OBJECTIVES
• Recognise cardiac arrest.
• How to perform chest compression and rescue breathing.
• Differentiate between shockable and
non- shockable rhythm.
• Understand Principal Drugs (Atropine–Adrenaline-
Amiodarone).
• Case presentations.

CASE 1
• You find a 72-year-old man lying unresponsive
in a restroom of a local airport. He is alone, and
you don't know how long he has been
unconscious. You speak loudly, trying to wake
him up, and you shake him; he continues to be
unresponsive.
What should be your sequential response in
this situation?

CASE 2
• A 56-year-old woman is found pulseless in her
room at a local hospital. The nurse calls "code
blue," and you are the first doctor responding.
• The nurse has started CPR, and the patient has a
patent I.V. line. After 2 minutes, the patient is still
pulseless. A defibrillator has now been brought to
the room.
What is the best intervention to take next in the
care of this patient?

What is CPR
• Cardiopulmonary Resuscitation (CPR) consists of
chest compression and mouth-to-mouth respiration .
• CPR allows oxygenated blood to circulate to vital
organs such as the brain and heart.
• CPR can keep a person alive until more advanced
procedures (such as defibrillation - an electric shock
to the chest) can treat the cardiac arrest.

Cardio Pulmonary Resuscitation
• BLS – basic life support.
• ACLS – advanced cardiac life support.

Causes of Cardiac Arrest

8
Causes of cardiac arrest
Cardiac
Extracardiac
Primary lesion of cardiac muscle leading to the
progressive decline of contractility, conductivity
disorders, mechanical factors
All cases accompanied with hypoxia

9
Causes of circulation arrest
Cardiac
• Ischemic heart disease
• Arrhythmias of different
origin and character
• Electrolytic disorders
• Valvular disease
• Cardiac tamponade
• Pulmonary artery
thromboembolism
• Ruptured aneurysm of
aorta
• Hypertrophic obstructive
CM
Extracardiac
• Airway obstruction
• Acute respiratory failure
• Shock
• Embolisms of different
origin
• Drug overdose
• Electrocution
• Poisoning

Cardiac Arrest
• Brain damage begins 4 - 6 minutes after
cardiac arrest
• Brain damage becomes irreversible in
8 - 10 minutes

Chain of Survival for OHCA
Andrew H. Travers et al. Circulation. 2010;122:S676-S684
1. Immediate recognition and activation
2. Early CPR
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care

Basic life support (BLS)
Implies that no equipment is employed
other than a protective device.
Consists of chest compression
mouth-to-mouth respiration and

Steps of CPR (3 Cs)
1) Check
• Scene
• Injuries
• Consciousness
2) Call
• EMS
3) Care
• C-A-B-D

CHECK
Establish Unresponsiveness
• Tap victim on
shoulder and
ask “Are you
OK?”

Check Pulse
• Check carotid pulse
• Check for 5-10
seconds
• If you are not sure if
the victim has a
pulse, start CPR
• Unnecessary CPR is
less harmful than not
performing CPR that
is needed

Check for Breathing
• Look, Listen
and Feel for
Breathing (for at
least 5 seconds
and not more
than 10)

CALL
Activate EMS
• If victim is unresponsive, activate EMS
immediately
• Instruct a bystander to call
• If you are alone, you must activate EMS before
performing any other step
• If unresponsive & victim is breathing, place in
recovery position
Patient unresponsive with no breathing
Start CPR

C-A-B-D
CARE

CARE
Hand Placement for Chest Compression
• Place the heel of one
hand in the center of
the victim’s bare
chest between the
nipples
• Put the heel of your
other hand on the top
of your first hand
• Straighten your arms
and position your
shoulders directly
over your hands

Put hand(s) in correct position for chest
compressions

Chest Compressions
• Push hard and fast—rate
of 100 per min
• Press down 1 ½- 2 inches
with each compression
• For each compression
press straight down
• At the end of the
compression allow the
chest to recoil or re-expand
completely

Opening the Airway
• Head tilt – Chin lift
• Remove any visible
objects from mouth
• If victim has possible
spinal injury, use jaw
thrust without a head
tilt

Jaw-thrust maneuver
Used on patients with a
suspected spinal
injury and is used on
a supine patient.
Prevents the tongue from
obstructing the upper
airways.

Give 2 Breaths
• Pinch the nose closed with
your thumb and index finger
• Take a regular breath and
seal your lips around the
victim’s mouth, creating an
airtight seal
• Slowly breath air into victim’s
mouth until victim’s chest
rises
• Remove your mouth to let
the air come out
• Repeat one more breath

Recheck Circulation
• Cycle=30
compressions
and 2 breaths
• Recheck pulse
after 5 cycles

During CPR
• Push hard & fast (100-
120/min)
• Compressions to
relaxation ration 50:50
• Ensure full chest recoil

During CPR
• Avoid hyperventilation
• Secure airway & confirm placement
• Rotate compressors every 2min with
rhythm checks
• After an advanced airway is placed,
rescuers no longer deliver “cycles” of
CPR. Give continuous chest
compressions without pause for breaths.
Give 6-8 breaths/min. check every 2min.

CPR
Pushing on the Chest
• Sometimes you may hear a
cracking sound.
• The sound is caused by
cartilage or ribs cracking.
• Even if this occurs the
damage is not serious.
• The risk of delaying CPR or
not doing CPR is far
greater than the risk of a
broken rib.

BLS Dos and Don’ts of Adult High-Quality CPR
Rescuers Should NotRescuers Should
Compress at a rate slower than
100/min or faster than 120/min
Perform chest compressions at a rate
of 100-120/min
Compress to a depth of less than 2
inches (5 cm) or greater than 2.4
inches (6 cm
Compress to a depth of at least 2
inches (5 cm)
Lean on the chest between
compressions
Allow full recoil after each compression
Interrupt compressions for greater than
10 seconds
Minimize pauses in compressions
Provide excessive ventilation
(ie, too many breaths or breaths with
excessive force)
Ventilate adequately (2 breaths after
30 compressions, each breath
delivered over 1 second, each causing
chest rise)

When to Stop CPR
• Victim is revived
• Replaced by another
equally trained person
or physician assumes
responsibility
• Exhaustion
• Scene becomes unsafe
• Physician direction to
stop

Simplified Adult BLS Algorithm.
Andrew H. Travers et al. Circulation. 2010;122:S676-S684

In Hospital Resuscitation
• In hospital resuscitation differs in ;
- location (monitored),
- training of the first responder,
- number of responders,
- equipment available and
- resuscitation team.

Physiology:Acute changes in:
−ThreatenedAirway
−All respiratory arrests
−Respiratory rate <5/ min
−Respiratory rate >36/ min
Breathing
−Pulse rate <40/min
−Pulse rate >140/min
−Systolic BP <90 mmHg
Circulation
−Sudden in level of consciousness
−Decrease in GCS >2points
−Repeated or prolonged seizures
Neurology
−Any patient - causing concern who does not
fit the above criteria
Other
Predictors of cardiac arrest

Sequence for collapsed patient
in a hospital
1) Ensure personal safety:
– Your personal safety and that of resuscitation
team members is the first priority.
– Check that the patient’s surroundings are safe.
– Put on gloves as soon as possible, eye
protection and face mask may be necessary.

2) Check the patient for a response:
If you see a patient collapse or apparently unconscious,
-shout for help
-assess response by gently shaking
the victim and ask loudly, "Are you OK?“
3) If he has a pulse or signs of life: ABCDE
4) If he has no pulse or signs of life:
call the resuscitation team and start CPR immediately
5) If he is not breathing and has a pulse
( respiratory arrest): keep ventilation and check for a
circulation / 10 breath.

6) If the patient has a monitored and
witnessed cardiac arrest:
– Confirm cardiac arrest and shout for help.
– Give precordial thump if the rhythm VF/ VT
or defibrillator is not to hand immediately, and
start CPR.
– Success  if done  10 sec of VF

Deliver a sharp impact to the lower half of the sternum from a height
20 cm, using the ulnar edge of a tightly clenched fist.

ABCDE

Airway (A):
 Airway obstruction hypoxia, and risk damage to
brain, kidneys, heart, cardiac arrest and even death.
 Signs of obstruction: stridor, wheeze, gurgling,
snoring..
TTT: Airway clearance
 Airway opening maneuvers, suction,
 Insertion of an oropharyngeal or nasopharyngeal airway
 Tracheal intubation.
 Use high concentration oxygen with sufficient flow (>10
L/ min.).

Oropharyngeal

Laryngeal mask

Tracheal tubes
Nasopharyngeal
airway

Breathing (B):
Diagnose and treat immediately life- threatening
condition,
- acute severe asthma,
- pulmonary edema,
- tension pneumothorax,
- massive hemothorax.
Look, listen and feel for general signs of respiratory
distress;
- sweating, central cyanosis,
- use of accessory ms of resp, abd breathing.
- resp rate, depth, JVP, record oxygen saturation %,
TTT: give oxygen, use bag-mask or pocket mask
ventilation if rate and depth of breathing is inadequate.

bag-mask
pocket mask

Circulation (C) :
Look for color and temperature of the hand
Assess state of veins, peripheral and central
pulse
Measure BP, auscultate the heart.
Look for signs of poor cardiac output
(reduced conscious level and oliguria)
Treat urgently life threatening conditions,
• cardiac tamponade, massive or continued
hge, septicemic shock.
Insert IV cannula, give fluids, reassess HR
and BP/5min. 12-lead ECG monitoring

Disability (D):
• Common causes of unconsciousness include
− profound hypoxia,
− hypercapnea,
− cerebral hypo perfusion or
− recent administration of sedatives or
analgesics.
• Exclude or treat hypoxia and hypotension
• Check drug chart and give antagonist
• Measure bl gl and give glucose if<50mg/dl.
• Rapid initial assessment of conscious level using
Glasgow coma scale
• Nurse unconscious patients in lateral position if their
airway is not protected.

Glasgow Coma Scale Score
4SpontaneousEye Opening
3To Speech
2To Pain
1Nil
5OrientedVerbal Response
4Confused
3Inappropriate words
2Incomprehensive sounds
1Nil
6Obeys commandsMotor Response
5Localizes
4Normal flexion
3Abnormal flexion
3Abnormal extension
1Nil

Exposure (E):
• To examine the patient properly full exposure of
the body may be necessary.
Respect the patient dignity and minimize heat
loss.
• Additional information:
-Take a full history
-Review the patient notes and charts
-Review the results of lab and radiology
-Assess, treat and record response to treatment
-Consider definitive treatment of underlying
condition.

Problems with CPR Technique
• CPR often ineffective because of poor technique
• Compressions not delivered steadily and
constantly during resuscitation efforts
• Often compressions are too shallow, resulting in
ineffective blood flow
• Compressions may be given at too fast a rate

Advanced Life Support
ALS

Advanced Life Support
Interventions intended to achieve
1- Adequate ventilation,
2- Control cardiac arrhythmias,
3- Stabilize blood pressure and cardiac output
4- Restoration of spontaneous circulation
5- Protection of the central nervous system

Advanced Life Support
The activities carried out to achieve these goals
include
1) Defibrillation / cardioversion and/or pacing,
2) Anti-arrhythmic medications
3) Intubation with an endotracheal tube, and
4) Insertion of an intravenous line.
Immediate defibrillation should precede
intubation and insertion of an intravenous line;
CPR should be carried out while the defibrillator
is being charged.

Advanced life support algorithm:
Heart rhythms associated with CA are either:
– Shockable rhythm
• VF
• pulseless VT
– Non-shockable rhythm
• Asystole
• pulseless electrical activity PEA

Asystole

Pulseless electrical activity
(electromechanical dissociation)

Treatment of shockable rhythm:
- If VF/VT is confirmed, follow the algorithm of European
Resuscitation Council ERC Guidelines for Resuscitation,
2010.
- Attempt defib. Give one chock of 150-200 biphasic or
360 j monophasic.
- Immediately resume CPR 30-2 without assessing the
rhythm or feeling the pulse for 2 min.
- If VF/VT persists give 2nd shock of 150-360 biphasic or
360 j monophasic. and resume CPR for 2 min

− If VF/VT persists give 3rd shock of 150-360 biphasic
or 360 j monophasic. resume CPR for 2 min.
− Pause briefly to check the monitor.
− If VF/VT persists give adrenaline 1 mg IV and
amiodarone 300 mg IV followed by 4th shock of 150-
360 biphasic or 360 j monophasic. resume CPR for 2
min.
− Pause briefly to check the monitor.
− Give adrenaline 1mg IV immediately before alternate
shocks ( every 3-5min).

Non-shockable rhythm
– survival following CA with asystole or PEA, is
unlikely unless a reversible cause can be
found and treated quickly and effectively.
• Treatment
− Start CPR 30-2
− Give adrenaline 1 mg IV as soon as I.V
access is achieved.
− Continue CPR 30-2 until airway is secured,
then continue chest compression without
pausing during ventilation.
− Recheck the rhythm after 2 min:

During CPR: consider potential causes or
aggravating factors during CA.
6 H’s
Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
Hypoglycemia
Hypothermia
5 T’s
Toxins
Tamponade
Thrombosis (coronary
or pulmonary)
Tension PTx
Trauma

Post–cardiac arrest care algorithm
Mary Ann Peberdy et al. Circulation. 2010;122:S768-S786

CASE 1
• You find a 72-year-old man lying unresponsive
in a restroom of a local airport. He is alone, and
you don't know how long he has been
unconscious. You speak loudly, trying to wake
him up, and you shake him; he continues to be
unresponsive.
what should be your sequential response in
this situation?

• The resuscitation of an adult victim of sudden
cardiac arrest should follow an orderly sequence,
no matter where the patient collapse occurs.
• This sequence is called the chain of survival.

CASE 2
• A 56-year-old woman is found pulseless in
her room at a local hospital. The nurse calls
"code blue," and you are the first doctor
responding. The nurse has started CPR,
and the patient has a patent I.V. line. After 2
minutes, the patient is still pulseless. A
defibrillator has now been brought to the
room.
What is the best intervention to take next
in the care of this patient?

• In the chain of survival, the importance of rapid
access to defibrillation cannot be ignored.
• In a patient who is dying from a shockable
rhythm, the chance of survival declines by 7% to
10% for every minute that defibrillation is
delayed.
• Early defibrillation is so critical that if a
defibrillator is immediately available, its use
takes precedence over CPR in patients with
pulseless VT or VF.
• If CPR is already in progress, it should be halted
while defibrillation takes place.

Questions

1. Success of any resuscitation attempt is built on:
A. high quality CPR
B. defibrillation when required by the patients ECG rhythm
C. neither 1 or 2
D. both 1 and 2

1. Success of any resuscitation attempt is built on:
A. high quality CPR
B. defibrillation when required by the patients ECG rhythm
C. neither 1 or 2
D. both 1 and 2

2) The most important algorithm to know for adult
resuscitation is:
A. Bradycardia
B. PEA
C. Tachycardia
D. Cardiac Arrest

2) The most important algorithm to know for adult
resuscitation is:
A. Bradycardia
B. PEA
C. Tachycardia
D. Cardiac Arrest

3) The systematic approach with a person in
cardiac arrest should include the BLS survey
and the ACLS survey?
A. True
B. False

3) The systematic approach with a person in
cardiac arrest should include the BLS survey
and the ACLS survey?
A. True
B. False

4) While conducting the BLS Survey, you should
do all of the following except:
A. check patient responsiveness
B. activate emergency response system
C. open the airway
D. get an AED

4) While conducting the BLS Survey, you should
do all of the following except:
A. check patient responsiveness
B. activate emergency response system
C. open the airway
D. get an AED

5) According to new 2010 Guidelines for CPR, which of
the following is in the correct order for the patient with
sudden cardiac arrest?
A. open airway, provide ventilations, give 30 chest compressions,
attach AED as soon as possible
B. give 30 compressions, open airway, provide ventilation, attach
AED as soon as possible
C. open airway, check breathing, check pulse , attach AED as
soon as possible
D. none of the above

5) According to new 2010 Guidelines for CPR, which of
the following is in the correct order for the patient with
sudden cardiac arrest?
A. open airway, provide ventilations, give 30 chest compressions,
attach AED as soon as possible
B. give 30 compressions, open airway, provide ventilation, attach
AED as soon as possible
C. open airway, check breathing, check pulse , attach AED as
soon as possible
D. none of the above

6) After providing a shock with an AED you
should:
A. Start CPR, beginning with chest compressions
B. check a pulse
C. give a rescue breath
D. let the AED reanalyze the rhythm

6) After providing a shock with an AED you
should:
A. Start CPR, beginning with chest compressions
B. check a pulse
C. give a rescue breath
D. let the AED reanalyze the rhythm

7) During CPR with no advanced airway in place
the compression-to-ventilation ratio is:
A. 5:1
B. 30:2
C. 10:1
D. 20:2

7) During CPR with no advanced airway in place
the compression-to-ventilation ratio is:
A. 5:1
B. 30:2
C. 10:1
D. 20:2

8) During CPR after an advanced airway is in
place, which of the following is true:
A. Breaths should be synchronized with the chest
compressions.
B. The goal is 20 or greater breaths per minute
C. Chest compressions should be stopped while giving
breaths.
D. One breath every 6 to 8 seconds should be given

8) During CPR after an advanced airway is in
place, which of the following is true:
A. Breaths should be synchronized with the chest
compressions.
B. The goal is 20 or greater breaths per minute
C. Chest compressions should be stopped while giving
breaths.
D. One breath every 6 to 8 seconds should be given

9) The most important intervention with witnessed
sudden cardiac arrest is:
A. early defibrillation
B. effective chest compressions
C. early activation of EMS
D. rapid use of resuscitation drugs

9) The most important intervention with witnessed
sudden cardiac arrest is:
A. early defibrillation
B. effective chest compressions
C. early activation of EMS
D. rapid use of resuscitation drugs

1) Typically, suctioning attempts in ACLS situations
should be:
A. 10 seconds or less
B. 20 seconds or less
C. 5 seconds or less
D. no more than 30 seconds

1) Typically, suctioning attempts in ACLS situations
should be:
A. 10 seconds or less
B. 20 seconds or less
C. 5 seconds or less
D. no more than 30 seconds

Thank you

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BLS healthcare provider algorithm.
Robert A. Berg et al. Circulation. 2010;122:S685-S705