Cardiopulmonary Resuscitation

Critical Concepts

 
High-quality CPR includes

• Start compressions within 10 seconds of recognition of cardiac arrest.

• Push hard, push fast: Compress at rate of atleast 100/min with a
depth of atleast 5 cm (2inches) for adults, approximately 5 cm (2
inches) for children , and approximately 4 cm (1½inches) for infants.
• Allow complete chest recoil after each compression
• Minimize interruptions in compressions (try to limit interruptions to
<10 seconds).
• Give effective breaths that make chest rise
• Avoid excessive ventilation.
 Chain of survival

• Immediate recognition of cardiac arrest and

activation of emergency response system.
• Early cardiopulmonary resuscitation (CPR)
with an emphasis on chest compressions.
• Rapid defibrillation
• Effective advanced life support
• Integrated post-cardiac arrest care
Chain of survival
 Sequence

• C Chest Compressions
• A Airway
• B Breathing
 BLS main parts

• Chest compressions
• Airway
• Breathing
• Defibrillation
 BLS Steps

Step Action

1 Assess the victim for a response and look for normal or abnormal
breathing. If there is no response and no breathing or no normal
breathing (ie, only gasping), shout for help.
2 If you are alone, activate the emergency response system and get
an AED (or defibrillator) if available and return to victim.

3 Check the victim’s pulse (take atlest 5 but no more than 10

seconds).

4 If you do not definitely feel a pulse with in 10 seconds, perform 5

cycles of compressions and breaths (30:2 ratio), starting with
compressions (C-A-B sequence)
  
Step 1 Assesment of scene safety

Action
i Make sure the scene is safe for you and the victim.
You do not want to become a victim yourself.
ii Tap the victim’s shoulder and shout, “Are you
alright?”
iii Check to see if the victim is breathing. If a victim is
not breathing or not breathing normally (ie, only
gasping), you must activate the emergency
response system.
  
Step 2

• Activate Emergency Response System and Get

and AED
 Step 3 Pulse check

• Check Pulse- take no more than 10 seconds

for pulse check.
 Action
i Locate the trachea, using 2 or 3 fingers
ii Slide the 2 or 3 fingers into the groove between the
trachea and the muscles of the side of the neck,
where you can feel the carotid pulse
iii Feel for pulse for atleast 5 but no more than 10
seconds. If you do not definitely feel a pulse, begin
CPR, starting with chest compressions (C-A-B
sequence).
 Step 4
 

• Begin Cycles of 30 chest compressions and 2

breaths (CPR), at rate of atleast 100
compressions per minute.
 Action
i Position yourself at victim’s side.
ii Make sure the victim is lying up on affirm, flat
surface. If the victim is lying facedown, carefully roll
him faceup. If you suspect the victim has a head or
neck injury, try to keep the head, neck, and torso in a
line when rolling the victim to a faceup position.
iii Put the heel of one hand on centre of victim’s chest
on the lower half of the breastbone.
iv Put the heel of your other hand on the top of first
hand.
v Straighten your arms and position your shoulders
directly over your hands.
 Action
vi Push hard and fast
1. Press down atlest 5 cm (2 inches) with each
compression (this reqires hard work). For each
chest compression, make sure you push straight
down on the victim’s breastbone.
2. Deliver compressions in a smooth fashion at a
rate of 100/min.
vii At the end of each compression, make sure you
allow the chest to recoil completely. Chest
compression and recoil/relaxation time should
be approximately equal.
viii Minimize interruptions
Opening the Airway for Breathing: Head Tilt-Chin Lift

Step Action
1 Place one hand on the victim’s forehead
and push with your palm to tilt the head
back.
2 Place the fingers on the other hand under
the bony part of the lower jaw near the
chin.
3 Lift the jaw to bring the chin forward.
Head Tilt-Chin lift
Jaw thurst
E-C clamp technique
 Using the Bag-Mask
Step Action
1 Position yourself directly above the victim’s head
2 Place the mask on the victim’s face, using the bridge of nose as a guide
for correct position
3 Use the E-C clamp technique to hold the mask while you lift the jaw to
hold the airway open:
1. Perform a head tilt
2. Place the mask on the face with the narrow portion at the bridge
of the nose
3. Use the thumb and index finger of one hand to make a “C” on the
side of the mask, pressing the edges of the mask to the face.
4. Use the remaining fingers to lift the angles of the jaw (3 fingers
form an “E”), open the airway, and press the face to the mask.
4 Squeeze the bag to give (1 second each) while watching for chest rise.
Deliver all breaths over 1 second whether or not you use
supplementary oxygen.
Using an AED
 AED
Step Action
1 POWER ON the AED (the AED will then guide you through the next steps)
1. Open the carrying case on top of AED
2. Turn the power on (some devices will “power on” automatically when you
open the lid or case).
2 ATTACH AED pads to the victim’s bare chest.
1. Choose adult pads (not child pads or a child system) for victims 8 years of age
and older.
2. Peel the backing away from the AED pads
3. Attach the adhesive AED pads to the victim’s bare chest.
Place one of the AED pad on the victim’s upper-right chest (directly below
the collarbone).
Place the other pad to the side of the left nipple, with the top of the pad
and a few centimetres below the armpit.
4. Attach the AED connecting cables to the AED box (some are preconnected).
Step Action
3 “Clear” the victim and ANALYSE the rhythm.
1. If the AED prompts you, clear the victim during analysis. Be sure no one is
touching the victim, not even the rescuer in charge of giving breaths.
2. Some AEDs will tell you to push a button to allow the AED to begin analyzing
the heart rhythm; other will do that automatically. The AED may take about 5
to 15 seconds to analyse.
3. The AED then tells you if a shock is needed.
4 If the AED advices a shock, it will tell you to clear the victim.
1. Clear the victim before delivering the shock: be sure no one is touching the
victim.
2. Loudly state a “clear the victim” message, such as “Everybody clear” or
simply “Clear.”
3. Look to be sure no one is in contact with the victim.
4. Press the SHOCK button.
5. The shock will produce a sudden contraction of the victim’s muscles.
Step Action
5 If no shock is needed, and after any shock delivery,
immediately resume CPR, starting with chest
compressions.
6 After 5 cycles or about 2 minutes of CPR, the AED will
prompt you to repeat steps 3 and 4.
If “no shock advised,” immediately restart CPR
beginning with chest compressions.
 BLS Steps Summary

Assess Assessment Technique and action

1 Check 1. Tap and shout, “Are you all right?”
responsiveness 2. Check for absent or abnormal breathing
(no breathing or only gasping) by looking
at or scanning the chest for movement
(about 5 to 10 seconds)
2 Activate the 1. Activate the emergency response system
emergency and get an AED if one is available or send
response system/ someone to activate the emergency
get AED response system and get an AED or
defibrillator.
 Assess Assessment Technique and action
3 Circulation 1. Check the carotid pulse for 5 to 10 seconds
2. If no pulse within 10 seconds, start CPR (30:2) beginning with
chest compressions
a. Compress the center of chest (lower half of the sternum)
hard and fast with at least 100 compressions per minute at a
depth of at least 5 cm (2 inches)
b. Allow complete chest recoil after each compressions
c. Minimize interruptions in compressions (10 seconds or less)
d. Switch providers about every 2 minutes to avoid fatigue
e. Avoid excessive ventilation

3. If there is a pulse, start rescue breathing at 1 breath every 5

to 6 seconds (10 to 12 breaths per minute). Check pulse
every 2 minutes.
 Assess Assessment Technique and action
4 Defibrillation 1. If no pulse, check for a shockable rhythm
with an AED/defibrillator as soon as it
arrives
2. Provide shocks as indicated
3. Follow each shock immediately with CPR,
begning with chest compressions.
 ACLS
• Respiratory Arrest
• VF/Pulseless VT
• Pulseless Electrical Activity
• Asystole
• Acute Coronary Syndromes
• Bradycardia
• Unstable Tachycardia
• Stable Tachycardia
• Acute Stroke
 RESPIRATORY ARREST

 
• Supplemental oxygen
• Opening the Airway
• Ventilation
 Airway Ajuncts

• Orophayngeal airway
• Nasophayngeal airway 
Oropharyngeal airway
Nasophayngeal airway
 Suctioning

• Soft flexible catheters for mouth or nose

• Rigid catheter for suction of orophaynx
 Ventilation

• Head tilt-chin lift

• Jaw thrust without head extension (suspected
cervical spine trauma)
• Mouth-to-mouth ventilation
• Mouth-to-nose ventilation
• Mouth-to-barrier device (pocket mask)
ventilation
• Bag-mask ventilation
 Advanced airway
• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal tube
• Endotracheal tube
Laryngeal mask airway
Esophageal-tracheal tube
Endotracheal tube
• 7.5 ET for most adult
• 7.0 ET for smaller female
• 8.0 ET for larger males
 ENDOTRACHEAL INTUBATION

Indications
1.Inability to maintain airway patency. Trauma/Foreign bodies/ Infection/
HematomaTumour/ Congenital anomalies/ Laryngeal oedema/ Laryngeal spasm

2.Inability to protect the airway against aspiration: Head injury/Drug

overdose/Cerebrovascular accident, GCS<8

3.Anticipation of a deteriorating course that will eventually lead to respiratory failure. Eg

airway burns

4.Respiratory Failure

5. Cardiopulmonary arrest

6. For general anesthesia

 Airway Device Ventillations during Ventillations during
Cardiac Arrest Respiratory Arrest
Bag-mask 2 ventillations after 1 ventillations every
every 30 5 to 8 seconds (10
compressions to 12 breaths per
Any advanced 1 ventillation every minute)
airway 6 to 8 seconds
(8 to 10 breaths per
minute)
 Cardiac Arrest
• VF/pulseless VT
• Asystole/PEA
• VF
• Pulseless VT
Ventricular tachycardia
Ventricular fibrillation
 Shock Energy

• Biphasic: 120-200J
• Monophasic 360J
 Drug therapy

• Epinephrine IV/IO 1mg every 3-5 minutes

Follow each dose given by peripheral injection with 20-mL flush of fluid
and elevate the extremity above the level of heart for 10 to 20 seconds.

• Vasopressin IV/IO 40 units can replace first or 2 nd dose of epinephrine

• Amiodarone 300 mg IV/IO bolus first dose , additional 150 mg IV/IO once
• Lidocaine 1 to 1.5 mg/kg IV /IO first dose, then 0.5 to 0.75 mg/kg at 5 to
10 minute intervals, to a maximum dose of 3 mg/kg
• Magnesium sulphate for torsades de pointes, loading dose 1 to 2 gram
IV/IO diluted in 10mL (Dextrose 5% , Normal saline) given as IV/IO bolus,
typically over 5 to 20 minutes.
 PEA and Asystole
PEA include
• Idioventricular rhythms
• Venricular escape rhytms
• Post defibrillation idioventricular rhythms
• Sinus rhythms
Asystole
Idioventricular rhythm
Ventricular escape rhythm
 Reversible causes of PEA and Asystole
Reversible Causes
Hypovolemia Tension pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen ion (acidosis) Toxins
Hypo-/hyperkalemia Thrombosis, pulmonary
Hypokalemia Thrombosis, coronary
 Return of Spontaneous Circulation (ROSC)

• Pulse and blood pressure

• Abrupt sustained increase in PETCO2 (typically
> = 40 mm Hg)
• Spontaneous arterial pressure waves with
intra-arterial monitoring
 Unstable Tachycardia
• Atrial fibrillation
• Atrial flutter
• Reentrant Supraventicular tachycardia
• Monomorphic VT
• Polymorphic VT
• Wide-complex tachycardia of uncertain type
 Synchronized Cardioversion
Initial Dose
Unstable atrial fibrillation 120-200J biphasic or 200J
monophasic
Unstable monomorphic VT 100J
Other unstable SVT/Atrial 50 to 100J
flutter
Polymorphic VT (irregular form Treat as VF with high-energy
and rate) and ustable shock(defibrillation doses)
 Acute Coronary Syndromes

General Group Description

STEMI ST elevation
High-risk NSTE-ACS ST depression or dynamic T-
wave inversion
Intermediate/low-risk ACS Normal or nondiagnostic ECG
 Symtoms and signs of ischemia (Box 1)

• Restrosternal chest discomfort more of pressure or

tightness than actual pain.
• Uncomfortable pressure, fullness, squeezing, or pain in
center of the chest lasting for several minutes.
• Chest discomfort spreading to the shoulders, neck, one
or both arms, or jaw.
• Chest discomfort spreading into the back or between
shoulder blades.
• Chest discomfort with light-headedness, dizziness,
fainting, sweating, nausea, or vomiting.
• Unexplained, sudden shortness of breath, which may
occur with or without chest discomfort.
Suspected stroke algorithm
Suspected or Confirmed case of COVID-19
 RAPID RESPONSE SYSTEM

Rapid response system to be activated when

• Threatened airway
• Respiratory rate < 6 or > 30 breaths per minute
• Heart rate < 40/min or > 140/min
• Systolic blood pressure (SBP) < 90 mm Hg
• Symptomatic hypertension
• Unexpected decrease in level of consciousness
• Unexplained agitation
• Seizure
• Significant fall in urine output