M2Resuscitation and Initial Management of Acutely Ill

Resuscitation and Initial Management of Acutely Ill
Video Transcript
Chain of Survival and Adult BLS
By the end of this topic, you will be able to:
• Recall the steps of the Chain of Survival
• Explain the difference between heart attack and cardiac arrest
• Describe the steps involved in BLS or Basic life support primary survey for adults and
• Recall the basic steps of 1 and 2 rescuer CPR for adults
The first point of contact with an acutely ill patient requires the clinicians to take appropriate
action to prevent or correct the physiological deterioration of the patient. This challenge can be
met by following the structured approach towards the patient management inculcating the
resuscitation algorithms. In this topic, we will discuss the General Concepts of adult Basic Life
Support.
Basic life support or BLS is a life-saving technique, which is used for patients with life-
threatening injuries or illness. Early initiation of BLS increases the probability of survival for a
victim with cardiac arrest. Following an adult chain of survival increases the odds of surviving a
cardiac event.
The chain of survival represents the steps of care required for the survival of the victim of
cardiac arrest. It also shows the link between events that are necessary to maximize the
chances of survival of the victim following a cardiac arrest.
The 5 steps in the adult Chain of Survival include:
Step 1 is recognition of cardiac arrest and activation of the emergency response system
Step 2 is early high-quality CPR with an emphasis on chest compressions
Step 3 is rapid defibrillation
Step 4 is to provide Basic and advanced life support
Step 5 is to provide Advanced life support and post-cardiac arrest care
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Now let’s understand the epidemology of cardiac arrest and how it is different from heart
attack.
Sudden cardiac arrest or SCD is the sudden cessation of cardiac activity leading to
unresponsiveness in patients with or without cardiac disease. Globally, about 7 million deaths
are associated with sudden cardiac death. No reduction in mortality associated with sudden
cardiac death in the past three decades. In India, the overall mortality rate associated with
sudden cardiac death is about 10.3% of overall mortality.
Basic life support and prompt administration of cardiopulmonary resuscitation or CPR can lead
to successful revival in many individuals. Cardiac arrest is reversible if the victim is
administered prompt and appropriate emergency care. This generally involves administration of
CPR, shock treatment to the chest to reset the heart's rhythm also known as defibrillation and
advanced life support. If CPR is performed in the first few minutes of the cardiac arrest, the
chance of survival of the victim is more than 50% to 75%.
The term "Cardiac Arrest" is often confused with the term "Heart Attack" but these two are
distinct conditions. A heart attack is caused due to impairment or blockage of blood circulation
to the heart. Some individuals who experience heart attack can go into cardiac arrest as a
complication. Cardiac arrest can be caused by other causes also such as congenital and
acquired heart diseases, electrocution or electrical shock, drowning, severe injuries and
illnesses.
Cardiac arrest occurs when the heart is unable to pump blood due to an abnormal rhythm,
whereas heart attack occurs when the blood flow to an area of the heart is blocked. Cardiac
arrest is caused by the development of abnormal heart rhythm, which obstructs heart from
pumping the blood. Heart attack is caused by clot formation in the blood vessels in the heart.
The symptoms of cardiac arrest include gasping or lack of breathing and unresponsiveness.
The clinical manifestations of heart attack include chest discomfort, shortness of breath,
sweating, and nausea.
The basic life support for an adult with cardiac arrest involves rapid initial assessment also
known as primary assessment followed by high quality CPR.

When preparing to provide basic life support to a victim, you should conduct an initial
assessment or primary survey. It helps in identifying and dealing with immediate and life-
threatening conditions. The acronym - ‘D-R-Call-ABC' or 'Doctor Call ABC’ will help you remember
the steps involved in the primary survey.
The steps of the primary survey include:
Step 1 is to Assess Danger
Step 2 is to Check Responsiveness
Step 3 is to Call Ambulance
Step 4 is to Assess ABCs of life support that is Airway, Breathing, and Circulation
Let’s see each of these steps in detail.
The initial step of primary survey is to assess the danger. When you find that a person is
collapsing or unconscious, approach him or her carefully. Check the surroundings for the
potential dangers such as fumes, electrical hazards, broken glass, and traffic. Checking the
surroundings will not only ensure safety but also help you to find the cause of the collapse. If
the surroundings are safe, place the victim on his or her back on a firm surface. If the victim is
too large to be moved, you can seek help from bystanders. All the clinicians and rescuers
should wear personal protective equipment such as gloves and eyewear before initiating basic
life support.
The second step of primary survey is checking responsiveness. For this, you must kneel next to
the victim's neck and shoulder to check the responsiveness. Always approach the victim from
their feet as it prevents hyperextension of the neck from a conscious victim. You can assess the
victim's responsiveness by tapping the victim and speaking loudly to them. Check for signs of
life such as blinking, breathing, and movement.
Use 'AVPU' scale while assessing the victim's responsiveness.
A is Alert: Check if the victim is moving or talking. Place your hand on the victim's shoulders
and gently shake them and ask "Are you OK?" If there is no response, Proceed to V
V is Voice: Check if the victim is responding to your speech. If No- Proceed to P

P is Pain: Check if the victim is responding to painful stimuli. If No- Proceed to U
U is Unresponsiveness: Establish that the victim is unresponsive.
The next step after checking the victim’s responsiveness is to call for an ambulance and get
assistance from bystanders.
Step 4 is to assess the responsive victim.
If the victim is responsive and talking without wheezing or airway compromise, then consider
that the airway is clear. Then check the victim's breathing by taking a quick note of the
respiratory effort, speaking pattern, depth, and rate and simultaneously assess pulse. If the
victim is breathing normally and pulse is present, then roll the victim on to his or her side into
the recovery position and monitor until he or she receives medical help. Never place a victim
who has a suspected head or spinal injury in the recovery position because it disrupts the spinal
alignment and causes further damage to the spinal cord.
Assess the breathing of the patient by using look, listen, and feel technique. The steps to assess
breathing include:
Step 1 is to look for chest movements.
Step 2 is to listen breathing sounds carefully by placing your ear about 1 inch above the
victim's nose and mouth.
Step 3 is to feel for the movement of air from the nose or mouth.
Assess circulation by checking the carotid pulse or radial pulse. You can find the radial (wrist)
pulse easily at the base of the thumb. However, it is difficult to feel a radial pulse in an
unconscious person. Therefore, you should check the carotid pulse if the victim is
unconscious.
For locating the carotid pulse, Place your index and middle fingers lightly on the victim's trachea
or Adam's apple. Then, lightly move your fingertips down into the groove of the neck to the
where the carotid artery is located. Now, you can feel the pulse in the groove between the larynx
and sternocleidomastoid muscle. You should assess the airways, breathing and pulse within 5

seconds and take not more than 10 seconds. Checking the victim's breathing and pulse
simultaneously will help you to complete the assessment within 5 to 10 seconds.
Before initiating CPR, check for the breathing and listen carefully for no more than 10 seconds.
In case a victim is not breathing or only gasping and has no pulse,
• You need to initiate CPR immediately as the victim has had a cardiac arrest
• One cycle of CPR is 30 chest compressions and 2 rescue breaths. If available, use
automated external defibrillation or AED
According to the American Heart Association, the recommended sequence of CPR for the lone
rescuer is to initiate compressions, second is to open the airway and then, give rescue breaths.
If the patient has pulse, provide 10 rescue breaths per minute that is one breath every 6
seconds. If the patient doesn’t have pulse, initiate the 5 cycles of CPR that lasts for
approximately 2 minutes.
Let’s begin with compressions.
Chest compressions consist of the fast and deep application of pressure on the lower half of
the sternum. An early high-quality chest compression improves blood flow to the vital organs
and will improve the chance of survival of the victim. Proper placement of your hand on the
victim's sternum will help you to deliver high-quality chest compressions.
Firstly, place the victim on his or her back on a flat and firm surface and kneel next the victim’s
neck and shoulder. Next, locate the correct hand position for CPR by following these steps.
Place the heel of your other hand next to your index finger so that the thumb side is next to your
index finger. The heel of your hand is now over the lower half of the sternum, which covers the
compression site. Then, place your other hand on top of the first and lock your fingers together.
Now exert firm downward pressure to depress the sternum at least 2 inches that is 5 cm or
centimeter using the weight of your body not just your arms. Next, Release the pressure without
removing your hands from the chest. Releasing pressure allows the chest to recoil and lets the
heart to fill with blood. Give 30 Compressions, counting each one out loud, " one, two, three"
This will enable you to achieve at least 100 compressions per minute.

The methods to open the airways include head tilt or chin lift maneuver and jaw-thrust
maneuver. Head tilt or chin lift maneuver is the most simple, easy and quick method to relieve
an obstruction in the airways. The jaw-thrust maneuver is another method for opening the
airways. It is most commonly used for patients with a suspected cervical spine injury or injury to
spine in the neck region.
Rescue breathing is a simple skill of blowing air into the lungs of a person who is not breathing.
While performing rescue breathing, you should first give two breaths to the victim and check the
pulse. If the pulse is present but the victim is not breathing, then continue to breathe for patient.
Deliver each rescue breath over 1 second, which is enough to produce visible chest rise. It is the
best method to check for chest rise after providing each breath. If the victim's chest does not
rise, then reposition the head and try rescue breathing again. If the patient still does not
respond, then suspect an airway obstruction and follow the maneuvers to open the airway.
Never perform a blind finger sweep as it can push the foreign particles if any in the throat
further deep into the airways. The rescue breathing rate for adults (onset of puberty and older)
is one breath every 5 to 6 seconds or 10 to 12 breaths per minute.
The methods of rescue breathing include Mouth to mouth, Mouth to nose, Pocket mask and
Bag-valve mask resuscitator.
Mouth to mouth Ventilation is the basic method for providing ventilation to apneic (temporary
suspension of breathing) patients. It does not require any special equipment to perform. The
exhaled air of a person contains about 16% oxygen, which is sufficient to provide adequate
oxygenation to a victim.
Here are the steps to perform mouth-to-mouth rescue breathing:
Step 1: Position yourself at the victim's head.
Step 2: Place your hand on the victim's forehead. Pinch his or her nose and close it with your
fingers.
Step 3: Make an air-tight seal by placing your mouth over the patient's mouth.
Step 4: Give two consecutive breaths. Each breath should be given over 1 second.

Step 5: Remove your mouth between breaths as it breaks the seal and allows the air to
escape.
Step 6: Take a break before re-sealing over the victim's mouth.
If you are unable to make a complete seal over a victim’s mouth, you can provide mouth-to-nose
ventilation by following these steps:
Step 1: Tilt the victim's head back and close the mouth by pushing his or her chin.
Step 2: Seal your mouth around the victim’s nose and breathe into the nose.
Step 3: If possible, open the victim’s mouth between ventilation to allow air to escape.
The pocket mask is a barrier device, which protects you from contact with the victim's blood,
vomitus and saliva while providing rescue ventilation. They provide a tight seal and allows to
supply the maximum amount of air to the victim during ventilation. Use an adult pocket mask
for an adult patient so that it covers the nose and mouth. Follow these steps while using a
pocket mask for rescue breathing:
Step 1: Position yourself at the victim's head. Assemble the mask and valve.
Step 2: Place the mask over the mouth and nose of the victim starting from the bridge of the
nose, then place the bottom of the mask below the mouth to the chin (the mask should not
extend past the chin).
Step 3: Open the victim's airways using the head tilt-chin lift maneuver
Step 4: Seal the mask by placing your index finger and thumb on the top of the mask above
the valve while placing your remaining fingers on the side of the victim’s face.
Step 5: Breathe into the one-way valve attached to the pocket mask. Each breath should
occur over a period of 1 second just enough to produce visible chest rise.
Step 6: Release pressure on the mask to allow air to escape.
A bag-valve mask is a handheld device, which is used to provide positive-pressure ventilation to

a victim who is not breathing normally or has a respiratory arrest. It consists of a self-inflating
bag attached to one-way valve that attaches to a face mask, tracheal tube, or supraglottic
device.

It administers higher concentration of oxygen than a pocket mask. If an oxygen reservoir is

attached to the bag-mask device, 100% oxygen can be delivered with a flow rate set between 12
and 15 liters per minute. If not attached to an oxygen flow, it provides nearly 21% oxygen from
surrounding air. Evidence suggests that bag-valve mask ventilation is most effective when
provided by two trained and experienced rescuers.
One-Person bag-valve mask ventilation:
You should follow these steps:
Step 1: Select appropriate size of the mask based on the victim's face so that it covers the
nose and mouth.
Step 2: Position yourself at the victim's head.
Step 3: Determine that the victim is not breathing.
Step 4: Apply the narrow portion (apex) of the mask over the bridge of the victim's nose.
Step 5: Stabilize the mask in place with your thumb and lower the mask over the patient's
face and mouth
Step 6: Grasp the mask and the victim's jaw with one hand.
Step 7: Use your index finger and thumb to stabilize the wide end of the mask over the
groove between the lower lip and chin. Use your remaining fingers to maintain proper head
position.
Step 8: When the mask is placed in proper position, your thumb, index finger creates a C, and
your remaining fingers create an E. This technique is known as E-C clamp technique and it
will create a good seal between the mask and face.
Step 9: Squeeze the bag completely with other hand and watch for visible chest rise. Allow
the bag to re-inflate slowly and completely. Aim to provide 10 to 12 breaths per minute.
Step 10: Attach oxygen if available at a flow rate of 12 to 15 liters per minute.
In case of Two-Person bag-valve mask ventilation, the steps would be:
Step 1: The first person maintains the mask seal by using an E-C clamp technique.

Step 2: The second person squeezes the bag completely over 1 second to provide visible chest
rise.
Let’s have a look at the steps involved in providing support to a victim by one rescuer.
Step 1: Make sure the scene is safe.
Step 2: Check the victim's responsiveness by using 'AVPU' scale
Step 3: Activate the emergency medical service or EMS or call for an ambulance.
Step 4: Check the victim's airways, breathing, and pulse.
Step 5: Position the victim in supine position on a hard, flat surface.
Step 6: Immediately remove start giving chest compressions at a rate of 100 per minute.
Step 7: Continue the cycle of 30 compressions followed by 2 breaths until the AED or
automated external defibrillator arrives, or help arrives, or the person begins to move.
Here are the steps involved in providing support to a victim by two rescuers.
Step 1: Make sure the scene is safe.
Step 2: Rescuer 1 should Check the victim's responsiveness by using ‘A-V-P-U' scale and check
the victim's airways, breathing, and pulse within 5 to 10 seconds. Rescuer 2 should Activate the
emergency medical service or call for an ambulance
Step 3: Rescuer 1 positions the victim in supine position on a hard and flat surface and begins
the one rescuer CPR until the second rescuer returns.
When the second rescuer returns after activating the EMS, he or she should assist the first
rescuer in performing CPR.
Rescuer 1: Gives chest compression at a rate of 100 per minute.
Rescuer 2: Provides rescue breathing by opening the airway using the head tilt-chin lift method.
Change position every 2 minutes as the rescuer performing chest compressions becomes only
40% effective with their compressions after providing 5 cycles of chest compressions due to
unrecognized fatigue. Therefore, after completing 5 cycles of CPR, the second rescuer should
be allowed to provide chest compression and the first rescuer should provide rescue breathing.

Now that we have come to the end of this topic, let’s recall what we have learnt
BLS is considered the basis for care in case of cardiopulmonary resuscitation. BLS is the
primary sequence of resuscitation that save lives, which may include:
• Immediate identification of the condition

• Activation of the emergency response
• Early CPR and defibrillation

Video Transcript
Pediatric Basic Life Support
By the end of this topic, you will be able to
• Describe the steps involved in primary survey and
• Recall the basic steps of 1 and 2 rescuer CPR for children and infants
For the purpose of BLS, anyone younger than 1 year is considered an infant. Anyone over the
age of 1 but has not yet reached puberty is identified as a child. Puberty can be identified by the
presence of chest hair or underarm hair in boys or development of breast in girls. There are
basic differences in providing CPR or Cardiopulmonary resuscitation for infants, children, and
adults:
• The method of chest compressions
• The compressions and breath ratio
• The depth of compression
• These differences are due to anatomical differences in infants and children such as the
presence of smaller airways and flexible sternum when compared to adults.
The emergency conditions in which infants and children require CPR are different from those of
adults. In adults, cardiac arrest commonly occurs before a respiratory arrest, but it is vice versa
in infants and children. In most cases, cardiac arrest in children results from respiratory arrest.
Some of the common causes of respiratory arrest in children are Drowning, Airway infection
Sudden infant death syndrome or SIDS, Aspiration of foreign objects such as peanuts, candy,
small toys.
The basic life support for a child with respiratory arrest involves rapid initial assessment also
known as primary assessment followed by high quality CPR or Cardiopulmonary resuscitation.
When preparing to provide basic life support to a victim, you should conduct an initial
assessment or primary survey. It helps in identifying and dealing with immediate and life-

threatening conditions. The acronym 'DR Call ABC' or 'Doctor Call ABC will help you remember
the steps of the primary survey.
Assess breathing by using look, listen, and feel technique. If the victim has normal breathing,
monitor him or her until additional help arrives. If the victim is not breathing or is only gasping,
provide rescue breathing.
While providing rescue breathing to an infant, you must remember that an infant is tiny and
must be treated extremely gently. The steps in rescue breathing for an infant are as follows:
Begin the rescue breathing by covering the infant's mouth and nose with your mouth. Blow
gently into the infant's mouth and nose for 1 second. Look for the chest rise with each breath.
Remove your mouth and allow the lungs to deflate. Use small puffs of air that are enough to
make the chest rise. After providing first two breaths, give one rescue breath every 3 to 5
seconds or 12 to 20 rescue breaths per minute. Do not overinflate the infant's lungs.
While providing rescue breathe for children, you need not apply much force to open the airways
and tilt their heads. The rate of rescue breathing is slightly faster for children than adults. Give 1
rescue breath every 3 to 5 seconds or 12 to 20 rescue breaths per minute.
Check brachial pulse in the infants as it is difficult to detect carotid artery in infants due to
shortness and chubbiness of the neck.
Steps to locate brachial pulse:
• Brachial pulse can be found on the inside of the upper arm.

• Place your index and middle fingers on the inside of the upper arm.
• Press gently, so that you do not collapse the artery.
• Feel the pulse for at least 5 seconds but not more than 10 seconds.
Check for carotid or femoral pulse in children. Steps to locate femoral pulse:
• Place index and middle finger in the inner thigh, midway between the hipbone and the
pubic bone.
• Feel the pulse for at least 5 seconds but not more than 10 seconds.

You can also check for signs of poor perfusion such as cool extremities, reduced
consciousness, weak pulse, pale skin, and cyanosis (turning blue). You should take at least 5
seconds to assess the victim's airways, breathing and pulse but not more than 10 seconds. To
prevent delay in initiating CPR, you can assess breathing and pulse simultaneously. In infants
and children, the cardiac output is dependent on the heart rate, so you should start chest
compressions if the heart rate is less than 60 beats per minutes. If you do not feel a pulse within
10 seconds, then initiate CPR and begin chest compressions.
An obstructed airway can cause respiratory arrest in children and infants. So check for airway
obstruction. The most common cause of airway obstruction in an unconscious child is due to a
foreign object or due to falling back of the tongue that is large relative to the size of oropharynx.
You can use head tilt-chin lift method to open the airways. Never perform a blind finger sweep
as it can push any foreign object (if present) further back into the airways.
According to the American Heart Association, the recommended sequence of CPR for the lone
rescuer is to initiate compressions, second is to open the airway and then, give rescue breaths.
If the victim is not breathing and has weak or no pulse, then initiate CPR. The rate of
compression is similar for infant, child and adult but the position and technique of providing
compressions is different for infants and younger children because of infant's smaller size.
Further, the compression and breath ratio differs in infants and children based on the number of
rescuers. To begin CPR, place the victim in a supine position on a hard, flat surface. Place the
victim's hands alongside the body.
To open the airway, the degree of tilt is different in infants and children. In infants use a neutral
position and, in a child, use a sniffing position (extension of the neck and flexion of the head).
You should not hyperextend the victim's neck as it can cause the trachea to collapse or narrow
down, resulting in blockage of the airway. In case of a suspected spinal injury, perform jaw-
thrust method to open the airways.
In case of single rescuer and the victim has pulse, follow the steps given below:
Step 1 is to give 12 to 20 breaths per minute
Step 2 is to check the pulse every 2 minutes

In case of single rescuer and the victim doesn’t have pulse, follow the steps given below:
Step 1 is to Call the EMS immediately and start giving chest compressions at a rate of 100 to
120 per minute.
Step 2 is to push the chest hard and fast. Press down at least 2 inches or 5 cm if the victim is a
child and 1.5 inches or 4 cm if the victim is an infant. Establish a regular rhythm. Allow the chest
to recoil during the compressions.
Step 3 is to give 30 compressions then open the airways by head tilt-chin lift method and give 2
breaths by using any of the rescue breathing methods. Each breath should take only 1 second
and each breath must make the chest rise.
Step 4 is to call EMS after providing 5 cycles of CPR if not called already.
You must continue compressions and breaths in a ratio of 30:2 until the AED or automated
external defibrillator arrives, or help arrives, or the victim begins to move. If the victim shows
signs of life such as coughing, breathing or movement, then place him or her in the recovery
position and monitor until a health care provider or paramedics arrive.
If two rescuers are present for providing CPR, 2 breaths should be provided after every 15
compressions to the victim. Continue compressions and breaths in a ratio of 15:2 until the AED
arrives, or help arrives, or the victim begins to move. If the victim shows signs of life such as
coughing, breathing, or movement, then place him or her in recovery position and monitor until
the health care provider or paramedics arrive. For children the chest compression can be done
either with one or both the hands as done in adults depending on the size of the child. For a very
small child, 1-hand compression may be adequate to achieve the desired compression depth,
whereas for a big child, you may have to use both the hands to provide adequate compression.
The chest of an infant is smaller and more flexible than an adult. So, you should not use both
the hands to compress the chest. In an infant, the chest compression can be performed either
by using two-finger technique or by two thumb-hands encircling technique.

Two-Finger technique is most commonly used by a single rescuer to provide chest

compressions to an infant.
You can follow these steps to provide chest compressions:
Step 1 is to place the infant in a supine position on a flat and hard surface.
Step 2 is to position yourself so that your knees are alongside the infant's chest.
Step 3 is to place your two fingers (Preferably middle and index finger) of your dominant hand
over the lower half of the sternum, approximately 1 finger breadth below an imaginary line
located between the nipples of the infant.
Step 4 is to compress the sternum approximately 1 by 3rd of the infant's chest that is 1.5 inch or
4 cm with your fingers.
Step 5 is to perform the compressions at a rate of at least 100 per min. Allow the chest to
completely recoil between the compressions.
Provide compressions and breaths in a ratio of 30:2 until the AED is available or help arrives.
Two thumb-hands Encircling method is used when two or more rescuers are present. You
should follow the steps give below to provide chest compressions using two thumb-hands
encircling technique:
Step 1 and 2 are similar to two-finger technique.
Step 3: is to place both your thumbs side by side over the lower half of the infant's sternum,
approximately 1 fingerbreadth below an imaginary line located between the nipples of the
infant. (You may need to overlap your thumbs in very small infants).
Step 4: is to encircle the infant's chest and support the infant's back with the fingers of your
both hands. With your hands encircling the chest, depress the infant's sternum about
1.5 inches or 4 cm using your thumbs.
Step 5: is to perform the compressions at a rate of at least 100/min. Allow the chest to
completely recoil between the compressions.

Step 6: After 15 compressions, pause briefly and allow the second rescuer to open the
airways and deliver two breaths. Allow the chest to recoil completely between the
compressions.
Step 7: is to provide compressions and breaths in a ratio of 15:2 until the AED is available or
help arrives.
The steps to be followed in case of two rescuers for providing pediatric BLS are given below:
Step 1: is to Make sure the scene is safe.
Step 2: Rescuer 1 should Check the victim's responsiveness by using 'AVPU' scale and check
the victim's airways, breathing, and pulse within 5 to 10 seconds. Rescuer 2 should Activate the
emergency medical service or EMS or call for an ambulance.
Step 3: Rescuer 1 positions the victim in supine position on a hard and flat surface and begin
the one rescuer CPR until the second rescuer returns.
Step 4: When the second rescuer returns after activating the EMS, he or she should assist the
first rescuer in performing CPR.
○ Rescuer 1 Gives chest compressions at a rate of 100-120 per minute. Establish a

regular rhythm and allow the chest to recoil after each compression. Give 10
compressions and pause for 2 seconds allowing the other rescuer to give rescue
breathing. Remember, compressions should be paused for rescue breaths.
○ Rescuer 2 Provides rescue breathing by opening the airway using head tilt-chin
lift method. Give 2 breaths after 15 compressions, each breath should take only 1
second and make the chest rise.
Change position every 2 minutes as the rescuer performing chest compressions becomes only
40% effective with their compressions after providing 5 cycles of chest compressions due to
unrecognized fatigue. Therefore, after completing the 5 cycles of CPR, the second rescuer
should be allowed to provide chest compression and the first rescuer should provide rescue
breathing. The victim's pulse and breathing should be assessed at 2 minutes interval. The
rescuers should try to work on opposite sides of the victim so that they can switch their roles
easily within 5 seconds without getting in each other's way. Continue cycles of 15

compressions and 2 breaths until the victim becomes responsive or until help reaches. If the
victim shows signs of life, then place him or her in the recovery position and monitor until help
arrives.
Pediatric BLS includes:
• Prevention of complications
• Early CPR
• Prompt access to emergency response system
Immediate CPR improves the survival from cardiac or respiratory arrest in children

Video Transcript
Automated External Defibrillator
At the end of this topic, you will be able to:
• Identify the parts of an Automated External Defibrillator device.

• Identify and explain the steps for the correct use of AED. and
• Recognize the use of AED in special circumstances.
An automated external defibrillator or AED is a computerized, portable electronic device that

can identify a situation of abnormal heart beats, which need an electric shock to treat. Such
abnormal heart rhythm may be due to ventricular fibrillation or ventricular tachycardia. In either
situation, an automated external defibrillator can be used to provide defibrillations to set right
the electrical rhythm of the heart. AED in combination with effective cardiopulmonary
resuscitation is a critical part of Chain of Survival.
Automated external defibrillators provide simple audio and visual commands to the
layperson. Automated external defibrillators are simple to use. The parts of the device include
On or off button, defibrillator pads, active status indicator, and softkey buttons. Let’s now
understand how to use an AED.
Here are the steps for the correct use of automated external defibrillator.
Step 1: is to Switch on the device. The AED device pads need to be attached to the skin of the
victim’s chest.
Step 2: is to remove any clothing from the patient’s upper body. Ensure that the patient’s chest
is exposed and that it is dry. Wipe away any sweat or water droplets from the victim’s chest.
Step 3: is to select the appropriate size of the pads to be applied to the patient. Adult sized pads
should be used for adults and children above the age of 8 years, or over 25 kilograms weight.
Placement of the pads should be done correctly. Usually, the pads will show where they should
be placed on the body. One pad should be attached to the left side, below the nipple, with the
top edge of the pad below the armpit. The other pad should be attached to the upper right chest,
directly below the right collarbone.

Step 4: is to plug in the connector. Depending on the device type, the AED will start
automatically analyzing the victim’s heart rhythm, or you will have to press a button for the
analysis to start. During analysis and while delivering a shock, the victim should be left alone,
that is, no one should touch the victim. The device will prompt you to ‘clear’ the victim, that is,
make sure that no one is touching the victim. This will help in precision in analysis during the
analysis phase, and avoid the rescuer incurring an electric shock during the shock phase.
Step 5: Once the analysis is done, automated external defibrillator will prompt whether or not a
shock is required. If yes, press the shock button to administer an electric shock to the victim.
Once the shock is administered, immediately resume providing compressions to the victim. If
no shock is advised, immediately resume providing compressions to the victim. The
compressions should be continued at the ratio of 30 compressions and 2 breaths, till the
automated external defibrillator prompts to clear the victim for the next analysis.
Here are some special circumstances where the use of AED requires certain safety measures.
An automated external defibrillator can be used around water, and in case of light rain, mist, or
snow. Such circumstances usually do not pose any issue in using automated external
defibrillator. However, if the patient is lying in the water, bring him/her out of the water and wipe
the chest dry before using the automated external defibrillator. The AED device and the pads
should be kept dry for maximum safety. The rescuers and the patient should be out of the water
and sheltered from the rain before automated external defibrillator use.
Automated external defibrillator device is totally safe to use even if the patient is lying on a
metal surface. The rescuer only needs to ensure that the automated external defibrillator pads
are not in direct contact with the metal surface.
AED device is totally safe to use even if the patient is lying on a metal surface. The rescuer only
needs to ensure that the AED pads are not in direct contact with the metal surface.
The method of usage of AED for child and infant remains the same. However, for children and
infants, smaller sized pads are usually available with the AED. Child pad should not be used for
adults, as the electricity voltage delivered would not be enough for an adult.
However, in case child pads are not available, the adult pads may be used for a child. Ensure
that the two pads do not touch each other. Placement of the pads for infants is done differently.

Usually, one pad is placed on the front in the middle of the chest, and another on the back,
between the scapulae.
Now that we have come to the end of this topic, let’s recall what we have learnt:
Automated external defibrillation in combination with effective CPR is a critical part of ‘Chain of
Survival’. Early defibrillation is the most important determinant of chain of survival in case of
cardiac arrest due to ventricular defibrillation.

Video Transcript
Relieving Choking
• Identify and explain the symptoms of choking and causes of airway obstruction
• Describe the steps to relieve choking in infants, children and adults
A choking incident can occur anytime and anywhere, to anyone. Therefore, it is important for a
person to know the basic skills to relieve choking and provide first aid to the victim. Choking is
the inability to breathe due to an airway obstruction. The common symptoms of choking in
adults and children include:
• Inability to speak
• Weak-ineffective coughing
• High-pitched sounds while inhaling
• Grabbing the throat with hand (which is a natural response to choking – the victim grabs
his or her throat with one or both hands to indicate choking)
• Wheezing and
• Cyanosis (a bluish discoloration of skin due to reduced oxygen supply).
The signs of airway obstruction in an infant are Silent cry, Silent cough, Difficulty in breathing
and Bluish discoloration of skin also known as cyanosis.
The causes of airway obstruction in an infant include Obstruction of food particles, Obstruction
of foreign objects and Swelling of airway passages. We will now discuss the techniques to
relieve choking in adults and children.
The techniques of relieving choking in adults and child that is one year to onset of puberty
remain same. However, the technique of relieving choking in infants is completely different and
will be discussed in the later part of this topic. If you find a person choking, encourage the
victim to be calm and cough hard to expel the object from the airway. If the object is not
expelled by coughing or if the victim is unable to cough hard then provide abdominal thrust, also
called as Heimlich maneuver.

To provide abdominal thrust to a victim who is choking, you must follow certain steps for
effective outcomes.
Step 1 is to Stand behind the victim and perform the abdominal thrusts while the patient is
standing or seated in a chair.
Step 2 is to locate the xiphoid process, the bottom of the sternum and the navel. Place your fist
above the victim's navel and much below the xiphoid process. The thumb side of your fist
should be against the victim's abdomen.
Step 3 is to grasp the fist with the other hand holding the abdomen of the victim.
Step 4 is to apply upward abdominal thrusts sharply and firmly. Apply pressure at the point
where your fist contacts the victim's abdomen. Each thrust should be sharp and forceful.
Step 5 is to repeat the abdominal thrusts until the foreign object is expelled or until the patient
becomes unresponsive.
If the victim is obese or pregnant then provide chest thrusts to expel the foreign object. To
provide chest thrust, stand behind the victim and place your arms under the victim's armpits
encircling the victim's chest. Now, press the victim's chest with quick backward thrusts. Repeat
the chest thrusts until the foreign object is expelled or until the victim becomes unresponsive.
If the victim becomes unresponsive during the abdominal or chest thrusts, then place the victim
in a supine position on a hard, flat surface and initiate CPR or Cardiopulmonary resuscitation.
While providing CPR, check for the foreign object each time you open the victim's airway for
rescue breathing. If the foreign object is visible and loose then remove it using finger sweep
method. Never perform a blind finger sweep as it may push the foreign object further back into
the respiratory tract. Activate EMS after providing 5 cycles of CPR. Continue providing CPR until
help arrives. Let’s now have a look at the steps to relieve choking infants.
Step 1: To relieve choking first place the infant in a facedown position over your arms. Support
your forearm on your thigh. Ensure that the infant's head is lower than the trunk.
In the step 2, use the heel of your other hand and deliver up to five back slaps forcefully between
the infant's shoulder blades.

In the step 3, use Support the head and turn the infant face up by placing the infant between
your hands and arms. Rest the infant on his or her back on your thighs with his or her head
lower than the trunk.
In the step 4, deliver 5 chest thrusts in the middle of the sternum using the two-finger technique.
Finally, in the step 5, repeat the abdominal thrusts until the foreign object is expelled or until the
patient becomes unresponsive.
If the infant becomes unresponsive, place the infant on a flat and hard surface on his or her
back and provide CPR. If you are a single rescuer, start CPR with 30 chest compressions and 2
breaths. Activate EMR after providing 5 cycles of CPR. If two people are available to perform
CPR then follow the 2-rescuer CPR, discussed in BLS for infants. Ensure to check for the foreign
object every time you open the airways for rescue breathing. Remove the foreign object only if
you can see it. Never perform a blind finger sweep as it may push the foreign object further back
into the respiratory tract. Continue providing CPR until help arrives.
A choking incident can occur at anytime and anywhere, to anyone. Therefore, it is important for
a person to know the basic skills to relieve choking and provide first aid to the victim. The
techniques of relieving choking in adults and child remain same. However, the technique of
relieving choking in infants is completely different.

Video Transcript
Systematic Approach – Overview
• Describe specific assessment and management that occur with each step of the
systematic approach
Physicians or healthcare providers should use the systematic approach to assess and treat
cardiac arrest, acutely ill or injured patients for optimal care. In a patient with cardiac or
respiratory arrest, the goal is to support the patient and to restore the active ventilation,
oxygenation, and circulation with intact neurologic function. An intermediate goal is the return
of spontaneous circulation or ROSC.
The components of systematic approach include BLS Assessment, Primary Assessment and
Secondary Assessment.
The steps involved in a systematic approach are:
• To determine whether the scene is safe or not?
• As you approach the patient, determine the level of consciousness.
• If the patient appears unconscious:
▪ For the initial evaluation, use the basic life support or BLS assessment.
▪ For more advanced assessment and treatment, after completing all the
appropriate steps of the BLS assessment, use the Primary and Secondary
assessments for further detailed evaluation.
• If the patient is conscious, then for the initial evaluation, use the Primary Assessment.
The steps included in the BLS assessment are:
Step 1 is to check for responsiveness of the patient. Tap the patient and shout "ARE YOU OK?"

Step 2 is to Shout for nearby help or activate the emergency response system. Use an AED if
one is available or activate the Emergency Response Team or ERT and get an AED
or defibrillator
Step 3 is to Check pulse and breathing. Check for abnormal or absent breathing. Ideally, the
pulse check is performed simultaneously along with breathing check to minimize the delay in
the detection of cardiac arrest and initiation of CPR or Cardiopulmonary resuscitation. Check
the patient's pulse for 5 to 10 minutes.
Step 4, if the pulse is not felt within 10 seconds, start CPR, beginning with chest compressions.
Initiate CPR with chest compressions. If there is a pulse, start to rescue breathing at one breath
every 5 to 6 seconds. Check pulse for every 2 minutes.
Step 5, If no pulse, check for a shockable rhythm with an AED or defibrillator as soon as
possible. Perform defibrillation. Begin with compressions and follow each shock immediately
with CPR
Avoid the following while providing BLS:
• Inappropriate or frequent pulse checks
• Prolonged analysis of rhythm
• Taking more time in providing the breaths to the patient
• Moving the patient unnecessarily
The primary assessment comprises the systematic CABDE approach to assess and treat the
critically ill patients. The CABDE stands for Circulation, airway, breathing, disability or
neurological assessment and exposure.
The secondary assessment involves a detailed medical history, identifying the underlying cause,
differential diagnosis, and treating the underlying cause that is H's and T's. Consider using the
mnemonic "SAMPLE".
S for Signs and symptoms
A for Allergies
M for Medications, including the last dose taken

P for Past medical history, especially relating to the current illness
L for Last meal consumed
E for Events
This table displays the emergency cardiopulmonary conditions and the potentially reversible
causes of cardiac arrest.
The most common causes of cardiac arrest are Hypovolemia, Hypoxia, Hydrogen ion that is
acidosis, Hypo or hyperkalemia, Hypothermia, Tension Pneumothorax, Tamponade that is
cardiac tamponade, Toxins, Thrombosis that is pulmonary thrombosis, Thrombosis that is
coronary thrombosis.
In cases of cardiac arrest, here are the steps you need to consider for identifying the underlying
cause:
• Analyze the ECG accurately for rhythm disturbances
• Identify if there is hypovolemia
• Look for signs of drug overdose or poisoning and
• Consider H's and T's that can cause pulseless electrical activity or PEA
The underlying conditions of cardiac arrest include Treating Hypovolemia, Acute coronary
syndrome, Pulmonary embolism, Pericardial Tamponade and Poisoning or Drug overdose
A common cause of PEA is hypovolemia. It usually presents with decreased systolic blood and
increased diastolic pressures and produces a physiologic compensation through rapid narrow
complex tachycardia or sinus tachycardia. Prompt treatment can reverse the pulseless state by
correcting the hypovolemia rapidly. Common non-traumatic causes of hypovolemia include
severe dehydration and unrecognized internal hemorrhage. Administer fluid infusions for PEA
associated with narrow-complex tachycardia.
In acute coronary syndrome cases, when large area of cardiac muscle does not get adequate
blood supply as seen in occlusion of the left main or proximal left anterior descending coronary
artery the pumping function of heart can reduce, and this can present as cardiogenic shock

rapidly progressing to cardiac arrest and pulseless electrical activity or PEA. Management of
ACS through fibrinolytic therapy is indicated in such cases.
Massive or saddle pulmonary embolism can obstruct the flow of blood in the pulmonary
vasculature and cause acute right heart failure. Treatment with fibrinolytic therapy is the
management needed in patients with known pulmonary embolism along with cardiac arrest.
Pericardial Tamponade can be a reversible cause. While definitive treatment is being planned
for the tamponade, volume infusion may be administered in the pre-arrest stage.
Specific harmful and toxic exposures and certain drug overdoses may lead to myocardial
infarction, peripheral vascular dilatation resulting in hypotension. In toxic exposures caused by
poisonous plants, urgent and aggressive treatment is essential as plant toxins will progress
rapidly. In these conditions, the arrhythmias and myocardial dysfunction may be reversible.
Treatments that can provide support at this level include Continuing basic CPR in special
resuscitation situations, Extra-corporeal CPR, Intra-aortic balloon pumping, Renal dialysis,
Intravenous lipid emulsion, Specific drug antidotes such as glucagon, bicarbonate, digoxin
immune Fab, Transcutaneous pacing, Reversal of severe electrolyte abnormalities such as
potassium imbalance, magnesium imbalance, calcium imbalance, acidosis, Specific
adjunctive medications.
Systematic approach is used to assess and treat cardiac arrest, acutely ill or injured patients for
optimal care. The component of systematic approach include BLS assessment, primary
assessment and secondary assessment. Prompt and timely management reduces the risk of
mortality

Video Transcript
Respiratory Arrest
• Discuss the common respiratory problems and

• Explain the management of respiratory arrest in detail
Respiratory arrest refers to the cessation of breathing. According to Advanced cardiac life
support or ACLS, respiratory arrest means that the respiratory activity of the patient is
completely absent or is insufficient to maintain adequate oxygenation. In the respiratory arrest
case, we discuss the management of patient with a pulse, but with absent respiration. The
present case discusses the right evaluation, interventions, and management options for a
patient in respiratory arrest, who is unresponsive and unconscious. Such cases must be
approached systematically, and the Basic life support or BLS, Primary, and secondary
assessments are to be performed during management.
Any deviation from these values can result in abnormal breathing activity.
• If the respiratory rate is less than 12 per minute, then it is known as bradypnea.
• If the respiratory rate is greater than 20 per minute, then it is known as tachypnea.
• If the respiratory rate is less than 6 per minute, it results in hypoventilation.
On the contrary,
• In an adult individual with normal breathing, the average rate of respiration is 12 to 16

per minute and
• The normal oxygenation and carbon dioxide elimination are maintained by a tidal volume
of 8 to 10 milliliters per kilogram.
To offer proper interventions and management procedures, the severity of the respiratory
problem must be identified. This can be done by carefully observing for specific signs and
symptoms.
The most common respiratory problems which require ACLS are:
• Respiratory distress

• Respiratory failure and
• Respiratory arrest
Raised respiratory effort such as nasal retraction, flaring
Irregular airway sounds such as wheezing, stridor, grunting
Agitation/change in the level of consciousness
Thermal and color changes of skin such as pale and cold skin; in case of sepsis, skin becomes
red, warm, and diaphoretic and
Tachypnea
Respiratory distress is a clinical condition characterized by abnormal that is increased or

inadequate respiratory effort or rate. Inadequate respiratory effort can be identified
by bradypnea or hypoventilation, while the increased respiratory effort is identified with nasal
retractions, flaring, and accessory muscle use.
Respiratory distress is categorized into two types.
Mild respiratory distress
Severe respiratory distress
Clinical Signs of Respiratory Distress include: Tachycardia
Respiratory failure is defined as a clinical condition where there is an inadequate oxygenation,

or ventilation, or both. Respiratory failure is characterized by hypoxia which is reduced oxygen
level in blood and hypercapnia which refers to increased carbon-dioxide in the blood. Lung
tissue pathology, airway obstruction that is upper or lower, and irregular control of breathing can
lead to respiratory failure.
Clinical Signs of Respiratory Failure
Respiratory failure can present with some of the important signs such as:
• Tachycardia (early)
• Bradycardia (late)
• Bradypnea, apnea (late)

• Cyanosis
• Significant tachypnea
• Decreased, increased, or no respiratory effort
• Decreased or no distal air movement and
• Coma
Complete absence or cessation of breathing is known as respiratory arrest. Many conditions

can cause respiratory arrest, such as head injury, electrocution or drowning. In cases of
respiratory arrest, the management approach is to externally provide a tidal volume of 6 to 7
milliliters per kilogram that is 500 to 600 milliliters, which is equivalent to the amount that can
make the chest rise. In cases of poor lung compliance or airway obstruction, high pressure is
required to achieve adequate ventilation and Resuscitation bag-mask device can be used to
deliver enough tidal volume in such cases.
When you encounter a patient with respiratory arrest, follow the systematic approach, when
evaluating the patient and continue with the BLS assessment. BLS assessment involves
assessing the patient for pulse and breathing. In patients who have respiratory arrest with pulse,
a bag-mask device may be used to provide ventilation once in every 5-6 seconds. During the
primary assessment, the healthcare provider decides on the need for the advanced airway. If
needed, advanced airway equipment such as a laryngeal tube, laryngeal mask, an endotracheal
tube, or esophageal-tracheal tube can be used.
BLS assessment involves assessing the patient for pulse and breathing. In patients who have
respiratory arrest with pulse, a bag-mask device may be used to provide ventilation once in
every 5-6 seconds. During the primary assessment, the healthcare provider decides on the need
for the advanced airway and if needed, advanced airway equipment such as a laryngeal tube,
laryngeal mask, an endotracheal tube (ET), or esophageal-tracheal tube can be used.
Now let us discuss about the supplementary oxygen administration:
Supplemental oxygen is to be administered in patients with acute cardiac symptoms or

respiratory distress. Monitor the oxygen saturation levels and titrate the supplemental oxygen to
maintain a saturation of 94% or higher and,
In cases of respiratory arrest and cardiac arrest, attempt to maintain oxygen saturation at
100%. Basic airway opening techniques will efficiently relieve airway obstruction. This

obstruction can be caused either due to relaxation of muscles in the upper airway or by the
tongue. Proper airway positioning is enough for patients who can breathe spontaneously. In
patients who are unresponsive and unconscious with no cough or gag reflex, to maintain the
patency of the airway, insert an Oropharyngeal airway also known as OPA or Nasopharyngeal
airway also known as NPA tube and if the patient was unconscious and was known to be
choking, then open the mouth wide and look for the foreign body. If you can see the foreign
body, remove it with your fingers and if you do not see the foreign body, start the CPR.
In airway management, the basic airway skills that are required to ventilate a patient include:
• Head tilt-chin lift
• In cases of suspected cervical spine trauma, Jaw thrust without head extension
• Mouth to mouth ventilation
• Mouth to nose ventilation
• Mouth to-barrier device (using a pocket mask) ventilation and
• Bag-mask ventilation
Let’s now explore the usage of basic airway adjuncts:
The Oropharyngeal Airway or OPA is a J-shaped device that holds the tongue and fits over it. It
keeps the soft hypopharyngeal structures away from the posterior wall of the pharynx. OPA is
usually preferred in patients who are at risk for developing airway obstruction due to relaxed
upper airway muscles and tongue. An OPA should not be used in the conscious and
semiconscious patients as it can stimulate gagging and vomiting. You must test if the patient
has an intact cough and gag reflex and avoid OPA in such patients. OPA is usually used in
unconscious patients, if head tilt-chin maneuver or when the jaw thrust maneuver fails to
provide and maintain an unobstructed clear airway in a patient. The OPA is also used to keep
the airway open during bag-mask ventilation. The OPA can be used in intubated patients to
prevent biting and occluding the endotracheal tube and during suctioning of the mouth.
The Nasopharyngeal airway or NPA is a soft rubber or plastic uncuffed tube that provides a
conduit for airflow between the nares and the pharynx. In patients who require a basic airway
management adjunct, NPA can be used as an alternative to an OPA. NPAs can be used in

conscious, semi-conscious or unconscious patients (patients with an intact gag or cough

reflex).
NPA is preferred when insertion of an OPA is difficult. Some of these examples include:
• Massive trauma around the mouth
• Trismus
• Wiring of the jaws and
• Neurologically challenged people with poor pharyngeal tone or coordination leading to

upper airway obstruction.
Suctioning is important for maintaining the airway of the patient. Suctioning must be done
immediately if the airway contains plenty of vomitus, blood or secretions. Suction devices can
be portable or wall-mounted type. Two types of suctioning procedures include
Oropharyngeal Suctioning Procedure and Endotracheal Tube Suctioning Procedure.
The advanced airway options include:
• Laryngeal Mask Airway
• Laryngeal tube
• Endotracheal tube and,
• Esophageal-tracheal tube
However, it must be noted that only trained healthcare professionals should use these
advanced airway devices.
The ventilation during cardiac arrest using any advanced airway involves giving one breath every
6 seconds and the ventilation during respiratory arrest using any advanced airway involves
giving one breath every 5 to 6 seconds.
The Laryngeal Mask Airway or LMA is a supraglottic airway device with a tube at the proximal
end and an elliptical mask on the distal end. The distal end is designed to provide a relatively
good isolation of the trachea by sitting in the patient’s hypopharynx and covering the
supraglottic structures. To use the LMA, the patient must be unconscious and unresponsive.

It can work as an alternative to endotracheal intubation, which requires greater skills

and laryngoscope to visualize the cords and, it can also be an alternative to bag-valve-mask
ventilation, because it can free the hands of the provider, and has the advantage of causing
lesser gastric distention. The laryngeal tube consists of an airway tube with two cuffs. It has a
smaller cuff at the tip (distal cuff) and a bigger balloon cuff in the middle part of the tube
(proximal cuff). It contains a single pilot tube for inflating the cuff and balloon for monitoring
cuff pressure. There are three black lines on the tube, that indicate the depth of insertion.
When inserted correctly, the laryngeal tube lies along the tongue and the distal tip reaches
the hypopharynx. The distal opening of the tube faces the glottic opening (opening of larynx).
The proximal cuff acts as a seal in the upper pharynx and the distal cuff seals the inlet
of esophagus. Like LMA, the laryngeal tube helps isolate the airway trachea and, compared to
the endotracheal tube, it is more compact, easy to insert and less complicated to use.
Endotracheal tube
It is an airway device made of polyvinyl chloride (PVC). However, the transparency helps in
observing any of the foreign materials within the tube and also by making a note of breath
fogging. Endotracheal intubation is the cornerstone of emergency airway management. The
decision to intubate is difficult, and clinical experience and training is needed for the
procedure.
In general, there are five broad indications for intubation:
• Firstly, the Inability to maintain airway patency
• Secondly, to ventilate
• Thirdly, the failure to oxygenate
• Fourthly, the inability to protect the airway against aspiration and,
• Lastly, deteriorating clinical course that can progress to respiratory failure
The esophageal-tracheal tube is another device that can help in securing the airways and
providing adequate ventilation. It is a double-lumen tube with two cuffs and is supplied with two
syringes that contain the correct inflation volume for the two cuffs.

Respiratory arrest is a medical emergency and life-threatening event. Aggressive and

appropriate management helps in reducing the complications. Initial management of
respiratory arrest is same though it is associated with diverse etiology

Video Transcript
Acute Coronary Syndrome
By the end of the lesson, you will be able to:
• Differentiate between ST elevation, myocardial infarction and non-ST elevation myocardial

infarction and
• Discuss the diagnosis and therapeutic interventions of acute coronary syndrome
Acute coronary syndromes or ACS, often called as 'heart attacks,' include acute myocardial
infarction and unstable angina. The myocardial infarction is further categorized as ST elevation
myocardial infarction or STEMI and non-ST elevation myocardial infarction or NSTEMI, based on
electrocardiographic changes. High prevalence of acute coronary syndrome cases poses a
significant burden on the health system. Nearly half of the patients with acute coronary syndrome
die before reaching the hospital.
An Advanced Cardiovascular Life Support or ACLS provider is expected to have the basic
knowledge on how to assess and stabilize a patient with acute coronary syndrome. A 12-lead
ECG is used to categorize the patients with acute coronary syndrome into three groups, which
include:
• Normal or non-diagnosing ECG
• Elevation of ST-segment suggests a continuing acute injury and
• Depression of ST-segment suggests ischemia
Let’s discuss about the pathophysiology of Acute coronary syndrome in detail
Thrombosis is considered as a triggering factor for acute myocardial ischemia. Thrombosis

occurs over a plaque through two mechanisms, which include endothelial denudation and plaque
disruption. Plaque disruption suggests enhanced inflammatory activity within the plaque.
Coronary atherosclerosis can lead to different degrees of coronary artery occlusion associated
with a range of clinical syndromes. ST-elevation myocardial infarction and non-ST elevation
myocardial infarction are common in this spectrum and they can lead to sudden cardiac death
too.

Let’s know in detail about the basic approach to ACS case.
Basic approach of a patient with acute coronary syndrome
Initially identify, assess and categorize patients with acute ischemic chest discomfort or acute
coronary syndrome. Emergency management system or EMS must be activated. Early CPR must
be provided. Early defibrillation with the available automatic external defibrillator should be done.
Basic management of the possible acute coronary syndrome. Management of the patient with ST
elevation myocardial infarction or acute coronary syndrome with early reperfusion
The goals of an ACLS provider while dealing with a case of acute coronary syndrome include:
To minimize the amount of myocardial necrosis associated with AMI to prevent heart failure by
preserving left ventricular function. To manage acute and life-threatening sequelae of ACS such
as pulseless VT, VF, unstable tachycardias, and symptomatic bradycardias. To prevent MACE
that is Major adverse cardiac event such as nonfatal MI and death
To identify patients with STEMI and categorize for early reperfusion therapy. To relieve ischemic
chest discomfort and to avoid the necessity of immediate post-infarction revascularization. The
classic or primary symptom of acute coronary syndrome is chest discomfort. Discomfort in other
regions of the upper body can also be noted. Nausea, vomiting, sweating, breathlessness, and
dizziness are other common symptoms.
A patient with acute coronary syndrome will predominantly feel discomfort in the chest or upper
body. It can also be associated with dyspnea and diaphoresis. Unusually, the patient may present
with isolated diaphoresis and
Older adults, women, and patients with diabetes, may exhibit less pain and show these unusual
symptoms. The classic or primary symptom of acute coronary syndrome is chest discomfort.
Discomfort in other regions of the upper body can also be noted. Nausea, vomiting, sweating,
breathlessness, and dizziness are other common symptoms. A patient with acute coronary
syndrome will predominantly feel discomfort in the chest or upper body. It can also be associated
with dyspnea and diaphoresis. Unusually, the patient may present with isolated diaphoresis and

Older adults, women, and patients with diabetes, may exhibit less pain and show these unusual
symptoms. Drug therapy is one of the common treatment regimens in the management of acute
coronary syndrome.
The diagnostic interventions of acute coronary syndrome include
Pre-hospital ECG or early ECG - According to 2015 American Heart Association guideline,
obtaining an ECG early helps in early detection of ST-elevation myocardial infarction. Also, early
ECG helps to decrease the time for ST-elevation myocardial infarction reperfusion. Computer-
assisted ECG ST-elevation myocardial infarction interpretation. Nonphysician ST-elevation
myocardial infarction ECG interpretation. Biomarkers in acute coronary syndrome such as
troponin.
An ACLS provider should have the basic knowledge of pharmacology, dosage of the drugs that
are prescribed in the algorithm, managing early life-threatening complications, triaging and early
management of ST elevation myocardial infarction with rapid perfusion.
Drug therapy in ACS primarily focuses on:
• Relieving ischemic pain
• Inhibiting platelets and thrombin and
• Dissolving clots
Acute coronary syndrome is associated with high morbidity and mortality. It is one of the major
causes of death in people over 35 years of age and timely diagnosis and treatment may help in
reducing the risk of mortality.

Video Transcript
Acute Stroke
By the end of the lesson, you will be able to:
• Recognize the different types and causes of stroke and

• Outline the stroke management
Acute stroke is a commonly encountered and devastating condition caused due to sudden
neurologic impairment caused through vascular origin leading to the interrupted blood supply to
certain parts of the brain. One-third of patients who suffer from acute stroke end up in death,
while another one-third of patients encounter severe morbidity and reduced quality of life. Survival
from acute stroke cases substantially depends on early diagnosis and treatment.
Early diagnosis is essential as it helps in providing intravenous fibrinolytic therapy as quickly as

possible that is usually in less than 3 to 4.5 hours of onset of symptoms. Many patients often
cannot identify, try to rationalize or deny the signs and this results in delayed treatment leading
to increased morbidity and mortality.
Let's discuss about the types of stroke in detail.
Hemorrhagic stroke accounts for 13% of all the strokes. It is due to a sudden rupture of a blood
vessel into surrounding tissue. Majority of hemorrhagic stroke is of intracerebral type while the
rest are the subarachnoid type and anticoagulants and fibrinolytic therapy are contraindicated in
hemorrhagic stroke.
Ischemic stroke accounts for about 87% of all strokes. It is generally caused due to occlusion of
the artery to the brain. The common symptoms of stroke include, trouble seeing in one or both
eyes, headache, loss of balance or coordination, dizziness, numbness or weakness of face,
weakness in one arm, trouble speaking and trouble walking.
The signs and symptoms of anterior circulation stroke include, unilateral inattention or sensory
loss, unilateral weakness, dysphagia, isolated dysarthria, monocular blindness, homonymous
hemianopia and visual inattention.
The signs and symptoms of posterior circulation stroke include:

• Nausea and vomiting
• Diplopia
• Isolated homonymous hemianopia
• Unsteadiness and incoordination and
• Unilateral/ bilateral sensory loss or weakness
Other miscellaneous signs include:
• Incontinence
• Dysphagia
• Loss of consciousness
• Sudden confusion
• Sudden trouble walking
• Severe headache and
• Sudden difficulty in speaking or understanding
Let’s now explore the critical steps in the management of stroke.
Initially identify the signs of stroke. Secondly, activate the emergency response system. Third
step is paramedic dispatch. This is followed by out-of-the-hospital assessment. Then, pre-notify
and transport to hospital. Activate the stroke protocol. Now, arrive at the emergency department.
Then, perform emergency brain or vascular imaging. Diagnose the condition. Provide medical
interventions and if the patient is stable, discharge from the emergency department or admit to
inpatient stroke unit center.
Primary goal of stroke management is to enhance the patient's recovery and minimize brain
injury. Out-of-hospital goals include, stroke screening and Stroke scale, rapid transport to the
hospital and pre-arrival alert to be sent to the hospital.
In-hospital goals include:
General assessment of the patient must be done by an emergency physician or stroke team, or
other experts - within 10 minutes of arrival. Notify the stroke team - within 15 minutes of arrival.

Perform CT scan - within 25 minutes of arrival. CT scan interpretation - within 45 minutes of

arrival. Fibrinolytic therapy - within 60 minutes of arrival or within 3 hours of symptoms onset and
Door to admission time that is admission to stroke unit or ICU - within 3 hours of arrival
According to the American Heart Association, every EMS personnel should be trained to identify
stroke by using various assessment tools. One such important assessment tool is Cincinnati
Prehospital Stroke Scale, an abbreviated and validated neurological evaluation tool for out-of-
hospital settings.
CPSS helps the physician to identify a stroke patient within 1 minute. The ACLS provider should
have formal training in using stroke assessment tools which helps in increasing the survival
rates of a patient.
CPSS uses three physical findings to identify a stroke.
Facial Droop
Arm drift
Abnormal speech
Facial Droop
• Ask the patient to smile or show teeth.
• Normally both sides move equally and
Consider the test abnormal when one side does not move as well as the other side. Arm Drift: Ask
the patient to close the eyes and extend both the arms straight out, with palms up, for 10 seconds.
Normally both arms move the same and consider the test abnormal when one arm does not move
or one arm drifts below the other. Consider the test abnormal if the patient is not able to speak,
uses wrong words or has slurring of speech.
Abnormal speech: Give the patient a sentence to repeat. Normally the patient should be able to
repeat the same words without slurring. Consider the test abnormal if the patient is not able to
speak, uses wrong words or has slurring of speech.
The 3 findings can be remembered by using the abbreviation FAST.

• F stands for face drooping

• A stands for arm weakness
• S stands for speech difficulty and
• T stands for time to call emergency
Let’s now discuss about the practices that should be performed by ED providers in general
assessment and stabilization in detail.
The critical EMS assessments in case of suspected stroke include:
• Evaluating the vital signs and assess airway, breathing, and circulation of the patient.
Supplementary oxygen should be provided to patients with hypoxemic stroke and
unknown oxygen saturation.
• IV access must be established, and blood samples should be obtained for baseline blood
investigations such as blood glucose, blood count, and coagulation studies.
• CT scan should not be delayed. Emergent CT scan of the brain should be ordered and
reported by the radiologist. Furthermore, the blood glucose must be checked, and any
hypoglycemia should be treated promptly.
Neurological screening assessment must be performed using various tools such as NIH Stroke
Scale or NIHSS. Stroke team should be activated, and expert consultation must be arranged. A
12-lead ECG should be obtained to identify any cardiac abnormalities. If hemorrhage is
present, fibrinolytic therapy is contraindicated.
A neurosurgeon must be consulted. The patient is transferred to appropriate care
If hemorrhage is absent, then fibrinolytic therapy should be initiated.
If fibrinolytic agents are contraindicated due to any other reason, consider administering aspirin
and if the patient can swallow, give aspirin orally. Otherwise, use a aspirin suppository. In selected
patients with acute ischemic stroke, fibrinolytic agents like recombinant tissue plasminogen
activator are given intravenously, within 3 to 4.5 hours of symptom onset. Lesser the time of
administration, greater are the benefits. Recombinant tissue plasminogen activator is excluded
in patients of age more than 80 years, who are on anticoagulants as well as in severe stroke

condition where the NIHSS score is more than 25, and in patients with prior ischemic stroke and
diabetes together.
Recently, advanced therapies such as endovascular therapy are used in the management of acute
ischemic stroke. The results are better when the time between onset of symptoms
and reperfusion is minimal. Cerebral intra-arterial recombinant tissue plasminogen activator has
shown improved outcomes. Clot retrieval or mechanical clot disruption with a stent has shown
clinical benefit.
The inclusion criterion for Endovascular therapy include:
Pre-stroke Modified Rankin score of 0 to1. Occlusion of proximal middle cerebral artery and
internal carotid artery and greater than or equal to 18 years. Greater than or equal to 6 NIH Stroke
Scale score. Greater than or equal to 6 ASPECTS or (Alberta Stroke Program Early CT Score).
Patients receiving intravenous recombinant tissue plasminogen activator in less than
4.5 hours of symptom onset and treatment can be started within 6 hours of onset of symptoms.
Stroke is considered as the leading cause of death globally. It is a treatable condition that requires
immediate medical intervention and drug treatment and specialist care impacts the survival and
recovery.

Video Transcript
Introduction to Bradycardia
By the end of this topic, you will able to
• List the rhythms associated with bradycardia
• Describe the management of adult bradycardia with a pulse algorithm and
• Discuss the treatment sequence involved in bradycardia
Bradycardia is characterized by a heart rate of less than 50 beats per minute. However, in some
individuals, it is physiologically normal to have a slow heart rate while in some greater than 50
beats per minute is also considered to be inadequate. Hence in ACLS, symptomatic bradycardia
which is clinically significant is considered. Bradycardia manifests with poor perfusion signs
and symptoms. Signs of deterioration should be monitored. Most of the times, bradyarrhythmia
and bradycardia are used interchangeably.
If bradycardia is resulting in some symptoms, it is known as symptomatic bradyarrhythmia

and usually the heart rate is less than 50 beats per minute.
Let’s begin with the rhythms of bradycardia.
Symptomatic bradycardia may show the following rhythms on a 12-Lead ECG:
➢ First degree atrioventricular block
➢ Second-degree atrioventricular block such as
o Mobitz I by Wenckebach that is Type I block
o Mobitz II that is Type II
➢ Third-degree atrioventricular block
➢ Sinus bradycardia
Knowledge of major atrioventricular block is essential as the type of block dictates the
treatment decision. Complete atrioventricular block is clinically the most significant block.

Third-degree or complete atrioventricular block may lead to cardiovascular collapse and need
immediate pacing.
Now we will look at the algorithm that focusses on the management of bradycardia
Management-Adult Bradycardia with a Pulse algorithm
Goals of bradycardia management
• Adult bradycardia has to be diagnosed promptly by recognizing its signs and symptoms.
The American Heart Association has proposed a step-wise treatment approach in the
form of an algorithm. This algorithm summarizes the steps for patient assessment and
management.
• The Primary goal in the management of Adult Bradycardia is to identify symptomatic

bradycardia due to AV block and the secondary goal is to recognize the type of AV block.
• There are seven steps to be followed in the management of bradycardia where step 1 is
to recognize bradycardia , Step 2 is to perform Basic Life Support or BLS , primary
assessment , and a 12-lead ECG for treating the underlying cause , Step 3 is to check for
symptoms and signs of poor perfusion and analyze if they are due to bradycardia , Step 4
is to check for adequate perfusion. If good, observe and monitor, Step 5 indicates that if
there is poor perfusion, atropine or epinephrine / dopamine or transcutaneous pacing
should be used. Step-6 indicates a need for transvenous pacing and expert consultation.
Treatment Case
• The sequence of treatment depends on the severity of the clinical presentation of the
patient. If a patient presents with symptomatic bradycardia, Atropine has to be
administered as the first line of treatment. Incase Atropine is ineffective a transcutaneous
pacing is placed. In case of 'pre-cardiac arrest,' multiple interventions must be applied
simultaneously and in case of poor perfusion, administer atropine at a dose of 0.5 mg
intravenously, which can be given up to 3mg total dose. If atropine is ineffective, go for
transcutaneous pacing.
• Do not rely on atropine alone in second-degree or type II or third-degree AV block. As
they may not respond to atropine's cholinergic-reversal effect, it is preferred to treat with

beta-adrenergic drugs or transcutaneous pacing as temporizations, while preparing the

patient for transvenous pacing. Epinephrine has the effect of enhancing survival
from bradycardia.
• Alternative drugs such as calcium channel blockers and beta-blockers may also be
helpful in certain circumstances. One should not wait until the maximum dose of
atropine to work, especially in second- and third-degree AV blocks. It is advisable to start
second-line management after 2-3 doses of atropine.
• Transcutaneous pacing is a non-invasive treatment approach for symptomatic
bradycardia and is usually indicated in hemodynamically unstable
bradycardia, symptomatic sinus bradycardia, second-degree and third-degree
atrioventricular block, fascicular or bundle branch block, and bradycardia associated
with symptomatic ventricular escape rhythms. When intravenous access is
unavailable, or patients are not responding to atropine, immediate pacing should be
considered in unstable patients.
• Transcutaneous pacing is performed where:
➢ In Step 1, pacing electrodes are to be placed on the chest as per the instruction
manual.
➢ In Step 2, pacer is switched on and In Step 3, Demand rate should be set to about
60/min. Once the pacing is established, the demand rate can be adjusted up and
down.
➢ The current output should be set to 2 mA more the dose at which persistent
capture is seen
• If the symptoms are due to bradycardia, a rate of 60-70/min should improve the condition.
Bradycardia refers to a rhythmic disorder with less than 50 per minute heart rate and where it
manifests with signs and symptoms of poor perfusion and early diagnosis and treatment
reduces the risk of mortality or morbidity.

Video Transcript
Introduction to Tachycardia
• Outline the various classifications of tachycardia and
• Discuss the management of stable and unstable tachycardia
Tachycardia is defined as an increased heart rate which is greater than 100 beats per min. It is
also called as tachyarrhythmia. Tachycardia may result in myocardial ischemia, hypotension,
low cardiac output, peripheral hypoperfusion, severe symptoms such as chest pain, weakness,
syncope, lightheadedness, cardiomyopathy, cardiac arrest and death.
Various classifications have been developed to explain tachycardia which are based on the QRS
complex, Symptomatic versus Asymptomatic and Stable versus Unstable.
The first classification of tachycardia is based on the appearance of QRS complex as
Narrow QRS complex tachycardias with QRS less than 0.12 seconds and which result from
sinus tachycardia, atrial flutter, atrial fibrillation and atrioventricular nodal re-entry.
Wide-QRS complex tachycardias with QRS greater than 0.12 seconds and includes
monomorphic VT, Polymorphic VT and Aberrant VT.
Irregular or regular tachycardia with atrial fibrillation with narrow-complex and irregular
tachycardia.
In the second classification, tachyarrhythmias can be either symptomatic or asymptomatic. If

there are symptoms and signs because of the rapid heart rate, it is known as symptomatic
tachyarrhythmia and absence of symptoms are classified as Asymptomatic tachyarrhythmia.
In the third classification, the heart rate in the patients with Stable tachycardia is greater than
100 beats per minute. And, the patient does not have any serious signs and symptoms resulting
from irregular heart rate.
Unstable tachycardia is when the fast heart rate is causing symptoms or an unstable condition
due to rapid rate or inefficient beats. Rapid heart rate can cause reduced cardiac output, that
can result in cardiac ischemia, pulmonary edema, hypotension, and reduced blood flow to vital

organs. Symptoms and signs of unstable tachycardia are hypotension, signs of shock, acute
heart failure, chest discomfort of ischemia and altered mental status.
Now we will look at the algorithm that focusses on the management of bradycardia.
The American Heart Association has provided a step-wise management approach in the form of
an algorithm, which describes the treatment protocol for both stable and unstable tachycardias.
Management of Tachycardia with pulse includes 6 steps where Step 1 is to recognize the
tachycardia with pulse. If pulse is absent, then it is a case of pulseless tachycardia and it has to
be managed as per the Cardiac Arrest algorithm. Step 2 is to identify and treat the underlying
cause. In case of tachycardia with pulse, perform BLS assessment, primary and secondary
assessments. Check for the airway, circulation, and breathing. Also, determine whether the
tachycardia is stable or unstable. Step 3 is to Confirm persistent tachyarrhythmia. In case of
persistent tachycardia, then look for the signs of hypotension, shock, acute heart failure,
ischemic chest discomfort, and altered mental status. Now, if it is confirmed that tachycardia is
a significant cause for the symptoms, then consider the patient unstable and start immediate
synchronized cardioversion which is Step 4. In Step 5 If the patient is stable, then evaluate the
ECG and check the QRS complex duration and regularity.
Stable tachycardia is managed appropriately based on the QRS complex.
Management of Unstable Tachycardia
The following steps are involved in the management of unstable tachycardia, Step 1 is to
assess the clinical condition of the patient. Step 2 is to look for any signs of respiratory distress
and hypoxemia using pulse oximetry. Also, monitor the oxygen saturation and administer
supplemental oxygen when needed. Monitor ECG rhythm. Check for the blood pressure and
establish IV access. Recognize and treat any reversible causes. If symptoms persist, despite
adequate ventilation and oxygenation support, proceed to step 3.
Step 3 is to confirm persistent tachyarrhythmia. In case of persistent tachycardia, then look for
the signs of hypotension, shock, acute heart failure, ischemic chest discomfort, and altered
mental status. Step 4 is to execute immediate synchronized cardioversion. An intravenous

access has to be established before performing cardioversion. If the patient is conscious,

administer sedation. In extremely unstable patients, do not delay cardioversion.
The recommended initial dose of synchronized cardioversion is as follows:
• For narrow regular tachycardia, provide 50 to100 Joules
• For narrow irregular tachycardia, provide 120 to 200 Joules if biphasic defibrillator or
200 Joules in monophasic defibrillators
• For wide regular tachycardia, provide 100 joules
For wide irregular tachycardia, defibrillation dose
• In cases of monomorphic wide-complex tachycardia or regular narrow-complex

supraventricular tachycardia, where the patient is not hypotensive, adenosine can be
administered while preparing for synchronized cardioversion.
• In case there is a cardiac arrest, manage according to cardiac arrest algorithm.
Management of Stable Tachycardia
• Initial assessment and management as in Step 1 and 2 of unstable tachycardia

management should be performed. If symptoms persist, go to step 3. If the patient's
condition is stable, you should manage the condition as per the stable section of the
algorithm.
• After confirming the presence of stable tachycardia, obtain an ECG and check for the
duration of QRS complex.
• If the ECG reveals wide QRS, the rhythm should be checked if it is regular/irregular.
• Wide-complex tachycardias are characterized by QRS of greater than or equal to 0.12

seconds. Consider expert consultation in such cases.
• In stable patients, who have monomorphic and regular wide-complex tachycardia, if the
origin of the arrhythmia cannot be ascertained, IV adenosine can be administered. First
dose 6 milligrams rapid IV push, followed by normal saline flush. Second dose of 12
milligrams if needed.

• Other IV antiarrhythmic drugs can be used such as procainamide, amiodarone, or

sotalol.
• Procainamide intravenous dose: 20 to 50 milligrams per minute until the arrhythmia is

suppressed, QRS duration increases greater than 50%, or there is adverse effects such
hypotension, or until the maximum dose of 17 milligram per kilogram is given.
• Amiodarone intravenous dose: First dose of 150 mg over 10 minutes is given. If

ventricular tachycardia recurs, repeat as needed. Maintenance dose is 1 mg/min for the
first 6 hours.
• Sotalol IV: 100 milligrams (or 1.5 milligrams per kilogram) over 15 minutes is given.
Avoid in cases of significant QT prolongation.
• In stable patients, who have irregular wide-complex QRS tachycardia, the focus of
management is on the control of rapid ventricular rate that is rate control, conversion of
unstable atrial fibrillation to sinus rhythm that is rhythm control, or both rate and rhythm
control. Expert consultation is advised in these cases.
• In narrow-QRS tachycardia with regular rhythm cases, management is generally by:
• Vagal maneuvers
• Administering adenosine
• Symptomatic narrow-complex tachycardias which are usually supraventricular in origin

are treated by vagal maneuvers and adenosine. About 25% of supraventricular
• Tachycardias are usually treated with vagal maneuvers alone. For the rest, adenosine is
used. The Vagal maneuvers include:
• Carotid sinus massage
• Valsalva maneuver
• If the supraventricular tachycardias do not respond to vagal maneuvers, adenosine is

used.

• Administer 6 milligrams adenosine as rapid intravenous push over 1 second into a large
vein such as an antecubital vein. A 20 ml saline flush is administered, and immediately
the arm should be elevated.
• If tachycardia is not converted, the second dose of 12 milligrams adenosine is pushed
rapidly intravenously.
• If the rhythm converts to sinus with adenosine, it is probably an SVT. In such cases,
observe for recurrence. If there is recurrence, use agents that have longer AV conduction
blocking effects such as beta blockers or non-dihydropyridine calcium channel blockers.
Obtain expert consultation if tachycardia recurs.
• If the rhythm does not convert with adenosine, it is likely to be atrial flutter, ectopic atrial
tachycardia, or junctional tachycardia. In such cases, obtain expert consultation on
management.
• Tachycardia is one of the common problems in clinical practice. It can be secondary to
physiological or pathological causes. One of the major pathological event due to
tachycardia is cardiomyopathy with subsequent heart failure. Early recognition and
treatment improves the heart rate and stabilizes the patient. Also, close monitoring for
recurrence of arrhythmia is required.

Video Transcript
Introduction to Cardioversion
• Differentiate between synchronized and unsynchronized shocks
• Describe challenges in the delivery of synchronized shocks and
• List the recommended energy doses for specific rhythms during cardioversion
Arrhythmias are responsible for preventing proper blood circulation to brain and
heart. Cardioversion is a medical procedure which is used to restore the regular rhythm, in
conditions with irregular heartbeat or tachycardia.
Cardioversion is usually used to treat atrial fibrillations, an irregular and fast heart rhythm.
Elective or non-emergency cardioversion is used to treat arrhythmias. Other abnormal
heartbeats such as atrial tachycardia, atrial flutter, and ventricular tachycardia are treated
with cardioversion. Cardioversion may also be used in emergency conditions such as sudden
life-threatening arrhythmias.
Cardioversion is contraindicated for the patients with multifocal atrial tachycardia, ectopic atrial
tachycardia, and junctional tachycardia. In these rhythms, an automatic focus arises from cells
which spontaneously depolarize at a rapid rate. These rhythms cannot be stopped with the
delivery of shock and may also increase tachyarrhythmia rate.
The risk of cardioversion includes embolus formation which may lead to stroke. Other risks
include abnormal heart rhythm and skin burns. Sometimes, normal heart rhythms cannot be
achieved with cardioversion. Drugs may be required in such situations.
Types of Cardioversion
There are two types of cardioversion. They are:
• Pharmacological cardioversion and
• Electrical cardioversion
Pharmacological cardioversion, also called chemical cardioversion, is a procedure which uses

drugs/pharmacotherapy to achieve the regular heartbeat. Electrical cardioversion is used to

restore regular rhythms by administering an electric shock to the heart. Let’s have a look at the
energy doses for specific rhythms during cardioversion.
Energy Doses in Cardioversion
The energy dose varies for different types of rhythms.
In case of unstable atrial fibrillations, monophasic waveform at a dose of 200 Joules

synchronized shock is delivered initially. Biphasic cardioversion at a dose of 120 - 200 Joules
synchronized shock is delivered initially.
In case of supraventricular tachycardia and atrial flutter, monophasic waveform at a dose of 50 -

100 Joules of energy is sufficient. Biphasic cardioversion at a dose of 50 -100 Joules of energy
is sufficient.
In case of monomorphic ventricular tachycardia and atrial flutter, monophasic waveform and
biphasic waveform at a dose of 100 Joules of energy is required. The dose can be escalated in
a step-wise pattern, if no response could be elicited in the first attempt.
Synchronized and Unsynchronized Cardioversion
In unsynchronized cardioversion, the shock is delivered as and when the operator uses the
shock-key to discharge the device. This may result in random fall of shock anywhere in the
cardiac cycle. Unsynchronized shocks require higher energy than synchronized cardioversion.
Indications of unsynchronized shocks are given:
• In pulseless patients
• In patients with clinical deterioration, where a slight delay may also result in cardiac
arrest and
• In unstable patient, where the ACLS provider is not sure if the patient is with polymorphic
or monomorphic ventricular tachycardia
If the shock leads to ventricular fibrillation or VF, immediately shift to defibrillation.
Synchronized cardioversion is used in unstable, symptomatic ventricular tachycardia or

supraventricular tachycardia with pulses.

This uses a sensor to deliver a synchronized shock with a QRS complex peak. When 'sync'
option is used, shock button is pressed to deliver a shock. A slight delay can be noticed before
a cardioverter delivers the shock, as the shock delivery will be synchronized with R wave peak in
the QRS complex of the patient. Synchronization has an advantage of avoiding shock delivery
during cardiac repolarization. This period of cardiac repolarization is known as the period of
vulnerability where VF can be precipitated during shock. Synchronized shocks use lower energy
when compared to unsynchronized shocks.
Indications of synchronized shocks include:
• Unstable atrial fibrillation
• Unstable SVT
• Unstable regular monomorphic tachycardia with pulses and
• Unstable atrial flutter
Cardioversion is a medical procedure used to restore the regular rhythm and is indicated to treat
arrhythmias and is contraindicated in multifocal atrial tachycardia and other conditions.
However, risk of cardioversion can lead to embolus formation and may eventually lead to
stroke.

M2Resuscitation and Initial Management of Acutely Ill

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Resuscitation and Initial Management of Acutely Ill

• Recall the steps of the Chain of Survival

• Explain the difference between heart attack and cardiac arrest

• Recall the basic steps of 1 and 2 rescuer CPR for adults

The 5 steps in the adult Chain of Survival include:

Step 2 is early high-quality CPR with an emphasis on chest compressions

Step 3 is rapid defibrillation

Step 4 is to provide Basic and advanced life support

Step 5 is to provide Advanced life support and post-cardiac arrest care

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The steps of the primary survey include:

Step 1 is to Assess Danger

Step 2 is to Check Responsiveness

Step 3 is to Call Ambulance

Let’s see each of these steps in detail.

Use 'AVPU' scale while assessing the victim's responsiveness.

V is Voice: Check if the victim is responding to your speech. If No- Proceed to P

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P is Pain: Check if the victim is responding to painful stimuli. If No- Proceed to U

U is Unresponsiveness: Establish that the victim is unresponsive.

Step 4 is to assess the responsive victim.

Step 1 is to look for chest movements.

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In case a victim is not breathing or only gasping and has no pulse,

Let’s begin with compressions.

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Bag-valve mask resuscitator.

Here are the steps to perform mouth-to-mouth rescue breathing:

Step 1: Position yourself at the victim's head.

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Step 6: Take a break before re-sealing over the victim's mouth.

Step 6: Release pressure on the mask to allow air to escape.

A bag-valve mask is a handheld device, which is used to provide positive-pressure ventilation to

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It administers higher concentration of oxygen than a pocket mask. If an oxygen reservoir is

One-Person bag-valve mask ventilation:

You should follow these steps:

Step 2: Position yourself at the victim's head.

Step 3: Determine that the victim is not breathing.

In case of Two-Person bag-valve mask ventilation, the steps would be:

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Step 1: Make sure the scene is safe.

Step 2: Check the victim's responsiveness by using 'AVPU' scale

Step 4: Check the victim's airways, breathing, and pulse.

Step 5: Position the victim in supine position on a hard, flat surface.

Step 1: Make sure the scene is safe.

Rescuer 1: Gives chest compression at a rate of 100 per minute.

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• Immediate identification of the condition

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Pediatric Basic Life Support

By the end of this topic, you will be able to

• Describe the steps involved in primary survey and

• The method of chest compressions

• The compressions and breath ratio

• The depth of compression

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Steps to locate brachial pulse:

• Brachial pulse can be found on the inside of the upper arm.

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Step 1 is to give 12 to 20 breaths per minute

Step 2 is to check the pulse every 2 minutes

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