of patient

AEDs

AEDs
• Semi-automated External Defibrillator-
o Similar to AEDs bt these can be overriden and usually have
ECG display
o Ability to pace
o Can be used by paramedics

IV / IO Access

IV /IO Access
• Important to give emergency medications
• Intravenous (IV) and Interosseous routes are approved
• Chest compressions should not be stopped to have IV access
• Should be easily accessible
• If central venous catheter in place , prefer giving drugs
through CVC
• When 2 or more rescuers are present then one rescuer should
continue giving chest compressions while others should
attach defib and find iv access simulteneously

IV / IO Access
• Interosseous route –
o is best to be taken in patient with severe burn , polytrauama
patients , difficult IV access beacause of obesity , history of IV
drug abuse
o Rapid and safe method
o Needs expertise
o When failure to access peripheral IV line placement
o Added in AHA guidelines 2005 of Cardiopulmonary
resuscitation

IV / IO Access
o May need pressure bags
o Contraindications for IO access
 Skin infection at the site of insertion
 Fractured bone
 Disorders of bone (osteoporosis, osteomyelitis, osteogenesis
imperfecta)
 Localised cellulitis
 Recent failed attempt in same bone

IV / IO Access
• Best sites for IO access –
o Proximal tibia (2cm below tibial tuberosity)
o Distal tibia (2cm above medial malleolus)
o Proximal humerus (Greater tubercle near coracoid process)
o Sternum has relatively thin medullary cavity so avoided
because of risk of transpassing through bone causing injury to
structures below sternum

Advanced Airway

Advanced Airway
• Accessible in IHCA
• Oropharyngeal Airway –
o Used in unconscious cases where head tilt – chin lift and jaw
thrust maneuvers fail to provide and maintain unobstructed
airway
o Should not be used in conscious / semiconscious patients
o Used to open airway for proper ventilation , suctioning , can
be used like a bite block in intubated patient .

Advanced Airway
• Nasopharyngeal Airway –
o May be used in conscious , semiconscious or unconscious
patients
o Where OPA placement is difficult (gag reflex, trismus , massive
trauma , wiring of jaws)
o Patient’s smallest finger or outer diameter of NPA compared
with nostrils can be used a guide to select proper size
o Length – tip of nase to earlobe

Advanced Airway
• Advanced Airway equipments used to provide ventilation are
–
o Laryngeal Mask Airway (LMA)
o Endotracheal Tube (ETT)
o Laryngeal Tube (LT)
o Combitube

LMA
• Can be used as a conduit to ETT for emergency airway

LMA
• Insertion Technique –
o Tightly deflated against flat surface (spoon shape)
o Position of patient – morning sniffing position
o Lubricated with water based jelly on its posterior surface
o Pressed along the palato-pharyngeal curve using the index finger.
o Once the give away is felt , It is finally pushed further down till
resistance is felt.
o Cuff is then inflated according to the size of LMA , Proper insertion
is checked with visible chest rise and air entry

ETT

ETT
• Technique of insertion –
o Fully deflate the cuff
o Patient position – morning sniffing
o Gentle direct laryngoscopy done by deflacting tongue to one side
and lifting the base of epiglottis
o Once the vocal cords visible , pass appropriate sized ETT through
the cords
o Inflate the ETT cuff and check visible chest rise and air entry

Laryngeal Tube

Laryngeal Tube
• Insertion technique –
o Choose the appropriate size King LT airway based on the patient’s height.
o Inflate and test the cuff for integrity then lubricate only the posterior portion of
the tube.
o Maintain the head tilt chin lift or modified jaw thrust if appropriate.
o Insert the King LT laterally into the corner of the mouth.
o Advance the tip of the tube under the base of the tongue, while rotating the tube
back towards the midline.
o Advance the tube until the base of the connector is aligned with the teeth or
gums.
o Inflate both the cuffs and check for visible chest rise and air entry

Combi-tube

Suctioning
• Essential component to maintaining patient’s airway by
clearing secretions
• Soft and flexible catheters used for mouth / nose / ETT
• Rigid catheters like Yankauer used for oropharynx having thick
secretions , particulate matter

Monitoring
• Done with standard monitors attached to the patient –
o Pulse Oximeter
o ECG
o NIBP
o ETCO2
o Central Venous O2 Saturation

Monitoring
• Pulse oximetry –
o To continously monitor oxygen saturation during and after the
period of resuscitation
o Monitors adequate oxygen delivery and ventilation
o Continous pulse rate monitoring
• ECG –
o Monitors continously the electrical activity of heart
o Detection of arrival of normal sinus rhythm after resuscitation
o Detection of arrhythmia during or after post-resuscitation
period
o Continous heart rate monitoring

Monitoring
• ETCO2 –
o Useful in intubated patients only (patients with advanced airway
ventilation)
o Measures exhaled gas at the end of expiration
o Measure of balance between ventilation and perfusion in lungs (V/Q
balance)
o Varied in directly with changes in cardiac output relative to ventilation
o When alveolar ventilation is constant , ETCO2 changes directly
proportional to CO

Monitoring
• ETCO2 –
o Normal range – 35 to 45 mmhg
o Serial measurements during CPR used to identify when ROSC
occurs or is unlikely to occur
o Patients achieving ROSC during CPR show progressive increase
in ETCO2 value while progressive declining ETCO2 in those
who don’t achieve ROSC
o Successful outcome is unlikely if ETCO2 is not higher than 10
to 15 mmhg after 20 mins of CPR

Monitoring
• Central Venous O2 Saturation (scvO2)–
o Measure of balance between systemic O2 delivery and
systemic O2 uptake
o Normal range – 70 to 80 %
o Failure to achieve the scvO2 more than or equal to 30%
during CPR is associated with failure to achieve ROSC

Medications

Medications
• Now only adrenaline/epinephrine and amiodarone are
approved as drugs useful in ACLS
• Atropine and vasopressin are not recommanded for the use
in ACLS as per 2015 guidelines by AHA
• Vasopressin was included till 2015 guidelines bt studies have
shown that there is no useful evidence of vasopressin used in
conjunction with adrenaline in survival of patient

Adrenaline
• Sympathomimetic agent
• Alpha and beta adrenergic action having approximately equal
activity on both receptors
• Dose - IV boluses of 1 mg followed by 10-20cc of normal saline to
flush as a standard dosing regimen repeated every 3-5 min as
required
• Previously it was thought that higher dose epinephrine will be
better if standard 1mg dose doesn’t produce desirable effect bt now
higher dose epinephrine is not recomended as it is shown not to
improve survival rate rather causes more chances of dysrhythmias

Adrenaline
• Positive ionotrope and positive chronotrope causing
increased cardiac output, increased oxygen consumption and
coronary blood flow
• Increases peripheral vascular resistance causing increase in
systolic blood pressure more than diastolic BP
• It is mainly used because of its action on beta adrenergic
effects causing vasoconstriction which increases cerebral and
coronary blood flow increasing MAP and aortic diastolic
pressure

Adrenaline
• Indications –
1. Cardiac arrest from VF
2. Pulseless VT unresponsive to initial counter shock
3. Asystole
4. PEA
5. Profoundly symptomatic bradycardia

Adrenaline
• Precautions –
o Should not be added to infusions that contain alkaline
solutions
o Can exacerbate ischemia and induce ventricular ectopy

Amiodarone
• A complex antiarrhythmic agent with –
o Effect on Na+, K+ and Ca++ channels
o Beta and Alpha adrenergic blocking properties
• Alters conduction through accessory pathways
• Class 3 antiarrhythmic agent
• Has direct action in isolated myocardial preperations to
decrease delayed slow outward K+ current and in higher
doses additionally decreases fast and slow inward currents
due to Na+ and Ca++ respectively

Amiodarone
• Indications-
o Pharmacological conversion of Afib
o Persistent vt/vf after defibrillation and adrenaline
o Hemodynamically stable VT
o Hemodynamically stable polymorphic VT
o Hemodynamically stable wide-complex tachycardia of
uncertain origin

Amiodarone
• Indications-
o Control of rapid ventricular rate in pre-excitation SVT due to
accessory pathway conduction
o AN adjunct to electrical cadioversion of reftractory PSVTs/
atrial tachycardias
o Control of ventricular rate in SVTs with severely impaired LV
function when digitalis has proved ineffective

Amiodarone
• Adverse Effects –
o Hypotension
o Bradycardia
These are the most significant adverse effects of amiodarone so have to be
given consciously and selectively
o Causes QT prolongation (Incidence of torsades de pointes and other
proarrhythmic complications are rare with amiodarone)
o Exacerbation of CHF (d/to negative ionotropic affect)
o Phlebitis (When administered through peripheral line), so better to administer
via central venous catheter
o Hepatitis, Hypo/hyperthyroidism, pneumonitis, neuropathy and tremors

Amiodarone
• Dosage-
o In VF/VT - 300mg bolus followed by 1mg/min for first 6 hours
then 0.5mg/hr for next 18 hrs
o Additional 150mg boluses can be given for breakthrough
arrhythmias upto a total load of approximately 2g/24hrs and
5-8gm total
o Can be loaded orally (800-1600mg daily for 2-3wks with
maintainance dose of 400mg daily for ventricular
arrhythmias)

Lidocaine
• Can be used in ACLS when amiodarone is not availabale
• Mechanism –
It suppresses automaticity of conduction tissue in heart, by
increasing the electrical stimulation threshold of the
ventricles, purkinje fibres, and causes spontaneous
depolarisation of ventricles during diastole by direct action on
the tissues

Lidocaine
• Dosage –
1 to 1.5 mg/kg IV/IO as a first dose then 0.5 to 0.75 mg/kg
IV/IO at 5-10 min intervals ; to a maximum of upto 3mg/kg
• It blocks permeability of neuronal membrane to sodium ions
causing blockade of depolarisation and blockade of
conduction

MgSo4
• MgSo4 should be considered for torsades de pointes
associated with long QT interval
• It can be classified as Na+/K+ pump agonist
• Mechanism –
It suppresses several atrial calcium channels and ventricular
after-polarisation
• Its routine use in Cardiac Arrest is not recommended unless
torsades de pointes is present

Newer CPR Devices

Newer CPR device
• Manual –
o Cardiopump
o CPR RsQ assist
o CPR PRO cradle
o Lifebelt
o Lifestick

Newer CPR Devices
• Electric –
o Autopulse
o Lifeline ARM
o LUCAS etc
o EM CPR
• Pneumatic –
o Thumper
o Lifestat
o Hydraulic-pneumatic band

Cardiopump

Cardiopump
• Handheld device
• Piston having a suction cup that sticks to patient’s chest
• Manual form of CPR device
• Operator operates the device by hand
• Alternate compression with active decompression increases
venous return by decreasing intrathoracic pressure and
increases overall flow

CPR RsQ assist

CPR RsQ assist
• Light and compact
• It has a handle which provides support for active compression
during CPR
• Manual device, operated by rescuer

CPR PRO cradle

CPR PRO cradle
• Manual device
• Have to be operated by rescuer
• Can be used for compression only because there is no
decompression

Lifebelt

Lifebelt
• Manual device
• For compression only, no decompression
• A provided levarage is pushed against the chest

Life-stick

Lifestick
• Manual device
• Dual handled rigid bar with two short pistons with adhesive pads
• Performs an interposed abdominal compression cardiopulmonary
resuscitation (IAC-CPR) that is abdominal compression alternated with
chest compressions
• This cyclic compressions doubles the flow and allows to decrease depth of
compression and decrease injury to sternum and ribs
• Compressions should be less vigorous so as to prevent any injury to vital
organs
• So it requires lower compression rates because of its double pumping
effect and danger to injure the abdomen

Autopulse

Autopulse
• Electricaly operated
• Consists of a load distributing band and a backboard
• The band is placed around the chest and tightened and
loosened by the motor
• It has a fixed compression rate of 80/min because it has a
greater effect on hemodynamics at lower compression rates

LUCAS

LUCAS
• Electrically operated
• Piston mounted on a removable frame placed around the
chest
• The frame is fixed on a rigid backboard
• It provides alternate compression with active decompression
by a suction cup that forces thorax back to its uncompressed
volume (recoil)

EM-CPR
• Electrically operated
• Do not exert any force on thorax
• Stimulates contraction of both abdominal muscles and
diaphragm by magnetic impulses generated by coils and such
a rhythmic contraction of abdominal muscles pump blood
from abdomen which contains 20-25% of the total blood
• It also provides negative pressure ventilation with this
mechanism which aids in circulatory output

Thumper

Thumper
• Pneumatically operated
• It has piston mounted on a arm fixed on a supporting column
• Rigiod backboard
• It gives compressions with the rate of 100 compressions per
min

When to stop CPR?
• A general approach is to stop CPR after 20 minutes if
there is no ROSC or viable cardiac rhythm re-
established, and no reversible factors present that
would potentially alter outcome.

• Reasons to cease CPR generally include:
o ROSC -
Resuscitation guidelines require 2 min of CPR post defibrillation prior to
checking for ROSC; may be identified by an upsurge in ETCO2
o Pre-existing chronic illness preventing meaningful recovery ie. nursing
home resident with dementia, disseminated cancer
o Acute illness preventing recovery
ie. 100% burns, non-survivable injuries, catastrophic TBI with no brain
stem reflexes
o No response to ACLS after 20min of efficient resuscitation in absence of
ROSC, a shockable rhythm or reversible causes

• In the pre-hospital setting a validated rule has been described :
Stop CPR if:
o No return of spontaneous circulation
o No shocks are administered, and
o The arrest is not witnessed by emergency medical-services
personnel
• Otherwise, the rule recommends transportation to the hospital,
in accordance with routine practice

• Other special situations:
o In a newly born baby with no detectable heart rate that
remains undetectable for 10 minutes, it is appropriate to consider
stopping resuscitation
o Traumatic arrest (perform emergency thoracotomy if
appropriate; closed-chest CPR is ineffective)
o When rescuers are exhausted (in the prehospital setting)
o If the patient is irrefutably dead!! (e.g. rigor mortis,
decomposition, hemisection, decapitation)

P.A.L.S.

PALS
• It is pediatric advanced life support
• For pediatric
1. Cardiac arrest
2. Bradyarrythmias
3. Tachyarrhytmias etc

PALS
• Pediatric CPR is followed with 1-rescuer and 2- rescuer guidelines
• Start with chest compressions as soon as cardiac arrest is detected (no
responsiveness, no breathing and no pulse)
• Chest compressions –
o For children – 1.5 inches to 2 inches deep
o Once the child reaches puberty we can give 2 inches to 2.4 inches deep
compressions same like adult guidelines
o For 1-rescuer –ratio of 30:2 (30 compressions: 2 rescue breath)
o For 2- rescuer – ratio of 15:2
o Compression rate should be 100-120/min

PALS
• Mouth to mouth or mouth to nose breathing can be given after perfoming
chin lift head tilt or jaw thrust giving 1 breath every 3-5 seconds with a
goal of 12-20 breaths per minute
• Bag and Mask ventilation is always batter and commonly used in IHCA (In
Hospital Cardiac Arrest)
• There is no role of atropine prior to intubation to avoid bradycardia
• Once the AED is available, attach paddles immediately and simulteneously
continue compressions with minimum/no interruptions

PALS
• After giving 2 breaths, immediately give 30 compressions. The
lone rescuer should continue this cycle of 30 compressions
and 2 breaths for approximately 2 minutes (about 5 cycles)
before leaving the victim to activate the emergency response
system and obtain an automated external defibrillator (AED) if
available

PALS
• When child is intubated then give 1 breath every 6 seconds
• Goal in intubated children is to maintain breathing rate of 10
breaths per min
• Defibrillation in pediatric ALS-
o 1ST SHOCK – upto 2 joules per kg
o 2ND SHOCK – upto 4 joules per kg
o SUBSEQUENT SHOCKS – should be more than 4 joules per kg ,
maximum upto 10 joules per kg

Medications in PALS

DRUGS IN PALS
• Adrenaline –
o Dose - 0.01mg/kg
o Repeated every 3-5 mins
o Can be given via endotracheat route with a dose of 0.1 mg/kg
• Amiodarone –
o Dose - 5mg per kg during cardiac arrest
o May repeat 2 times in case of refractory VF or pulseless VT

DRUGS IN PALS
• Lignocaine –
o Loading dose : 1mg per kg
o Maintainance dose : 20-50 micgm per kg per min infusion
o Can repeat bolus dose if infusion started more than 15 mins
after the loading dose

PREGNANCY & CPR
• In pregnant woman, because of gravid uterus and IVC
compression, enough venous return is not achieved so CPR
with 2 – rescuers is recommanded with one rescuer pushing
the uterus to the left side s and 2nd rescuer to give chest
compressions
• Patient should on a flat surface or if IHCA situation and table
can be tilted then slight leftward tilt can be allowable
• Compression rate – 30 compressions: 2 breaths

Pregnancy & CPR
• Risk of aspiration of gastric content more
• Advanced airway management can be used if available which
reduces risk of aspiration
• Emergency C-section should be done

THANK YOU