DR AMEER YASSER ZAID FCPS, MCPS CONSULTANT ANAESTHESIOLOGIST

and whoso saveth the life of one, it shall be as if he had saved the life of all mankind.

CARDIAC ARREST
Definition: Inability of heart to pump blood in to aorta. Presents in two types of rhythms. 1. Shockable Rhythms a. Pulseless Ventricular Tachycardia b. Ventricular Fibrillation 2. Non-shockable Rhythms a. Pulseless Electrical Activity b. Asystole

WHAT IS CPR?
Cardiopulmonary resuscitation (CPR) is an emergency technique that anyone can learn to help someone whose heart and/or breathing has stopped. It can keep a victim alive until skilled help arrives or the victim is transferred to a hospital.

HISTORY OF CPR

Mouth-to-mouth resuscitation described in the Bible. Rediscovered in the 1950s. The discoverers of mouth-to-mouth ventilation were Drs. James Elam and Peter Safar. In early 1960 Drs. Kouwenhoven, Knickerbocker, and Jude discovered the benefit of chest compression to achieve a small amount of artificial circulation. Later in 1960, mouth-to-mouth and chest compression were combined to form CPR similar to the way it is practiced today.

FACTS

In the US and Canada, approximately 350 000 people/year suffer a cardiac arrest and receive attempted resuscitation. (not including those who suffer an arrest without attempted resuscitation) Incidence of EMS-treated out-of-hospital cardiac arrest in the US and Canada is about 50 to 55/100 000 persons/year approximately 25% of these present with pulseless ventricular arrhythmias. Cardiac arrest victims who present with ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) have a substantially better outcome compared with those who present with asystole or pulseless electric activity

In Oct 2010 the American Heart Association hosted meetings of international organisations to evaluate the evidence on resuscitation.

Guidelines 2010 released on Nov 2nd, 2010 provide an up-to-date link between the science of resuscitation and improved survival from cardiac arrest.

EXPERTS IN AHA MEETINGS

American Heart Association European Resuscitation Council Heart and Stroke Foundation of Canada Australian Resuscitation Council New Zealand Resuscitation Council Resuscitation Council of Southern Africa Latin American Resuscitation Council Japan.

WHATS NEW IN 2010 GUIDELINES

Key changes and continued points of emphasis from the 2005 BLS Guidelines include the following:

Immediate recognition of SCA based on assessing unresponsiveness and absence of normal breathing (i.e., the victim is not breathing or only gasping) Look, Listen, and Feel removed from the BLS algorithm Encouraging Hands-Only CPR by lay-rescuer Sequence change to chest compressions before

WHATS NEW IN 2010 GUIDELINES

HCPs continue effective chest compressions/CPR until return of spontaneous circulation (ROSC) or termination of resuscitative efforts Increased focus on methods to ensure that highquality CPR compressions of adequate rate and depth
minimizing interruptions in chest compressions avoiding excessive ventilation

Continued de-emphasis on pulse check for health care providers Simplified adult BLS algorithm

WHATS NEW IN 2010 GUIDELINES

Recommendation of a simultaneous, choreographed approach for chest compressions, airway management, rescue breathing, rhythm detection, and shocks (if appropriate) by an integrated team of highly-trained rescuers in appropriate settings

CPR BUILDING BLOCK

CONCEPT OF BLS

All You Need is!

ADULT CHAIN OF SURVIVAL

Immediate

Recognition & Activation of

EMS Early CPR Early defibrillation Effective Advanced Life Support

FIRST ACTIONS
Assess

Responsiveness, Gentle Shake/Tap and Shout Lay Rescuer:

Call

for Help

Health
Also

Care Provider (HCP):

Check Breathing then all for Help

CALL FIRST CALL FAST

FIRST ACTIONS
Position

the Victim

Position

the Rescuer

POSITION THE VICTIM

POSITION THE RESCUER

ABC TO CAB

C (Check) Circulation / (Start) Compressions

No pulse check for Lay Rescuers

Start Chest Compressions

A - Open Airway B - Breathing

Ventilate if patient has high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim).
Attach AED or Single Shock (360J monophasic or 150 - 200J biphasic).

D - Defibrillate

CHECK PULSE

CHECK PULSE

No Pulse Check for lay rescuer

Assume

cardiac arrest if an adult suddenly collapses or an unresponsive victim is not breathing normally.

Healthcare provider should take

no

more than 10 seconds if no definite pulse, within that time period, start chest compressions

CONFIRMING PULSELESSNESS

BLS

No Longer Recommended for lay rescuers.

If the person is unresponsive and NOT breathing START CPR

CHEST COMPRESSIONS

CLOSED CHEST COMPRESSIONS

Sit as near to the patient as possible Hand Placement: Locating the Xiphoid/ In the centre of the chest Sternum depressed by 2 inches. Two hands Two inches Fingers off the Chest Serial and Rhythmic Equal time for diastolic filling

CLOSED CHEST COMPRESSIONS

Focus on High Quality CPR

adequate
adults:

rate (at least 100/minute) adequate depth

a compression depth of at least 2 inches (5

cm) infants and children: a depth of least one third the anterior-posterior (AP) diameter of the chest or about 1.5 inches (4 cm) in infants and about 2 inches (5 cm) in children
allow

complete chest recoil after each compression minimize interruptions in compressions avoid excessive ventilation

CHEST COMPRESSIONS

BASIC CONCEPT OF CHEST COMPRESSIONS

CLOSED CHEST COMPRESSIONS

Hand Placement Push Hard and Push Fast Minimum Interruption in Chest Compressions Rate: 100/minute CV Ratio 30 : 2 Reassess after 5 cycles NEVER Interrupt for > 7 secs

CORONARY ARTERY PERFUSION PRESSURE IMPROVES WITH LONGER SERIES OF CHEST COMPRESSIONS IN ADULT VICTIMS
Coronary Artery Pressure at 5:1 ratio

Pressure at 15:2 ratio

OPENING THE AIRWAY

OPEN THE AIRWAY

OPENING THE AIRWAY

Not done by Untrained Lay Rescuer By Trained Lay rescuer

Head

Tilt Chin Lift

By Health Care Provider

Head Jaw

Tilt Chin Lift Maneuver

Thrust Maneuver

Clearing The Airway

Head Tilt and Chin Lift

Jaw Thrust

RESCUE BREATHING

RESCUE BREATHS

Chest compressions can be started immediately

Positioning the head Achieving a seal for mouth-to-mouth breathing take time

Getting a bag-mask apparatus.

Beginning CPR with 30 compressions rather than 2 ventilations leads to a shorter delay to first compression

TWO NORMAL BREATHS (ONE SECOND EACH)

RESCUE BREATHS

Deliver each rescue breath over 1 second Give a sufficient tidal volume to produce visible chest rise

Compression to ventilation ratio of 30:2

(until

advanced airway is placed, then 8-10

breaths per minute)

PATIENT UNRESPONSIVE BUT BREATHING

RECOVERY POSITION

Several variations of the recovery position

No

single position is perfect for all victims. position should be stable, near a true

The

lateral position, with the head dependent and with no pressure on the chest to impair

breathing

RECOVERY POSITION

For victims with known or suspected spinal injury

Extend Roll

the lower arm above the head

the head onto the arm both legs

Bend

DEFIBRILLATOR ARRIVES !!

Place paddles on the chest and assess rhythm

If PEA or Asystole
No shock
Give Adrenaline 1mg every 3-5 min IV or 2.5 mg TT or

Vasopressin 40 IU single dose

Continue CPR @ CV 30:2

If VF or VT

Defibrillation

DEFIBRILLATION
Types
Precordial Thump Manual Defibrillators AEDs (Automated External Defibrillators) ICDs (Internal Cardioverter Defibrillators)

Ideal Time: Immediately After Cardiac Arrest

DEFIBRILLATION
Turn the defibrillator on. Place the paddles after applying electrode gel, or apply AED pads. Correct paddle placement is essential. Charge to desired level. Shout: One, I am clear; Two, you are clear; Three, All are clear. Deliver the energy by pressing both buttons simultaneously.

EFFECT OF TIME TO DEFIBRILLATION ON SURVIVAL FROM WITNESSED VF ARREST WITHOUT CPR

100 90 80 70 60 50 40 30 20 10 0 1 MIN 2 MIN 3 MIN 4 MIN 5 MIN 6 MIN 7 MIN 8 MIN 9 MIN

Percent survival

Cummins, 1989

10 MIN

DEFIBRILLATION

As early as possible Single Shock. 360J Monophasic or 120 200J Biphasic Chest compressions immediately after shock Assess rhythm after 5 cycles of 30:2

DEFIBRILLATION

Persistent or recurrent VF/pulseless VT

Amiodarone 300 mg IV push Defibrillate 1X360J Continue sequence Shock-Epi-Shock

WHAT IS AED?

OPERATION OF AEDS:
1.

POWER ON the AED

2. ATTACH pads 3. ANALYZE rhythm

4. SHOCK (if advised)

AED SAFETY

With every analysis and shock: no one touches patient! Verbal: warning to bystanders

Im clear Youre clear Everybodys clear

Visual: check all clear Physical: add hand gestures Only then press to shock

AEDS
Advantages Easier to operate. Little education needed. Quicker operation. Rhythm detection. Hands Off defibrillation. Rhythm monitoring. Disadvantages CPR must be stopped for 10-15 secs. Interruption in analysis by agonal breathing, transport, radio receivers.

SECONDARY SURVEY
Lay rescuers should not interrupt chest compressions to palpate pulses or check for ROSC Lay rescuers should continue CPR until

an AED arrives the victim wakes up EMS personnel take over CPR

Healthcare providers should

interrupt chest compressions as infrequently as possible no longer than 10 seconds except for specific interventions such as insertion of an advanced airway or use of a defibrillator

SELF CPR
Self initiated CPR is possible. Limited to situations when patient has a monitored cardiac arrest or can feel dysrhythmia which could be VT leading to VF. Situation only present for first 10-15 secs. Vigorous coughing is recommended which generates a high intrathoracic pressure resulting in increased blood flow to brain.

BASIC LIFE SUPPORT

for Adults with Obstructed Airway

CONSCIOUS ADULT WITH CHOKED AIRWAY

In signs of severe airway obstruction:

act

quickly to relieve the obstruction.

In mild obstruction when victim is coughing forcefully

do

not interfere with the patients spontaneous coughing and breathing efforts. Attempt to relieve the obstruction only if signs of severe obstruction develop:
the

cough becomes silent respiratory difficulty increases accompanied by stridor victim becomes unresponsive

IN SEVERE OBSTRUCTION
Ask one question: Are you choking? Say one sentence: I am going to help you. Go behind the victim while s/he is still standing or sitting. Perform Heimilich Maneuver. Keep giving abdominal thrusts until the object is removed or the victim becomes unconscious.

BLS

Conscious Adult with Obstructed Airway

BLS

SELF RESCUE
Self Administered Hemlich Maneuver: To treat own complete FBAO one should perform Heimlich maneuver as on any other victim getting inward and upward thrusts to the diaphragm. Failing this, victim should press the upper abdomen quickly over any firm surface e.g. back of a chair, side of a table, porch railing.

UNCONSCIOUS VICTIM WITH CHOKED AIRWAY

Carefully support the patient to the ground Activate EMS, then begin CPR Higher sustained airway pressures are generated using the chest thrust rather than the abdominal thrust. Look for FB in the victims mouth when airway is opened during CPR -> if found, remove it Proceed to the 30 chest compressions.

BLS

BLS

FINGER SWEEP

THANK YOU

CLASSIFICATION OF INTERVENTIONS

Class I. Definitely recommended. Evidence of usefulness, " Excellent. Class IIa. Acceptable and useful. Evidence of usefulness, Good to Very Good. Class IIb. Acceptable and useful. Evidence of usefulness, Fair to Good. Class Indeterminate. Preliminary research stage. Evidence, No harm but No benefit. Class III. Unacceptable, no documented benefit, may be harmful.

Level of Evidence
Level 1: Randomized clinical trials or meta-analyses of multiple clinical trials with substantial treatment effects Level 2: Randomized clinical trials with smaller or less significant treatment effects Level 3: Prospective, controlled, nonrandomized cohort studies Level 4: Historic, nonrandomized cohort or case-control studies Level 5: Case series; patients compiled in serial fashion, control group lacking Level 6: Animal studies or mechanical model studies Level 7: Extrapolations from existing data collected for other purposes,theoretical analyses Level 8: Rational conjecture (common sense); common practices accepted before evidence-based