Cardiopulmonary resuscitation for children and adults

It is about the performance of cardiopulmonary resuscitation in its two main types, BLS and ACLS

1. BASIC LIFE SUPPORT
BLS
AMERICAN HEART ASSOCIATION
AHA
RANIA GASHAN

2. Cardio Pulmonary Resuscitation is a basic
emergency procedure for life support consisting of
artificial respiration and manual cardiac massage.
Aim of CPR:
1. To provide oxygen to the vital organ (heart, brain
and lung) until normal circulation is restored.
2. To establish an airway.
3. To initiate breathing.
4. To maintain proper circulation.

3. Fundamental aspects of BLS:
Include immediate recognition of sudden cardiac arrest
(SCA) and activation of the emergency response
system, early cardiopulmonary resuscitation
(CPR), and rapid defibrillation with an automated
external defibrillator (AED).
Initial recognition and response to heart attack and
stroke are also considered part of BLS.

4. Most common causes of arrest:
5-H
Hypovolemia
Hypoxia
Hypo\Hyper kalemia
Hydrogen ion
5-T
Thrombosis ( coronory)
Thrombosis ( pulmonary )
Toxins
Tamponade
Tension pneumothorax

5. Signs of cardiac arrest:
1. Unconsciousness in several seconds.
2. Respiratory arrest (apnea) or the last gasps
(1-3 minutes after cardiac arrest).
3. Pulse-less on large (major) arteries (carotid
or femoral artery).
4. Changed general appearance (colour
changes, face changes).
5. Pupil's dilation (mydriasis) –not reliable.

6. New guidelines in BLS :
A-B-C changed to C-A-B
Delay in A-B
Early defibrillation
Immediate recognition of SCA based on assessing
unresponsiveness and absence of normal breathing
(ie, the victim is not breathing or only gasping)
“Look, Listen, and Feel” removed from the BLS
algorithm
Encouraging Hands-Only (chest compression only)
CPR (ie, continuous chest compression over the
middle of the chest) for the untrained lay-rescuer .

7. They intended to encourage early CPR and
avoid bystanders interpreting agonal
breathing as signs of life and withholding
CPR.

8. “Chain of Survival :
a core set of actions provides a universal strategy for
achieving successful resuscitation.
For adults they include:
●Immediate recognition of cardiac arrest and
activation of the emergency response system
●Early CPR that emphasizes chest compressions
●Rapid defibrillation if indicated
●Effective advanced life support
●Integrated post–cardiac arrest care

10. Early CPR can improve the likelihood of survival,
Chest compressions are an especially critical
component of CPR because perfusion during CPR
depends on these compressions. Therefore , chest
compressions should be the highest priority
and the initial action when starting CPR in the
adult victim of sudden cardiac arrest.
Rapid defibrillation is a powerful predictor of
Successful resuscitation following VF SCA.

12. Recognition of Arrest :
The necessary first step in the
treatment of cardiac arrest is
Immediate collapse of a victim or find
someone who appears lifeless.
At that time several steps should be
initiated :
Check for response ,to do this, tap
the victim on the shoulder and shout
“Are you all right?” If the victim is
responsive he or she will answer,
move, or moan.

13. •Activate the emergency response system :
• Send someone for help and to get an AED.
• If alone, call for help while assessing for breathing
and pulse. (The AHA emphasizes that cell phones
are available everywhere now and most have a built-
in speakerphone. Call for help without leaving the
person.)
•Check for breathing ( no breathing or
gasping breathing ) for 5 to 10 seconds .
Ideally checking pulse simultaneously is
performed with checking the breathing of the
patient to minimize the delay and early
detection of arrest and starting CPR .

14. Check pulse for 5 to 10
seconds if no pulse begin
CPR ,
If there is pulse , start
rescue breathing 1 every 5
to 6 seconds and check
pulse every 2 minutes .

15. -if no pulse , check if it’s
shockable rhythm by
AED \defibrillator
give shock as indicated.
Quickly switch between roles to
minimize interruptions in
delivering chest compressions.
-When the AED is connected,
minimize interruptions of CPR
by switching rescuers while the
AED analyzes the heart rhythm.
If a shock is indicated, minimize
interruptions in CPR. Resume
CPR as soon as possible.

16. Technique of
Chest
Compressions

17. Chest Compressions:
Chest compressions consist of forceful rhythmic
applications of pressure over the lower half of
the sternum. These compressions create blood flow
by increasing intrathoracic pressure and directly
compressing the heart.
This generates blood flow and oxygen delivery to
the myocardium and brain.

18. To provide effective chest compressions, push hard
And push fast. It is reasonable for health care
providers to compress the adult chest at
of at least 100 compressions per minute with a
compression depth of at least 2 inches/5 cm .
should allow complete recoil of the chest
after each compression, to allow the heart to fill
completely before the next compression
Rescuers should attempt to minimize the frequency
and duration of interruptions in compressions to
maximize the number of compressions delivered per
minute .
A compression-ventilation ratio of 30:2 is
recommended .

19. If a lone healthcare provider sees an adolescent
suddenly collapse, the provider may assume that the
victim has suffered a sudden cardiac arrest and call
for help get an AED (if nearby), and return to the victim
to attach and use the AED and then provide CPR.
If a lone healthcare provider aids an adult drowning
victim or a victim of foreign body airway obstruction
who becomes unconscious, the healthcare provider
may give about 5 cycles (approximately 2 minutes) of
CPR before activating the emergency response
system.

20. To maximize the
effectiveness of chest
compressions, place the
victim on a firm surface
when possible, in
a supine position with the
rescuer kneeling beside the
victim’s chest or standing
beside the bed the rescuer
should place the heel of one
hand on the center (middle)
of the victim’s chest ,

21. (which is the lower half of the
sternum) and the heel of the
other hand on top of the first so
that the hands are overlapped
and parallels allow the chest
to completely recoil after
each compression .
Incomplete recoil during
BLS CPR is associated with
higher intrathoracic pressures
and significantly
decreased hemodynamics,
including decreased coronary
perfusion, myocardial blood flow,
and cerebral perfusion.

22. When 2 or more rescuers are available it is reasonable
to switch chest compressors approximately every
2 minutes (or after about 5 cycles of compressions and
ventilations at a ratio of 30:2) to prevent decreases in
the quality of compressions.
Healthcare providers should interrupt chest
compressions asinfrequently as possible
and try to limit interruptions to no longer than 10
seconds, except for specific interventions
such as insertion of an advanced airway
or use of a defibrillator.

23. Rescue Breaths :
A change in the 2015 AHA Guidelines for CPR
is to recommend the initiation of compressions
before ventilations , it is clear that blood flow depends
on chest compressions. Therefore, delays in,
and interruptions of chest compressions should be
minimized throughout the entire resuscitation.

24. •After 30 compressions, stop compressions and open
the airway by tilting the head and lifting the chin
•a. Put your hand on the person’s forehead and tilt
the head back.
•b. Lift the person’s jaw by placing your index and
middle finger on the lower jaw; lift up.
•c. Do not perform the head-tilt-chin lift maneuver if
you suspect the person may have a neck injury. In
that case the jaw-thrust is used.
•d. For the jaw-thrust maneuver, grasp the angles of
the lower jaw and lift it with both hands, one on each
side, moving the jaw forward. If their lips are closed,
open the lower lip using your thumb

25. Compression-Ventilation Ratio :
A compression-ventilation ratio of 30:2 is reasonable in
adults, but further validation of this guideline is needed
This 30:2 ratio in adults .
Once an advanced airway is in place, 2 rescuers no
longer need to pause chest compressions for
ventilations. Instead , the compressing rescuer should
give continuous chest compressions at a rate of at
least 100 per minute without pauses for ventilation.
The rescuer delivering ventilation can provide a breath
every 6 to 8 seconds (which yields 8 to 10 breaths per
minute).

26. Managing the Airway:
Open the Airway
By or
Jaw thrust
Head tilt chin lift

27. Mouth to Mouth Barrier Devices
Give a breath while watching the chest
rise. Repeat while giving a second
breath. Breaths should be delivered
over one second.

28. ADULT MOUTH-TO-MASK \BAG
VENTILATION
1-Seal the mask against the person’s face by
placing four finger of one hand across the
top of the mask and the thumb of the other
hand along the bottom edge of the mask
2-Using the finger of your hand on the
bottom of the mask, open the airway using
head-tilt or chin-lift maneuver. (Do not do this
if you suspect the person may have a neck
injury)
3-Press firmly around the edges of the
mask and ventilate by delivering a breath
over one second as you watch the person’s
chest rise .
4-Practice using the bag valve mask; it is
essential to forming a tight seal and delivering
Ventilation .

29. AED Defibrillation:
Rapid defibrillation is the
treatment of choice for VF of
short duration, such
as for victims of witnessed out-
of-hospital cardiac arrest
or for hospitalized patients
whose heart rhythm is
monitored .

31. When to stop the CPR:
1. When the victim revives
2. If you are exhausted and another person can help.
3. If the time of CPR is more than 30 minutes and victim
did not relive.
4. Medical assistance arrives and instructs you to stop
CPR.
5. When signs of biological death develop (post-mortal
rigidity, post-mortal.
•Unsafe scene
•Physician directed (do not resuscitate orders)

32. Rescuer's safety:
1. The rescuer should never place him/herself or others at more
risk than the victim
2. Before starting resuscitation: assess the risks of ongoing
traffic, electrocution, toxic fumes and poisons.
3. Risk of infections transmission:
o Blood borne infections (hepatitis B and C, HIV) can be
transmitted by blood and other body solutions, excretes
o Airborne infections (TBC and several infectious diseases -
herpetic, meningococcal can be transmitted by mouth-to-mouth
breathing.
4. Always: protect yourself !!!
Personal protective equipment (gloves).
Barrier protective devices.
Moth –to -barrier protective devices breathing.

33. CPR for Infants
(Under 1 Year of Age)
•Start with A B C
•Same procedures except:
•Seal nose and mouth or
nose only
•Give shallow “puffs”

34. Tilt the baby's head back with one hand and
lift his chin slightly with the other.
Check for signs of breathing for no more
than ten seconds.
To check for breathing in a baby, put your
head down next to his mouth, looking
toward his feet. Look to see whether his
chest is rising, and listen for breathing
sounds. If he's breathing, you should be
able to feel his breath on your cheek.
check brachial pulse for not more than 10
seconds.

35. CPR: Infants
-Give CPR
-Press sternum 1/2 to 1/3 depth of the chest
-Use middle and ring finger
30 compressions to 2
-If alone, resuscitate for 2 minutes then call 911

36. Optimal Compression-Ventilation Ratio for
Infants and Children :
For ease of teaching and retention, a of30:2 is
recommended for the lonerescuer performing CPR in
infants and children, as is used for adults.
For health care providers performing 2-rescuer
CPR in infants and children, a compression-ventilation
ratio of 15:2is recommended.

37. When a tracheal tube is in place, compressions
should not be interrupted for ventilations.
And give a breath each 3-5 per seconds
or 12 -20 breath per minute .

38. Chest Compression Depth:
In infants, rescuers should be taught to compress the
Chest by at least one third the anterior-posterior
dimension or approximately 11⁄2 inches (4 cm). In
children, rescuers should be taught to compress the
chest by at least one third the anterior-posterior
dimension or approximately 2 inches(5 cm).

39. Newborns (Out of the Delivery Area)
Without an Endotracheal airway :
There are insufficient data to recommend an optimal
compression-ventilation ratio during CPR for all infants
In the first month of life (beyond the delivery room).
The limited data available suggest that if the etiology of
the arrest is cardiac, a 15:2 ratio (2 rescuers) may be
more effective than a 3:1 ratio.

40. Recovery position

41. Choking
•The tongue is the most common
obstruction in the unconscious victim
•Vomit
•Foreign body
–Balloons
–Foods
•Swelling (allergic reactions/ irritants)
•Spasm (water is inhaled suddenly)

42. How To Recognize Choking
•Can you hear breathing or coughing
sounds?
–High pitched breathing sounds?
•Is the cough strong or weak?
•Can’t speak, breathe or cough
•Universal distress signal (clutches neck)
•Turning blue

43. Recognizing Choking #2
•A partial airway obstruction with poor air
exchange should be treated as if it were a
complete airway blockage.
•If victim is coughing strongly, do not
intervene

44. Conscious Choking
(Adult Foreign Body Airway Obstruction)
•Give 5 abdominal thrusts (Heimlich
maneuver)
–Place fist just above the umbilicus
(normal size)
–Give 5 upward and inward thrusts
–Pregnant or obese? 5 chest thrusts
•Fists on sternum
•If unsuccessful, support chest
with one hand and give back
blows with the other , Continue
•until successful or victim becomes
unconscious

46. If Victim BecomesUnconscious
After Giving Thrusts
•Call 911
•Try to support victim with your
knees while lowering victim to
the floor
•Assess
•Begin CPR
•After chest compressions, check
for object before giving breaths
breaths .

47. Choking in Conscious Infants
•Position with head
downward
•5 back blows (check for
expelled object)

48. •5 chest
thrusts (check
for expelled
object)
•Repeat

49. Choking: Unconscious
Infants
•If infant becomes unconscious:
•When the first breaths don’t go in, check for
object in throat then try 2 more breaths.
•If neither set of breaths goes in, suspect
choking
•Begin 30 compressions
•Check for object in throat (no blind finger
sweep)
•Give 2 breaths
•Repeat the chest compressions and so on,
until help arrives.

50. ADVANCED CARDIAC LIFE
SUPPORT
ACLS

51. ADVANCED CARDIAC LIFE SUPPORT
Advanced cardiac life support or advanced
cardiovascular life support (ACLS) refers to a
set of clinical interventions for the urgent
treatment of cardiac arrest, stroke and other
life-threatening medical emergencies, as well
as the knowledge and skills to apply those
interventions .

52. IMPORTANCE OF BLS IN ACLS
ACLS is built heavily upon the
foundation of BLS

58. THE ACLS SURVEY
(A-B-C-D)

60. AIRWAY
Monitor and maintain an open airway at all
times. The provider must decide if the benefi
of adding an advanced airway outweighs the
risk of pausing CPR.
If the individual’s chest is rising without using
an advanced airway, continue giving CPR
without pausing. However, if you are in a
hospital or near trained professionals who
can efficient insert and use the airway,
consider pausing CPR.

61. BREATHING
In cardiac arrest, administer 100%
oxygen. Keep blood O2 saturation (sats)
greater than or equal to 94 percent
as measured by a pulse oximeter.

62. Use quantitative waveform
capnography when
possible. Normal partial
pressure of CO2 is between
35 to40 mmHg.
High-quality CPR should
produce a CO2 between 10
to 20 mmHg. If the ETCO2
reading is less than 10
mmHg after 20 minutes of
CPR for an intubated
individual, then you may
consider stopping
resuscitation attempts .

63. CIRCULATION
Obtain intravenous (IV) access, when
possible; intraosseous access (IO) is also
Acceptable blood pressure with a blood
pressure cuff or intra-arterial line if available.
Monitor the heart rhythm using pads and a
cardiac monitor. When using an AED, follow
the directions (i.e., shock a shockable
rhythm). Give fluid when appropriate. Use
cardiovascular medications when indicated.

64. Adjuncts for
Airway Control
and Ventilation

65. OROPHARYNGEAL AIRWAY:
The OPA is a J-shaped device
that fit over the tongue to hold
the soft hypopharyngeal
structures and the tongue away
from the posterior wall of the
pharynx.
OPA is used in individuals who
are at risk for developing airway
obstruction from the tongue or
from relaxed upper airway
muscle.
A properly sized and inserted
OPA results in proper alignment
with the glottis opening.

66. •If efforts to open the airway fail to provide and
maintain a clear, unobstructed airway, then use the
OPA in unconscious persons. An OPA should not
be used in a conscious or semiconscious
individuals, because it can stimulate gagging,
vomiting, and possibly aspiration. The key
assessment to determine if an OPA can be placed
is to check if the individual has an intact cough and
gag reflexs If so, do not use an OPA.

67. NASOPHARYNEGEAL AIRWAY
(NPA)
The NPA is a soft rubber or plastic uncuffed
tube that provides a conduit for airflow
between the nares and the pharynx. It is
used as an alternative to an OPA in
individuals who need a basic airway
management adjunct.
Unlike the oral airway, NPAs may be used
in conscious or semiconscious individuals
(individuals with intact cough and gag
reflex The NPA is indicated when insertion
of an OPA is technically difficult or
dangerous.

68. NPA placement can be facilitated by the use
of a lubricant. Never force placement of the
NPA as severe nose bleeds may occur. If it
does not fit in one nares, try the other side.
Use caution or avoid placing NPAs in
individuals with obvious facial fractures.

69. Advanced Airway Placement Choice
Either a bag-mask device or an advanced
airway may be used for oxygenation and
ventilation during CPR in both the
inhospital and out-of-hospital setting.
For healthcare providers trained in their
use, either an SGA( supraglottic airway )
device or an ETT may be used as the initial
advanced airway during CPR .

70. ●When an advanced airway (I.e, endotracheal tube,
or laryngeal mask airway [LMA]) is in place during
2-person CPR, give 1 breath every 6 to 8
seconds without attempting to synchronize
breaths between compressions
this will result in delivery of 8 to Endotracheal T.
10 breaths/minute).
Laryngeal mask

71. Defibrillation Strategies for VF or
Pulseless VT
Defibrillators are recommended to
treat atrial and ventricular arrhythmias.
Based on their greater success in
arrhythmia termination, defibrillators
using biphasic waveforms are
preferred to monophasic defibrillators
for treatment of both atrial and
ventricular arrhythmias.
A single-shock strategy (as opposed
To stacked shocks) is reasonable for
defibrillation.

72. DEFIBRILLATION
Biphasic wave form: 120-200 J
Monophasic wave form: 360 J
AED-device specific
Failure of a single adequate shock to
restore a pulse should be followed by
continued CPR and second shock delivered
after five cycles of CPR
If cardiac arrest still persist-patient is
intubated and IV/IO access achieved

73. Defibrillation Sequence
●Turn the AED on.
●Follow the AED prompts.
●Resume chest compressions immediately after
theshock (minimize interruptions).
1-SHOCK PROTOCOL VERSUS 3-SHOCK SEQUENCE
Some studies suggested significant survival benefit
With the single shock defibrillation protocol compared
with 3-stacked-shock protocols
If 1 shock fails to eliminate VF, the incremental
benefit of another shock is low, and resumption of
CPR is likely to confer a greater value than another
shock

74. Anti-arrhythmic Therapy for Refractory VF/pVT
Arrest:
Amiodarone may be considered for
VF/pVT that is unresponsive to CPR,
defibrillation, and a vasopressor therapy
Lidocaine may be considered as an
alternative to amiodarone for VF/pVT that
is unresponsive to CPR, defibrillation, and
vasopressor therapy .
The routine use of magnesium for VF/pVT
is not recommended in adult patients.

75. Lidocaine
• Indications:
–PVCs, Vtach, Vfib
–Can be toxic so no longer given
prophylactically
• IV dose :
–1-1.5 mg/kg bolus then continuous infusion
of 2-4mg/min
–Can be given down ET tube
• Signs of toxicity:
–slurred speech, seizures, altered
consciousness

76. Magnesium
• Used for refractory Vfib or Vtach caused by
hypomagnesemia and Torsades de Pointes
• Dose:
–1-2 grams over 2 minutes
• Side Effects
–Hypotension
–Asystole

77. Epinephrine
• Because of alpha, beta-1, and beta-2
stimulation, it increases heart rate, stroke
volume and blood pressure
–Helps convert fine vfib to coarse Vfib
–May help in asystole
–Also PEA and symptomatic bradycardia
• IV Dose:
–1 mg every 3-5 minutes
–May increase ischemia because of increased
O2 demand by the heart

78. Atropine
Indications:
Symptomatic sinus bradycardia
Second Degree Heart Block Mobitz I
May be tried in asystole
Organophosphate poisoning IV Dose:
.5 –1 mg every 3-5 minutes
Max dose is .04mg/kg
Can be given down ET tube
Side Effects:
May worsen ischemia

79. Isoproterenol (Isuprel)
•Indications:
–Temporary stimulant prior to pacemaker
–Bradycardia refractory to atropine
–Torsades de Pointes refractory to
magnesium sulfate
•IV dose:
–Continuous infusion of 2-10
micrograms/ml of infusion fluid

80. MONITORING DURING CPR
Physiologic parameters
Monitoring of PETCO2 (35 to 40 mmHg)
Coronary perfusion pressure (CPP)
(15mmHg)
Central venous oxygen saturation (ScvO2)
Abrupt increase in any of these parameters
is a sensitive indicator of ROSC that can be
monitored without interrupting chest
compressions .

81. Quantitative waveform capnography
If Petco2 <10 mm Hg, attempt to improve
CPR quality
Intra-arterial pressure
If diastolic pressure <20 mm Hg, attempt to
improve CPR quality
If ScvO2 is < 30%, consider trying to
improve the quality of CPR .

82. INITIAL OBJECTIVES OF POST–
CARDIAC ARREST CARE
Optimize cardiopulmonary function and vital organ
perfusion.
After out-of-hospital cardiac arrest, transport
patient to an appropriate hospital with a
comprehensive post–cardiac arrest treatment
Transport the in-hospital post–cardiac arrest
patient to an appropriate critical-care unit
Try to identify and treat the precipitating causes of
the arrest and prevent recurrent arrest