BLS and ACLS

DEEPIKA SELVA

– 2015 update
AHA guidelines
BASIC LIFE SUPPORT– AHA
GUIDELINES
Chain of survival
CPR POSITION
 High quality CPR
• Start compression within 10 sec of recognition of cardiac arrest.
• Position patient on hard surface in supine position
• Push hard Push fast:
Rate: 100-120/minute
Depth: 2-2.4” (5-6cm) 5 cm for children , 4 cm for infants.
• Allow complete recoil of chest (avoid leaning on the chest
between compressions)
• Minimize interruptions for ventilation (<10Sec)
• Give effective breath (2 breaths after 30 compressions, each
breath delivered over 1 second, each causing chest rise)
• Avoid excessive ventilation.
 AIRWAY
HEAD TILT CHIN LIFT JAW THRUST
MOUTH – MOUTH BREATH
BARRIER DEVICES
AMBU BAG
E-C CLAMP TECHNIQUE
AUTOMATED EXTERNAL DEFIBRILLATOR
Electrode Placement
•4 pad positions
• anterolateral,
• anteroposterior,
• anterior-left infrascapular, and
• anterior-rightinfrascapular
• For adults, an electrode size of 8 to 12 cm is
reasonable
• Any of the 4 pad positions is reasonable for
defibrillation
ADULT PEDIATRIC
Sequence:
Choking
ADULT
Infants
summary
ADULT CHILDREN INFANTS
ADVANCED CARDIAC LIFE
SUPPORT– AHA GUIDELINES
 REVERSIBLE CAUSES of CARDIAC
ARREST

H’s
T’s

• HYPOVOLEMIA • TENSION PNEUMOTHIRAX

• HYPOXIA • TAMPONADE

• HYDROGEN IONS(ACIDOSIS) • TOXINS

• HYPO/HYPERKALEMIA • THROMBOSIS,

• HYPOTHERMIA PULMONARY
• THROMBOSIS, CORONARY
Rhythm changes during cardiac arrest
Shokable rhythm Non-shockable rhythm
• Ventricular Tachycardia (VT) • PULSELESS ELECTRICAL
 Monomorphic ACTIVITY (PEA)
 Polymorphic • ASYSTOLE
• Ventricular Fibrillation (VF)
 Coarse
 Fine ( Close d/d for
asystole )
A
R
R
E PULSELESS
S ELECTRICAL
ACTIVITY
T

R ASYSTOLE

H
Y
T

NON-SHOCKABLE
H
 MONOMORPHIC A
VT
R

R
POLYMORPHIC
E
VT
S

R
COARSE VF
Y

T
FINE VF
H

SHOCKABLE S
CARDIAC ARREST
NON SHOCKABLE RHYTHM ( PEA/
ASYSTOLE )

SHOCK
 Monitoring During CPR
Physiologic parameters
• Monitoring of PETCO2 (35 to 40 mmHg)
• Coronary perfusion pressure (CPP)
(15mmHg)
• Central venous oxygen saturation (ScvO2)
Abrupt increase in any of these parameters
is a sensitive indicator of ROSC that can be
monitored without interrupting chest
compressions
Quantitative waveform capnography
• If Petco2 <10 mm Hg, attempt to improve
CPR quality Intra-arterial pressure
• If diastolic pressure <20 mm Hg, attempt to
improve CPR quality
• If ScvO2 is < 30%, consider trying to improve
the quality of CPR
 Interventions Not Recommended for
Routine Use During Cardiac Arrest
• Atropine : Available evidence suggests that routine
use of atropine during PEA or asystole is unlikely to
have a therapeutic benefit

• Sodium Bicarbonate : routine use of sodium

bicarbonate is not recommended for patients in
cardiac arrest. In some special resuscitation
situations, such as preexisting metabolic acidosis,
hyperkalemia, or tricyclic antidepressant overdose,
bicarbonate can be beneficial
• Calcium : Routine administration of calcium for
treatment of in-hospital and out-of-hospital
cardiac arrest is not recommended
• Fibrinolysis : Fibrinolytic therapy should not be
routinely used in cardiac arrest
• Pacing : Electric pacing is not recommended for
routine use in cardiac arrest
• Precordial Thump : The precordial thump may
be considered for termination of witnessed
monitored unstable ventricular
tachyarrhythmias when a defibrillator is not
immediately ready for use(Class IIb, LOE B), but
should not delay CPR and shock delivery
When Should Resuscitative
Efforts Stop?
• Withholding and
Withdrawing CPR
• (Termination of Resuscitative
Efforts)
• Related to In-Hospital
Cardiac Arrest
 or Paco 35– 45

(30ml/kg)
To keep
MAP>65mm Hg
 Targeted Temperature Management
• comatose adult patients with ROSC after cardiac arrest &
in- hospital cardiac arrest should have TTM for
“nonshockable”)
• Core Temperature Measurement If Comatose
• Induce therapeutic Hypothermia ( if no contraindications)
• Surface or endovascular cooling
• Cold IV fluid Bolus 30 mL/kg
• Selecting & maintaining a constant temperature of 32°C–
34°C×24 hours
• After 24 hours, Slow rewarming 0.25°C/hr
• to actively prevent fever in comatose patients after TTM
• routine prehospital cooling of patients after ROSC with
rapid infusion of cold intravenous fluids is NOT
recommended
• An EEG for the diagnosis of seizure should be
promptly performed and interpreted, and
then should be monitored frequently or
continuously in comatose patients after
ROSC.
• The same anticonvulsant regimens for the
treatment of status epilepticus caused by
other etiologies may be considered after
cardiac arrest
 Prognostication After Cardiac
Arrest
• The earliest time to prognosticate a poor neurologic
outcome using clinical examination in patients not
treated with TTM is 72 hours after cardiac arrest, but
this time can be even longer after cardiac arrest if the
residual effect of sedation or paralysis is suspected to
confound the clinical examination

• In patients treated with TTM, where sedation or

paralysis could confound clinical examination, it is
reasonable to wait until 72 hours after return to
normothermia before predicting outcome
POOR NEUROLOGICAL OUTCOME
• Absence of pupillary reflex to light at 72 hours or more after
cardiac arrest
• Presence of status myoclonus (different from isolated myoclonic
jerks) during the first 72 hours after cardiac arrest
• Absence of the N20 somatosensory evoked potential cortical
wave 24 to 72 hours after cardiac arrest or after rewarming
• Presence of a marked reduction of the gray-white ratio on brain
CT obtained within 2 hours after cardiac arrest
• Extensive restriction of diffusion on brain MRI at 2 to 6 days
after cardiac arrest
• Persistent absence of EEG reactivity to external stimuli at 72
hours after cardiac arrest
• Persistent burst suppression or intractable status epilepticus
on EEG after rewarming
 Organ Donation
• All patients who are resuscitated from cardiac
arrest but who subsequently progress to
death or brain death should be evaluated as
potential organ donors.

• Patients who do not achieve ROSC and who

would otherwise have resuscitation
terminated may be considered as potential
kidney or liver donors in settings where
rapid organ recovery programs exist
ADULT BRADYCARDIA WITH A PULSE
ALGORHYTHM
 RECOGNITION of
BRADYCARDIA
SIGNS & SYMPTOMS ECG
CHARACTERISTICS
 LIGHT-HEADEDNESS  SLOW HEART RATE for Age
 PRESYNCOPE/SYNCOPE  P-Wave may/may NOT be
 PALPITATIONS Visible
 HYPOTENSION  QRS Complex may be
 DECREASED LEVEL OF Narrow / may be Wide
CONSCIOUSNESS  AV Dissociation may be
 SHOCK present
 POOR END ORGAN
PERFUSION
 RESPIRATORY DISTRESS
/FAILURE
 SUDDEN COLLAPSE
 NORMAL

SINUS BRADYCARDIA

A
1ST DEGREE
V

2ND DEGREE
MOBIZ TYPE-1 B
(WENCKEBACH L
PHENOMENON) O
C
2ND DEGEREE K
MOBIZ TYPE-2

3RD DEGREE
COMPLETE
HEART BLOCK
 CAUSES
• HYPOXIA
• HYPOTENSION
• ACIDOSIS
• ELECTROLYTE
IMBALANCE(HYPERKALEMIA)
• DRUGS ( β-BLOCKER, CCB, DIGOXIN)/
TOXINS
• INCREASED VAGAL TONE
• INTRINSIC SA/AV NODAL DISEASE
• CONGENITAL HEART/ CONDUCTION
DEFECT
ADULT TACHYCARDIA WITH A PULSE
ALGORHYTHM
TACHYCARDIA : RECOGNITION
SIGNS/SYMPTOMS ECG
• NONSPECIFIC & Differ acc • HR > FASTER for Age
to Age of the Child A.NARROW COMPLEX(≤0.09sec)
1. ST (MC) HR
• Palpitation
2. SVT( MC
• Light-headed ness/ tacchyarrythmia cardio-
syncope vascular compromise in
• Respiratory distress Infancy)
3. ATRIAL FLUTTER
• Shock
B. WIDE COMPLEX
• Altered mental status ( ≥0.09sec)
• Sudden collapse with 4. VT
rapid ,weak pulse 5. SVT with Aberrant
Conduction
SINUS
TACHYCARDI
A N

SUPRAVENTRIC A
ULAR
TACHYCARDIA R

R
ATRIAL
FLUTTER
O

VT W
MONOMORPHIC W
I

D
E
VT
POLYMORPHIC
ACUTE CORONARY SYNDROME
ALGORHYTHM
MANAGEMENT
ALGORHYTHM
 Thrombolysis in Myocardial
Infarction

Thrombosis in Myocardial Infarction (TIMI) score is a seven item tool that helps
stratify patients with potential ACSs in the ED. Patients with a score of 0 to 2 have a 2%
to 9% 30-day risk of death, myocardial infarction, or revascularization. Patients with
higher scoreshave higher risks
DRUGS IN
STEMI
DRUGS IN
NSTEMI
Acute stroke - algorithm
 REFERENCES

• AHA 2015 GUIDELINES : BLS &

ACLS
• TINTINALLI’S 8TH EDITION
• HARRISON’S 19TH EDITION
• BRAUNWALD’S 10TH EDITION
Time is essence .. Act in time and
save a life!!!