GAJE SINGH

American Heart Association

Instructor
 Course Objective

► The purpose of this course is to inform

healthcare professionals about current
guidelines for emergency cardiac care.
 Approach

► BLS ( Basic Life Support) Primary survey.

► ACLS (Advanced Cardiovascular Life Support)

Secondary survey
 Cardiopulmonary
Resuscitation

C - Circulation
A - Airway
B - Breathing
D- Defibrillation
 C-A-B Rather than A-B-C
Steps
► Change in the BLS sequence of steps from A-
B-C (Airway, Breathing, Chest compressions)
to C-A-B (Chest compressions, Airway,
Breathing).

► Initiate chest compressions before giving

rescue breaths (C-A-B rather than A-B-C).

► Why: Highest survival rates from cardiac

arrest due to sooner starts of chest
compression.
 What is CPR?
► CPR stands for Cardio Pulmonary
Resuscitation, i.e. to help restart the heart
(pulse) and lungs (breathing).

► CPR is performed when a person stops

breathing and/or the heart stops.
 Why is timing important?

► When the heart (pulse) and lungs (breathing)

stops, the victim has 5 minutes before
(gradual) brain death starts to occur, if no
CPR is performed.

► Brain damage is certain after 5 - 10 minutes

without CPR

► Therefore, it is very important to start CPR as

soon as possible for better chance of survival.
 Learning Objectives
► Use the principles of patient assessment to
guide treatment decisions.
► Describe the appropriate care of a patient in a
pulseless arrest.
► Relate factors to consider when evaluating a
patient with an arrhythmia.
► Justify the emphasis on rapid evaluation and
treatment of a patient with acute coronary
syndromes.
► Discuss how the physiological differences in
the phases of cardiac arrest drive the
appropriate treatments for each phase.
Why is it required to learn Basic Life Support ?
 What is Cardiac Arrest ?
► Sudden cardiac arrest occurs when electrical
impulses in the heart become rapid or
chaotic, which causes the heart to suddenly
stop beating.

► Cardiac arrests are more common than you

think, and they can happen to anyone at any
time even in healthy looking person.

► Nearly 383,000 out-of-hospital and 209,000

in hospital sudden cardiac arrests occur
annually.
 Cardiac Arrest (contd..)
► Associated with very poor survival rate,
● 9.5 % for out of hospital cardiac arrest and
● 23.9% for in hospital cardiac arrest.

► Early resuscitation and prompt defibrillation

(within 1-2 minutes) can result in >60%
survival.

► Basic life support - one of the most important

skills you will learn here in this session.
BASIC LIFE SUPPORT
(BLS)
 Objectives
► At the end of this session, participants should be
able to demonstrate:

● How to assess the collapsed victim.

● How to perform chest compression and rescue
breathing.
● How to operate an automated external defibrillator
safely.
● How to place an unconscious breathing victim in the
recovery position.
 Basic Life Support (BLS)
► BLS is the foundation for saving lives
following cardiac arrest.

► Fundamental aspects of adult BLS include

five links called Adult Chain of Survival.
 Chain of Survival

The 5 links in adult chain of survival are:

► Immediate recognition of cardiac arrest and activation
of the emergency response system.
► Early CPR with an emphasis on chest compressions.
► Rapid defibrillation.
► Effective advance life support.
► Integrated post-cardiac arrest care.
Basic Life Support (BLS)
Approach safely
Check response
Shout for help
Call for emergency
Chest Compression
Open Airway
2 rescue Breaths
Defibrillation
 APPROACH SAFELY!

Approach safely
Scene
Check response
Rescuer Shout for help
Call for emergency
Victim
Chest compression

Bystanders Open airway

2 rescue breaths
Defibrillation
CHECK RESPONSE

Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway
2 rescue breaths
Defibrillation
 CHECK RESPONSE

By Shake & Shout Method

Shake shoulders gently
Ask “Are you all right?”
If he responds
• Leave as you find him.
• Find out what is wrong.
• Reassess regularly.

If doesn't respond,
• Scan the chest & Check
pulse
 SHOUT FOR HELP

For Unresponsive Cardiac Arrest Patient

Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway
2 rescue breaths
Defibrillation
 CALL FOR EMERGENCY
For Unresponsive Cardiac Arrest Patient
Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway
2 rescue breaths
Defibrillation
CHEST COMPRESSION

Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway
2 rescue breaths
Defibrillation
CHEST COMPRESSION

By Good Hand Position

• Place the heel of one hand in the
centre of the chest on the lower
sternum.
• Place other hand on top
• Interlock fingers
• Compress the chest
– Rate - At least 100 min-1 100-120
compression /min
– Depth - At least 2 inches.(5-6 cm)
– Equal compression : relaxation
• When possible change CPR
operator every 2 min
 COMPRESSIONS

► Quality: PUSH HARD, PUSH FAST, ALLOW

COMPLETE RECOIL AND MINIMIZE INTERRUPTIONS
► Site: Lower half of the sternum between nipples for
adult and child; Just below nipple line for infants
► Depth: at least 2 inches(5 cm) for adults; 5 cm for
children and 4 cm for infant
► Technique : two hand in adult and children, two
thumb, or two finger in infant
 OPEN AIRWAY

By Head Tilt Chin Lift Method

Approach safely
Check response
Shout for help

Call for emergency

Chest compression
Open airway
2 rescue breaths
Defibrillation
 Open The Airway

► Opening the airway by

head tilt chin lift
method.

► Placing one hand on

the victim’s forehead
with the other hand
on the chin and tilting
the head back.
RESCUE BREATHS

Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway

2 rescue breaths
Defibrillation
 BREATHING
► Give two rescue breaths 1 breath in
one sec.
► Three methods to give breathing

► mouth-to-mouth breathing
► mouth-to-mask breathing
► bag-valve-mask ventilation
RESCUE BREATHS
► Pinch the nose
► Take a normal breath

► Place lips over mouth

► Blow until the chest

rises
► Take about 1 second

► Allow chest to fall

► Repeat

► For infant cover nose

and Mouth by lip &
give rescue breath
 Rescue Breathing
Mouth to Mouth Method
► 2 rescue breaths after
30 compressions.

► Each breath should be

delivered over 1 Mouth to Mask Method
second with any
delivery method
available.

► A good breath will Bag-Mask Method

cause the chest to
rise.
 CONTINUE CPR

Compression To Ventilation Ratio

30 2
Five cycles of the 30:2 compressions/ventilations should be
delivered, which should take approximately 2 minutes. Only then
is the pulse check repeated.
 COMPRESSION VENTILATION RATIO

► For Adults its 30:2 (1 or 2 rescuers)

► For Children and Infants 30:2 (1
rescuer) and 15:2 (2 rescuers)
► One set of compressions and
ventilations form one cycle
► Five cycles of compression and
ventilation over 2 minutes
► Check pulse after five cycle if no pulse
start same at least 20 min
 How CPR Works?
► Compression of the chest during CPR raises
the intrathoracic pressure which forces the
blood out of the heart chambers.
► When the chest recoils, a negative
intrathoracic pressure is produced which
allows blood to return to the heart, feeding
the coronary arteries and filling the heart
chambers so that the next compression will be
even more effective - A cumulative effect.
► Successive compressions will continue to
increase coronary artery pressure and organ
perfusion.
 How CPR Works? (contd...)

► Effective CPR provides ¼ to 1/3 normal blood

flow.

► Rescue breaths contain 16 % Oxygen (out of

21 %)
► Tidal volume approx. 450 ml for effective
vantilation
AUTOMATED EXTERNAL
DEFIBRILLATORS

Approach safely
Check response
Shout for help
Call for emergency
Chest compression
Open airway

2 rescue breaths
Defibrillation
 AUTOMATED EXTERNAL
DEFIBRILLATORS
Attach pads to casualty’s bare chest

One pad - Left of the left nipple a Another pad on the upper-right
few inches below the left armpit. side of the patient’s bare chest
 AUTOMATED EXTERNAL
DEFIBRILLATORS
Analysing rhythm Shock indicated
Do not touch victim Deliver shock
 DEFIBRILLATION

Chest Compression - Shock Delivery (With in 5

seconds) - Chest compression Again

30 2
 Recovery Position

If he is breathing normally
• Turn him into the recovery position
• Send or go for help, or call for an ambulance.
• Check for continued breathing.
 RECOVERY POSITION

If victim starts to breath normally place

in recovery position
 When CPR Should Stop?

► Victim revives

► Trained help arrives

► To exhausted to continue

► Unsafe scene

► Physician directed

► Cardiac arrest for more than 20

minutes
 Complications of CPR

► Rib fractures (Most common)

► Vomiting and Aspiration

► Internal Injuries to vital organs like

lung & liver.

► Body Fluid Exposure - Risk of AIDS &

hepatitis like communicable diseases.

► Gastric Distention
Basic Life Support Algorithm
Mega code

In Hospital code Blue

 ACLS …(American hear
Association )
Advanced Cardiovascular Life Support (ACLS)
builds on the foundation of Basic Life Support
(BLS), emphasizing the importance of
continuous, high-quality CPR. The hands-on
instruction and simulated cases in this advanced
course are designed to help enhance their skills
in the recognition and intervention of
cardiopulmonary arrest immediate post-cardiac
arrest, acute arrhythmia, stroke, and acute
coronary syndromes.
 Code blue- 500

► Anesthesia team
► Critical care nurses (from
MICU/CCU/neuro ICU)
► Critical care

► 1st & 2nd Rescure

► (code blue kit )

 Who runs the code?
► First resident/ nurse on the scene, or
► The leader of the code assigns roles
and responsibilities to the other
residents and interns available
 Roles during the code
► Stabilizing/managing airway
► Line for chest compressions

► Recording timing of events

► Managing code cart/ Medication

administration
► Checking labs and past medical history,
telemetry
► Obtaining emergency access

► Thinking through Hs and Ts

► Calling the patient’s family

 Code Blue
You are the in room 302 and while
giving medicine patient feel sweating
… What do you do?
 Scenario 1
► You feel a thready femoral pulse, the
patient feels tachycardic
► Automatic blood pressure cuff is not
reading
► Patient is agonal breathing, not
responding to verbal or painful stimuli
► The nurses look to you and say
“Doctor, what do we do?”
• On arrival, you do a quick initial assessment
while assessing his responsiveness and vital
signs and immediately instruct someone to begin
compressions.
• While compressions are occurring you ask the
nurse to apply pads and electrodes to the patient
to analyze the rhythm.
• In addition, you ask that oxygen be applied to
the patient
• You ask about any complaints the patient may
have had and find that minutes ago he was
complaining of chest pain, palpitations, and
dizziness.
• Being a very keen intern, you recognize this may
be Acute Coronary Syndrome causing arrest.
Cardiac Arrest, 4 rhythms
► As you pause during compressions you analyze the
rhythm… the patient is in Ventricular Fibrillation
► The DACR runs into the room, you notify him/her
of the patient’s rhythm and
► ANALYZE.. CLEAR…SHOCK DELIVERED
► Resume CPR! Wait to reanalyze the rhythm after
the next round of CPR
► The patient receives a dose of Epinephrine in
addition to another shock and has conversion to
sinus rhythm. He has ROSC. His vitals begin to
improve and he is rushed to the Cardiac
Catherization Lab.
 High quality CPR is key

► Rate at least 100/min

► Compression depth at
least >2 inches (5-
6cm) in adults
► Allow complete chest
recoil after each
compression
► Minimize interruptions

► Rotate every 2
minutes
► You arrive at the patient’s room and the
nurse informs you that the patient’s HR was
60-70’s during the day but suddenly
decreased from 48 to 35bpm.
► Current vitals: HR 35bpm, SBP 70/DBP is
undetectable RR 16/min, and O2 saturation
93%.
► The patient was initially complaining of
lightheadedness but now is more lethargic.
► You take a look at the EKG that was obtained.
► You request oxygen be applied to the patient
and the pads for transcutaneous pacing be
applied.
► Just as you are doing so, additional help
arrives and your Nightfloat senior assists you.
► Atropine is obtained from the crashcart and
the patient is bolused 0.5mg.
► The patient’s HR slightly improves to 49bpm
but he remains somewhat confused and
lethargic.
► Transcutaneous pacing is started with a
target HR of 60bpm. She begins to wake up
and her BP improves to 110/57.
► EP is consulted and the patient receives a
transvenous and ultimately an implanted
 Last Scenario
► You are on waiting to sign out at 630
pm on a Sunday when you’re paged
about a patient with past hx of SVT
here for CP now has a HR of 160.
► BP 125/80, narrow complex
tachycardia as below
► After attempting vagal maneuvers
(unsuccessful) you give adenosine
6mg IV push, and then 12 mg IV push
► Now the patient develops severe
chest pain, He 220, BP not obtainable,
pulse weak. The patient begins losing
consciousness. What do you do next?
► Synchronized cardioversion is
unsuccessful. Patient now is pulseless
and unconscious.

What next? Time to shock!

(unsynchronized 120-200 J)
 Synchronized vs unsynchronized cardioversion

Synchronized Unsynchronized
Low energy shock High energy shock
delivers shock w/ delivers as soon as
peak of QRS shock button is
Indications: unstable pushed
A fib, A flutter, SVT Indications: pulseless
VT/VF
If shock occurs on t-
wave, high likelihood
of VF
► After 5 cycles of CPR, the rhythm
check suggests a second shock. Now
with 200 J. Which medications should
you be giving?

► Epinephrine 1mg IV q3min and/or

vasopressin 40 U IV to replace first or
second epi dose
► Amiodarone after 3rd shock in
pulseless VT (300 mg IV x1, then
consider 150 mg IV x1
• SROC! The patient was intubated by
anesthesia at the scene, and is not
responding to verbal commands. Patient
transported to CICU. What post cardiac
arrest intervention would this patient benefit
from?
 What Is ACLS?
• ACLS guidelines first published 1974 by AHA, most
recent update 2010
• A series of interventions for urgent treatment of
cardiac arrest, stroke, and life threatening medical
emergencies
• Several algorithms for VF/Pulseless VT, Bradycardia,
Suspected Stroke
• An essential part of using the algorithm correctly is to
search for and correct potentially reversible causes of
arrest
• Performing high quality CPR, identifying arrhythmias
and understanding the pharmacology behind key
drugs are central to ACLS.
 H’s and T’s
Treatable causes of cardiac arrest
► Hypoxia ► Thrombosis
► Hypovolemia (pulmonary)
► Thrombosis (coronary)
► Hydrogen ion
(acidosis) ► Tamponade

► Hypokalemia ► Tension

► Hyperkalemia pneumothorax
► Toxins
► Hypothermia
 Things to discuss with
patients
► All patients admitted to the hospital
should be asked about their code
status
► It’s important to discuss the morbidity
associated with ACLS
► Statistics regarding survival after
arrest
► Adverse outcomes of CPR and
Advanced Airway Support
Don’t forget to pick up your ACLS cards
from the chiefs office!

Remember to check your own pulse

first.