1. Cardiopulmonary Resuscitation

2. Cardiac Arrest
Cardiac arrest is the cessation of all cardiac
mechanical activity. It’s clinical diagnosis is
confirmed by
Unresponsiveness
Absence of detectable pulse
Apnea (or agonal respirations )

3. The Cardiac Arrest Rhythms
The four cardiac arrest rhythms are




Asystole
PEA ( Pulseless Electrical Activity )
Pulseless Ventricular Tachcardia (VT)
Ventricular Fibrillation (VF)

4. International Guidelines for CPR 2005

International consensus on the art
& science of CPR

Based on the most extensive
evidence review of CPR

Recommendations designed to
improve survival from sudden
cardiac arrest (SCA)

Circulation Volume 112, Issue 24
Supplement; December 13, 2005

5. AHA Class of Recommendation
 Class I
Definitely recommended
 Class II a
Acceptable and useful
 Class II b
Acceptable and useful
 Indeterminate
Promising, evidence
lacking, immature
 Class III
May be harmful: no
benefit documented
excellent evidence
good to very good evidence
fair to good evidence
no harm and no benefit
not acceptable, not useful,
may be harmful

6. Chain Of Survival – 4 links
BLS
Call for help
Early Defibrillation
Early CPR
Early Advanced
Care

7. 1. Check Responsiveness

8. 2. Call for help with AED defibrillator

9. 3. Open the Airway
Head Tilt –Chin Lift Maneuver

10. 3. Open The Airway
Jaw Thrust Maneuver

11. 4. Check for Breathing
“ Look, Listen and Feel ”

12. 5. Give 2 slow rescue breaths
(over 1 second )
“The Chest Must Rise”

13. 6. Check for Pulse (carotid pulse )

14. 7.Start Chest Compressions (if pulse absent)
Site for chest compressions

15. Locate the margin of the ribs and follow
upto xiphoid process

16. Place hand 2 finger spaces above the
xiphoid process

17. Place other hand over hand on sternum

18. A
C
Chest Compressions
B
D

19. “Push hard and Push fast”
Minimise interruption of chest compression
• 100 /min.
• 30:2 ratio ( C:V )
• 5 cycles (2 minutes)
• 50% : 50 % ( C/R )
• 1 ½ -2 inches sternal depression
• Arms Straight, elbows locked,
shoulder over hands
• Complete recoil of chest

20. Attach defibrillator(AED) as soon as
available and shock if indicated

21. D – Early Defibrillation
Automated External Defibrillator (AED)

Single greatest advance in CPR

The survival rate is 90% if
the patient is defibrillated
within 1 min. and only 10%
if it is delayed till 10mins
(Circulation 1984;69:943-8.)

Survival rate after cardiac
arrest has been reported to
go up from 30% to 49%
(Ann Emerg Med 1996;28:480-5.)

22. Biphasic vs Monophasic Defibrillation

Advantages
- greater efficacy
- low energy produces same effect
- less myocardial damage
- less incidence of S-T changes
( Ital Heart J Suppl. 2002 Jun;3(6):638-45 )

Energy
- Monophasic 360 J
- Biphasic 150/200 J

All AEDs are Biphasic

High first shock success of
Biphasic defibrillation (84%-95%)

23. BLS Algorithm ( Primary ABCD )
Step 1. Assess Responsiveness
Step 2. Activate the EMS and call for the defibrillator
Step 3. Open the airway
Step 4. Assess Breathing (“ look, listen and feel ” )
Step 5. If Breathing is absent, give two slow rescue breaths
Step 6. Check for pulse (carotid pulsations)
Step 7. If pulse is absent initiate “ Chest Compressions ”
As soon as a defibrillator is available attach and
defibrillate if indicated

24. ADVANCED
LIFE SUPPORT

25. A - Airway
 Definitive airway should be secured as soon as possible
 Tracheal intubation using cricoid pressure (by trained
personnel only)
 Laryngeal Mask Airway (LMA) and Esophageal–tracheal
Combitube are accepted alternatives for others
 Cricothyrotomy to be performed in an emergency

26. B. Breathing - Confirm device placement
 Primary Confirmation

Direct Visualisation of ETT passing through cords

Chest expansion

5 point auscultation
- L and R anterior,
- L and R mid-axillary
- Over stomach

Still in doubt –repeat laryngoscopy

Further confirmation
- Exhaled CO2 detector (ETCO2)
- Oesophageal detector device
 Inflate cuff and secure the tube

27. B. Breathing –
Confirm effective oxygenation and ventilation

No synchrony between ventilation and chest
compressions once definitive airway is secured

No longer 30 : 2 compression ventilation cycles
COMPRESSION @100/min
VENTILATION @ 6 – 8 breaths/min

28. C. Circulation
 Identify the rhythm
 Defibrillation /Pacing
 Secure IV line-large easily accessible peripheral veins
 Give rhythm appropriate medication

29. Recognition of Rhythm
Cardiac Arrest (lethal rhythms)
Shockable-VF,Pulseless VT
Non Shockable – Asystole.PEA
Non Cardiac Arrest (non lethal rhythm)
Rate too fast - >120/min
Rate too slow- <60/min

30. Defibrillation

For shockable rhythms – VF / Pulseless VT

Monophasic or Biphasic defibrillators (Biphasic preferred)
Monophasic 360 J ~ Biphasic 200 J

Steps of Defibrillation
- Mains plugged in or on battery, On Defib mode
- ECG size/gain maximum
- Set on leads: Only set on paddles if no leads
- Select joules (200,300 & all others 360)
- Charge, (“all clear”chant to count of 3 before discharge)
- Discharge

31. Pacing
Disappointing results for asystole, PEA
 No benefit in post shock asystole
 May be indicated for cardiac arrest with
narrow QRS complexes
 Not useful during terminal wide complex
agonal rhythms
 Extensive use in pre-arrest bradyarrhythmias
 Transcutaneous or transvenous


32. C-Circulation
IV Access
Wide bore peripheral upper limb vein
 Push each bolus with 20cc fluid
 Raise extremity
 Urgent central/femoral line only if peripheral
access impossible or difficult & taking a long time
to cannulate


33. C-Circulation
Other Drug Delivery Routes

Tracheal
- 2-3 times IV dose
- Dilute in 10 ml saline
- Preferably inject down a suction catheter which
is wedged deep into the bronchus
- Rapid bagging

Intracardiac route
- Not recommended
- Dangerous
can result in refractory VF or convert to
nonshockable rhythm

34. C - Circulation
Rhythm appropriate medications
Epinephrine
 Indicated in all cardiac arrest rhythms
i.e. VF, Pulse less VT, Asystole and PEA
 IV dose is 1mg administered every 3-5 minutes
followed by 20 ml IV saline flush
 Adrenaline causes intense cardio-cerebral sparing
vasoconstriction CPR generates CO 25% of normal
 Beneficial effects outweigh negative effects on the myocardium

35. Vasopressin
 Antidiuretic hormone and a powerful vasoconstrictor
when used in the higher doses.
 Positive effects of epinephrine with lesser adverse
effects . Effect lasts for 20 minutes
 Dose - 40 IU
 Drug of choice for all 4 rhythms
Pulseless VT , VF, Asystole and PEA
 One dose of vasopressin may replace either the first
or the second dose of epinephrine

36. Atropine
 First drug of choice in symptomatic bradycardia (class I )
 Second drug after epinephrine for asystole and
bradycardic PEA ( class II b ).
 Dose is 1mg IV push, repeat every 3-5 minutes up to a
maximum dose of 0.04 mg /kg .

37. Amiodarone
 Persistent or recurrent VF or VT ( class II b )
 Dose is 300 mg IV push (150 mg may be repeated after
3-5 minutes ) may be followed by a 24 hour infusion of
1mg / minute for 6 hours and then 0.5 mg/minute for the
remaining 18 hours.
 Amiodarone preferred over Lignocaine (class
indeterminate ) in the treatment of persistent or
recurrent VF /VT.

38. Sodium Bicarbonate
Specific indications are as follows
 class I
if known pre-existing hyperkalemia
 class II a if known bicarbonate responsive acidosis TCA overdose
 class II b after prolonged resuscitation with
effective ventilation
 class III hypercarbic acidosis
The dose is 1 meq/kg bolus, repeat half this dose every
10 minutes thereafter

39. Calcium
Detrimental effect on ischaemic myocardium
Impairs cerebral recovery
NOT TO BE USED ROUTINELY
Indicated in PEA due to
 Hyperkalaemia
 Hypocalcaemia
 Ca channel blocker overdose

40. Magnesium sulphate
 Shock
refractory ventricular fibrillation in
pr of possible hypomagnesemia
 Torsades de pointes
 VT in pr of possible hypomagnesemia
Dose : 1 –2 g (4-8 mmol ) MgSO4 over 1-2
min,can be repeated after 10 –15 min

41. D. Differential Diagnosis
Review the most frequent causes
( the 5 H’s and 5 T’s )
Hypovolemia
Tablets ( Toxins)
Hypoxia
Tamponade - cardiac
Hydrogen ions – acidosis
Tension pneumothorax
Hyper / hypokalemia
Thrombosis - coronary
Hypothermia
Thrombosis - pulmonary

42. ACLS - Secondary ABCD
Survey
A Airway :
place airway device as soon as possible
B Breathing :
confirm airway device placement
by examination plus confirmation device
secure airway device
confirm effective oxygenation & ventilation
B Breathing :
B Breathing :
C
C
C
C
Circulation :
Circulation :
Circulation :
Circulation :
identify rhythm – monitor
Defibrillation/Pacing
establish IV access
give medications appropriate for rhythm and
condition
D Differential Diagnosis : search for and treat identified reversible
causes

43. Monitoring the Victim -
To assess effectiveness of rescue efforts
 Monitor for signs of circulation and breathing
 Check pulse during compression to assess
effectiveness of compression
 To determine ROSC after 2 minutes of chest
compression check for pulse
 ETCO2

45. THANK YOU