Basic Life Support

Azra Durak-Nalbantić
MD, PhD
 Background
 Approximately 700,000 cardiac arrests per year
in Europe
Outcome:
 Survival to hospital discharge presently
approximately 5-10 - 14%
 Bystander CPR = vital intervention before arrival
of emergency services
 Early resuscitation and prompt defibrillation
(within 1-2 minutes) can result in >60% survival
Chain of survival
 CardioPulmonary
Resuscitation
Definition:
CPR is an emergency first-aid procedure
that is used to maintain respiration and
blood circulation in a person, whose
breathing and heartbeats have suddenly
stopped,
(one or more vital functions failed ).
 CardioPulmonary
Resuscitation
Three basic vital functions:

 Breathing
 Circulation
 Consciousness
Basic life support www.erc.edu
CardioPulmonary Resuscitation

“Thoracic pump theory“ -

the chest compression propels blood
out of the thorax by increasing
intrathoracic pressure …
the time of the chest compression and
decompression should be equal
Pressure should be completaly released
Hands should remain in the contact with
the chest
CardioPulmonary Resuscitation
Theoretical background
Oxygene content
In atmospheric air - 21%
In alveoli - 14,5%
Expired air – diluted by air from the airways
(dead space)
- 16 – 18 % O2

Provided that there is an adequate amount of expired

air reaching the victim's lungs, oxygen delivery will be
sufficient to ensure that the victim's haemoglobin will
be over 80% saturated with oxygen.
Theoretical background

Cardiac arrest
1. Asystole
2. Ventricular fibrillation
Most cardiac arrest victims have an electrical
malfunction of the heart  heart´s pumping
function abruptly ceases
3. Pulseless ventricular tachycardia =
Fast ventricular contractions without
haemodynamc effect Signs of the both =
identical!!!
Differential dg: only ECG
Theoretical background
At best
chest compressions provide only 30% of
normal perfusion  brain + heart

Time! Time! Time! Time! Time! Time! Time! Time!

Failure of the circulation 3 - 5 minutes 
irreversible cerebral damage.

Chances of successful CPR - restoration of

spontaneous circulation (ROSC) decreases by
10% with each minute following sudden
cardiac arrest…
 Cause of cardiac arrest and
emergency system activation
Adults
• Ischemic heart disease - AMI-
with/or ventricular fibrillation (>
80%)
Children
• Suffocation or choking with
hypoxemia or asphyxia.
Ventricular fibrillation is rare in
children (only 5-8%)
Cause of cardiac arrest and emergency system
activation
 different approach to the emergency system activation.

Adults
electric defibrillator is necessary as soon as possible;
therefore, if telephone is available and you are alone:
1. call for help, then
2. start with CPR

Children
1. start CPR immediately for 1 minute to provide some
tissue oxygenation
2. then call for help
Emergency telephone number

112, 124
in the Bosnia and
Herzegovina
 Indication of CPR

 to victims with unexpected cardiac arrest

in otherwise healthy individuals …
 = to those, who can be described as
having ”heart too good to die”
 Indication of CPR

• malignant arrhythmia
• acute myocardial infarction (AMI)
• pulmonary embolism
• intoxication
• electrocution
• drowning
• acute suffocation
• severe trauma
• stroke and alike
 CPR is not indicated
 signs of definitive biological death
 witnessed information, that cardiac arrest had happened 15 or more
minutes before the rescuer arrived (time assessment in the stressing
situation is not precise)
 terminal stage of incurable disease (generalised malignant disease…)
 an evident trauma without chance to survive (catastrophic head injury)
 “living will” - only in countries when constitution accepts it
 DNR - “Do not attempt resuscitation” has been written in the file (incurable
disease after all available therapy failed)
execution

Age of the patient is not restriction of CPR

 Outcome after CPR
Ventricullar fibrilation – better than asystole
- in case of immediate CPR

Special emphasis

Soon defibrilation
 1 minute - survival - 90%,
 5 minutes - survival - 50%,
 7 minutes - survival - 30%
 10 - 12 minutes - survival - 2 – 5%.
 CPR outcome

• In first 4 minutes – brain damage is unlikely, if

CPR started
• 4 – 6 minutes – brain damage possible
• 6 – 10 minutes – brain damage probable
• > 10 minutes – severe brain damage certain

Cells of the brain cortex

• Most sensitive for the stop of perfusion and
oxygenation
Without perfusion and oxygenation
 irreversibly damaged after 3-5 minutes
Signs of cardiac arrest
(Guidelines 2000)

1.  Unconsciousness in several seconds

2.   Respiratory arrest ( apnea) or the last gasps
(1-3 minutes after cardiac arrest)
3.   Pulse-less on large ( major) arteries
(carotid or femoral artery)
4.   Changed general appearance
(colour changes, face changes…)
5. Pupils dilation (mydriasis) – not reliable
 Signs of cardiac arrest
(Guidelines 2005)

1. Unconsciousness
2. No reactivity
3. Absence of normal breathing
Basic conditions for CPR
1. Rescuer’s safety = the first priority
2. To assess the risk of trauma, intoxication,
infection …
3. a victim position: supine on to his/her
back
4. on the firm flat surface to make
effective chest compressions
5. victim´s position in relation to rescuer´s
position
6. CPR during transfer ???
 Rescuer’s safety

The rescuer should never place him/herself or others at more

risk than the victim

• before starting resuscitation – assess the risks of

ongoing traffic, falling masonry, electrocution, toxic
fumes and poisons
• risk of infections transmission
• bloodborne infections (hepatitis B and C, HIV)
- can be transmitted by blood and other body
solutions, excretes
• airborne infections (TBC and several infectious diseases -
herpetic, meningococcal etc.
- can be transmitted by mouth-to-mouth breathing
 Rescuer’s safety

•
Always: protect yourself !!!
• personal protective equipment (gloves)
• barrier protective devices
• Moth – to - barrier protective devices
breathing
 Personal Protective Equipment
 Can control the risk of exposure to bloodborne pathogens
–prevents an organism from entering the body (medical
exam gloves, eye protection, mask)
 All human blood and body fluids should be considered
infectious

Mouth-to-mouth barrier devices

 Can prevent air-borne pathogens transmission
 Not documented case of disease transmission
 But…should be used whenever possible
CardioPulmonary Resuscitation
Barrier devices

 S – tube
 Face shields (resuscitation veil )
 Pocket face mask + one-way valve
 Handkerchief
 Towel
 Stop CPR if

 Victim starts to breathe normally

 Medical assistance arrives and instructs

you to stop CPR

 You are physically exhausted

 Stop CPR if:
When CPR has been performed for 20 minutes
without restoration of the spontaneous
circulation

It can be stopped earlier, when:

 rescuer is physically exhausted

 when signs of biological death develop (post-

mortal rigidity, post-mortal cooling and
gravity-dependent livid stains) ???
CardioPulmonary Resuscitation
Safar´s algorithm of CPR
stressing conditions  an inadequate situation assessment

Airways
Breathing BLS
Circulation ALS
Drugs ?
ECG
 New resuscitation
alphabet – in adults
Algorithm of CPR

EKG
Circulation BLS
Airways ALS
Breathing
Drugs
BLS sequence
Kneel by the side of
the victim
BLS sequence

Shake shoulders
Ask “Are you all right?”
BLS sequence
If he responds
• Leave as you find him
• Find out what is wrong
• Reassess regularly
BLS sequence

Unresponsive

Shout for help

BLS sequence

Unresponsive

Shout for help

Open airway
BLS sequence

Unresponsive

Shout for help

Open airway

Check breathing
BLS sequence

 Look, listen and feel for

NORMAL breathing
 No breathing – apnea
 Gasps (agonal breathing)
 Agonal breathing
 Occurs shortly after heart stops in up to
40% of cardiac arrests

 Described as barely, heavy, noisy or

gasping breathing

 Recognise as a sign of cardiac arrest

 Do not confuse agonal breathing with
NORMAL breathing
BLS sequence

Unresponsive

Shout for help

Open airway

Check breathing

Call 155 (112)

BLS sequence

Unresponsive

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock the fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
Chest compression
Unresponsive

Shout for help

Open airway

Check breathing

Call 112

30 chest compressions

2 rescue breaths
2 rescue breaths
 Pinch nose
 Place and seal your lips
over the victim´s mouth
 Blow until the chest rises
 Takes about 1 second
 Allow chest to fall
 Repeat (10 – 12 times
per minute)
 B) Breathing
 expired air resuscitation - several
techniques:
- Mouth-to-mouth breathing
  -  Mouth-to-nose breathing
  - Mouth-to-mouth + nose breathing ( small
children)
       -  Mouth-to the barrier device ( to protect the rescuer)
- Mouth to tracheostomy

Self-inflating bag
CardioPulmonary Resuscitation
Artificial breath during expired air
resuscitation

 Volum = normal breathing volum

 Volum = 6-7 ml/ kg bw = 500 ml
 Breath duration in adults = 1 second
Expiration – passive
 Check the chest rise during rescue breath
Self-infalting bag

Capacity 1500 ml Breathing by atmospheric air

1 way valve Oxygene source - conection
Volume controlled by compression Oxygene reservoir – 100% O2
 Continue CPR
Continue CPR

30 : 2
Ratio 30 : 2

One uniform ratio

• always in adults
• in children in the prehospital CPR
• in children when the rescuer is alone
 Defibrillation
Defibrillation
Automated External Defibrilators
(AEDs)

A new generation of “smart“ defibrilators

 Advanced computer technologies
 Ability to interprete heart (ECG) rhythm
 Ability to determine whether defibrilation is required
 Delivery of electric shock
 Guides the operator through every action
 Provides voice and message prompts
 Legal aspects
 AEDs

Easier than CPR

 Readily available on places with haevy
people concentration, where can be
probably used once during 2 years
 Extendes beyon healthcare prefessional
personnel to trained citizens
Switch on AED

 AEDs will
automatically switch
themselves on when
the lid is opened
Attach pads to casualty’s bare chest
Analyse rhythm – do not touch victim
Shock indicated – stand clear
Rescuer giving defibrilation shock

•is responsible for his safety

•is responsible for the safety of other
people surronding the victim
Immediately resume CPR

Need new
picture

30 : 2
Give CPR every moment, when AED is
not available, always if AED is not
available within 5 minutes
Need new
picture

30 : 2
If victim starts to breathe normally
place him in recovery position

Need new
picture
 Recovery position
 After breathing and
circulation has been
restored
 To maintain the opening of
the airway
 To prevent inhalation of
gastric content
 CPR should not usually be
abandoned after 20 minutes:

       in case of the victim´s hypothermia

       in case of persistent ventricular
fibrillation = AED indicates
defibrilation shock

Responsibility during CPR

 Precordial chest thumps
Indication:
 wittnessed cardiac arrest (patient´s
collapse)
 adults only
 within 20 sec.

Only experienced rescuers

Contraindications:
 uknown time of cardiac arrest
 chest injury
 children
A. Airway management
A)

Head tilted backward

Chin lift

Triple manouvre ???

 „A“
• head titlted
backward
• chin lift
Jaw thrust
• suspected cervical spine injury
• experienced rescuer ( anaesthesiologist)
Lower jaw pulled forward
 A. Airway management
1. Unconscious patient – tongue
tilt the head backward + lift the chin
2. Conscious patient - foreign body airway
obstruction  choking - partial
airway blockade
 encourage the victim to cough
 add several hits to his/her back

Cough is much more effective than any

other manoeuvre.
 A. Airway management

1. Foreign body airways obstruction

2. Potentially treatable
3. Mostly during eating
4. Commonly witnessed event
5. Oportunity for early intervention
6. Can cause mild (partial) or severe (comlete) airway
obstruction

Heimlich manoeuvre (several thrusts (5))

pregnant ladies, children
 A. Airway management
Signs of mild (partial) large airways
obstruction

 Suffocation
 Difficult intensive inspiration
 Neck and thorax soft tissues retraction
 Hoarse (croupy) sounds accompanying
inspiration (noisy breathing)
 Barking cough
 A. Airway management
Signs of severe or complete large
airways obstruction

 Difficult intensive inspiratory effort

 Powerful breathing movements
 Neck and thorax soft tissues retraction
 No breathing phenomena hearable
 Patients non-cooperation, restlessness,
convulsions, coma, blue skin color
Equipment for airway
management
 C: Circulation
Diagnosis:
• Signs of functional circulation
(breathing, coughing, movement, skin condition,
responsiveness, pulse)
• Pulse-less on large ( major) arteries –
only experienced rescuers
 Compression-only CPR
“Top-less”
 Reluctance of rescuers to perform mouth-
to-mouth breathing on strangers
 Unwilling person to breathe…
 Unability to perform …(vomiting,
bleeding, trauma, unskilled rescuer…)
 Chest compressions only

 Better some resuscitation than no

resuscitation
 Compression-only CPR

 New recommendation of AHA

 Witnessed collapse of the patient
 First 10 minutes
 Contraindications:
 Children
 Sudden cardiac arrest due to choking
 CPR in children
Who is an infant? 0 – 1 year

Landmark between child and adult: puberta

Who is a child? 1 - puberta

 CPR in children

Differencies:
 Cause of cardiac arrest –choking, trauma
 Activation of emergency system
 Hypoxia developes faster – high metabolic rate
 Ventricular fibrillation – rare
 Primary cardiac arrest uncommon,
 Precordial thump is contraindicated

Length of CPR = identical

Chain:
Choking- hypoxia – hypercapnia – apnoea – bradycardia –
cardiac arrest

Trauma
 CPR in children
C)

 Technique of chest compressions

 Rate of chest compressions
 Algorithm of CPR: 2:15
 1 rescuer: 2:30
 Infants: 1:3
 CPR in children
2 : 15

2 : 30
 CPR in children
Chest compressions in infants