cardiopulmonary resuscitation for students by Dr.Shahna Ali,JNMC,AMU

1. CARDIOPULMONARY
RESUSCITATION (CPR)
Dr. Shahna Ali
Assistant Professor
Department of Anaesthesiology
Faculty of Medicine
Jawaharlal Nehru Medical College

2. “The most common reason many
people die is because no one near by
knew CPR, or if they did know it, they
did not actually do it .”
-Michael Sayre

3. Cardio Pulmonary Resuscitation
• 1960 CPR program was started by
American Heart Association (AHA)
• 1966, the first CPR guidelines were
developed by AHA.

4. Current Statistics
• 383,000 cardiac arrest in USA/year
• Major cause is Sudden Cardiac Arrest
(SCA)
 VF/Pulseless VT most common initial
rhythms in SCA
 Other causes are asphyxia, as in
drowning, choking or drug overdose

5. 1. Immediate recognition & activation
2. Early CPR
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post cardiac arrest care
BLS ACLS
Chain of Survival - Adults

6. What are the goals of CPR?
3 mins

7. 2010 AHA Guidelines2010 AHA Guidelines
How do we do that?

8. Adult BLS sequence
• BLS algorithm is series of sequential
assessments & actions.
• Before approaching the victim, the
rescuer must ensure that the
scene is safe.

9. TAP ON THE SHOULDER & SHOUT “are you all right”
Assessing responsiveness

10. Unresponsive adult
 If a lone rescuer finds an unresponsive adult
activate the EMS system, get an AED
return to the victim to provide CPR &
defibrillation
 If 2 or more rescuers are present:
one rescuer should begin the steps of CPR
2nd rescuer activates the EMS system & gets
AED.

11. Unresponsive adult
 If a lone healthcare provider sees an
adult suddenlycollapsing(Witness arrest)
should phone, get an AED, & start CPR
(Phone First)
Aids a drowning victim or victim of likely
asphyxial (primary respiratory arrest)give
5 cycles (about 2 mins) of CPR before leaving
the victim to activate the EMS system.
(Phone Fast)

12. Activate EMS
• Call EMS/ERS
• Centralised Accident & Trauma Services (CATS)
New Delhi 1099
• Medical Helpline, State (Andhra Pradesh,
Gujarat, Uttarakhand, Goa, Tamil Nadu,
Rajasthan, Karnataka, Assam, Meghalaya,
Madhya Pradesh and Uttar Pradesh )108
• Give the following information:
– Location of the emergency
– What happened
– Victims’ specification &Aid being given

13. C - Circulation
• Pulse Check
–Health Care Providers:
•check for carotids for 10 sec
•no definite pulse, begin
compressions

14. CHECKING FOR CAROTID PULSE
Gutter between
trachea and
sternocleidoma
stoid muscles

15. Chest Compression/Technique
• To maximize the
effectiveness of
compressions:
–Victim should lie supine on a
hard surface
–Rescuer kneeling beside the
victim’s thorax.
–Rescuer should compress
lower half of the sternum in
the center of the chest,
between Nipples

16. PLACEMENT OF FIRST HAND

17. CORRECT POSITION FOR COMPRESSIONS:
ELBOWS STRAIGHT, SHOULDERS ABOVE THE VICTIM’S
CHEST

18. Chest Compression
–“Effective” chest compressions
essential for providing blood flow
during CPR
–“push hard and fast.” Compress @
about 100/min, with a
compression depth of 2 inches (5 cm)
–Allow complete chest recoil after each
compression
– Minimize interruptions in chest
compressions.

19. A - Airway
 Tongue is the most common cause of
airway obstruction in unresponsive
patient
 Victim should be lying flat (supine)
 HEAD TILT - CHIN LIFT maneuver lifts the
tongue and relieves obstruction
 JAW THRUST maneuver in cases of
suspected neck injuries
 Quickly remove food particles, or loose

20. TONGUE CAUSING AIRWAY OBSTRUCTION

21. HEAD TILT - CHIN LIFT lifts the tongue & relieves obstruction

22. B - Breathing
• Provide 2 rescue breaths
• Each over 1 second
• Small TV, sufficient for a visible chest
rise
• Compression ventilation ratio of 30:2
• Prevents stomach distension

23. Mouth to mouth breathing

24. Mouth to mask / Bag mask
breathing

25. D - Defibrillation [BLS]
• In VF, early defibrillation is Class-1
intervention..
• Use of low energy biphasic current for
defibrillation improves outcome.
• 90% patients with primary VF revert to
normal rhythm with defibrillation, if done
within 1 minute.
• New Recommendation: D is now BLS.

26. Why early defibrillation is critical?
Survival rates after VF arrest decrease approx.
7% to 10% with every minute that defibrillation
is delayed

27. Current Recommendation
– Biphasic 120-200 J
– Monophasic 360 J
– Immediate CPR
– Rhythm check only after 5 cycles /2 mins of CPR

28. Technique
Basic Life
Support(BLS)
Advance
Cardiac Life
Support
(ACLS)

29. Automated External Defibrillator
1. Ease of use by untrained
rescuers
2. Automated detection of
defibrillatable rhythms
3. Advises shock & delivers
it
4. Portable

30. Automated External Defibrillator
AED ELECTRODE PLACEMENT
• Anterolateral
• Anteroposterior
• Antero left infrascapular
• Antero right infrascapular
SIZE: 8-12cm
TRANSTHORACIC IMPEDENCE
• 70-80 Ω.
• use conductive material like gel pads or
electrode paste or self adhesive pads

31. Steps of AED
1) Power on the AED
2) Attach Electrode Pads to pt’s bare
chest
3) Analyze rhythm (ALL CLEAR)
4) Deliver Shock if advisable

32. Resume CPR
• After shock is delivered,
resume CPR
• Start chest compression
• Give cycle of 30:2
• Do not perform pulse or rhythm check
• After 2 min of CPR, AED will prompt you
to repeat steps 3 and 4

33. AED in Special Situation
Hairy Chest
• If pad stick to the hair, press down
firmly on each pad
• Quickly pull of the pads
• If too much hair remains then shave
the area with razor
• Put on a new set of pads

34. AED in Special Situation
Implanted Pacemaker
• Hard lump beneath the skin of the
upper chest or abdomen with visible scar
mark.
• Place the AED electrode pads to either side
and not directly on top of the device.
• If implanted D. is delivering shock, wait for
30-60 sec before giving shock with AED

35. AED in Special Situation
Water
• Do not use AED in water (conduct)
• The patient chest is covered with water-
Wipe the chest quickly before attaching
the electrodes
• The patient is lying on snow or ice: you
can use AED

36. AED in Special Situation
Trans-dermal medical patch
• Do not place AED electrode pad directly on top
of trans-dermal patch( nitroglycerine, nicotine,
analgesic, hormone, anti HTN)
• Block energy transfer and cause skin burns
• Remove the patch and wipe the area clean

37. Unresponsive
No breathing or no normal breathing (gasping)
Get defibrillatorActivate emergency
response
Start CPR
Push hard
Push fast
Check rhythm/ shock if indicated
Repeat every 2 min
BASIC LIFE SUPPORT

38. ACLS CARDIAC ARREST ALGORITHM
Adult Cardiac
Arrest
VF/ VT Asystole / PEA
Rhythm shockable
Start CPR
• give O2
• monitor/
defibrillator
Call for help / EMS
noyes

39. VF represents disorganized electric activity.

40. Pulseless VT represents organized electric
activity of the ventricular myocardium.
Neither of these rhythms generates significant forward
blood flow

41. PEA absence of mechanical ventricular activity or
mechanical ventricular activity that is insufficient to
generate a clinically detectable pulse.

42. Asystole represents absence of detectable
ventricular electric activity with or without
atrial electric activity
Asystole
Flat line protocol
• Check lead attachment.
• Check lead selection
• Check the gain
• Check power on/off

43. VF/ VT
SHOCK
CPR x 2 min
• IV / IO access
Rhythm shockable ?
CPR x 2 min & epinephrine every 3 – 5 min
Consider advanced airway, capnography
yes
SHOCK
Rhythm shockable ?
yes
SHOCK
CPR x 2 min & amiodarone
treat reversible causes
no
no
• go to Asyst / PEA algorithm
• ROSC +, go to post-cardiac
arrest care

44. Asystole / PEA
CPR x 2 min
• IV / IO access
• epinephrine every 3 – 5 min
• Consider advanced airway, capnography
yes
no
Rhythm shockable ?
CPR x 2 min
• treat reversible causes
Rhythm shockable ?
yes
• go to VF / VT algorithm
• ROSC +, go to post-cardiac
arrest care
no

45. ACLS Cardiac Arrest Algorithm.

46. Drugs used in resuscitation
NAME DOSE MECH OF ACTION INDICATION
Adrenaline 1 mg IV/ IO
every 3-5 min
α adr receptor
stimulation
Confirmed adult
cardiac arrest
Vasopressin 40 units IV/ IO Non adrenergic
peripheral
vasoconstrictor
May replace 1st
or 2nd
dose of
adrenaline
Amiodarone Initial 300 mg
IV/ IO f/b 1 dose
of 150 mg IV /
IO
Affects Na, K & Ca
channels and has α &
β adrenergic blocking
properties
VF or pulseless
VT
unresponsive to
shock, CPR or
vasopressor

47. Drugs used in resuscitation
NAME DOSE MECH OF ACTION INDICATION
Lidocaine 1 to 1.5
mg/kg IV IO
every 3-5
min
Na channel blocker If amiodarone
is not available
Magnesium
Sulphate
1-2 gm
diluted in 10
ml 5 %
dextrose IV/
IO
Termination of torsades de pointes
(irregular/polymorphic VT associated
with prolonged QT interval)

48. Advanced Airways

49. New Recommendation:
Early institution of EtCO2 monitoring. It correlates well
with CO. EtCo2 > 20 mmHg indicates adequate CO & a
good outcome. Rise of EtCo2 > 40 mmHg is the earliest
sign of ROSC.
New Recommendation:
TV has been reduced to just that which causes the chest
to rise & fall (8-10 ml/kg, O2 – 6-7 ml/kg)
Initial Rescue breaths – 2 over 1 sec each.
Ratio of Compression: Ventilation be 30:2 in adults.
When the airway has been secured, compression rate is
kept 100/min independent of 8-10 ventilation

50. Reversible causes
H s T s
Hypoxia Toxins/tablets
Hypovolemia Tamponade (cardiac)
Hydrogen ion (acidosis) Tension pneumothorax
Hypo/ hyperkalemia Thrombosis,
pulmonary/coronary
Hypothermia/Hypoglycemia Trauma

51. Immediate Post Arrest Care –Return of
Spontaneous Circulation (ROSC)

52. NEW IN CPR?

53. AUTOPULSE did it……

54. LifeBand / Autopulse
• Conforming, load-distributing band
• Fully releases during relaxation
– Maximizes time for diastolic blood flow
– Allows visual confirmation of inhalation via chest
rise
• Single-use disposable
– Infection control
– Minimal clean-up between patients

55. Patient Specifications
• Chest circumference: 29.9 in / 80.0 cm to
51.2 in / 130.0 cm
• Chest width: 9.8 in / 24.9 cm to 15 in / 38 cm
• Maximum patient weight: 300 lbs / 136 kg
AHA gives LDB-CPR Class II b recommendation.
(Acceptable .Good evidence provides support)

56. • PocketCPR is placed on the chest and chest
compressions are started. The device notifies the
rescuer to “push harder” if the compressions are
less than 1.5 inches. If good compressions are
delivered, PocketCPR will respond “good
compressions”. Four LED lights on the device flash
for a good compression and one LED flashes if the
compression is less than 1.5 inches.

57. Extra-Corporeal Cardiopulmonary
Resuscitation (ECPR)
• Stage 1:
Placement of femoral artery and vein catheters
• Stage 2: Placement of ECLS Cannulas
• Stage 3: Going on Pump
The ECPR algorithm typically involves 2 physicians.
With the first physician supervising ACLS ( the “code
doc”), the second doctor is responsible for
percutaneous femoral venous and arterial access
( the “line doc”). On average, it takes 20 to 30
minutes to complete all 3 stages

59. • ECMO in the Cardiac Arrest setting2011
• Guidelines for ECPR:ELSO ECPR Supplement to the
2013
• CHEER Trial 2014

63. When to STOP CPR
• Spontaneous return of circulation/Scene
unsafe
• Turn to properly trained personnel(ACLS)
• Operator is exhausted
• Patient has signs of irreversile death

64. Breaking Bad Newsws