basic life support basic airway chain of survival

1. Basic life support

2. • Approximately 700,000 cardiac arrests per year
in Europe.
• Survival to hospital discharge presently
approximately 5-10%.
• Bystander CPR vital intervention before arrival
of emergency services.
• Early resuscitation and prompt defibrillation
(within 1-2 minutes) can result in >60% survival.
• Heart attack is the leading cause of arrest in
Europe.

3. • EARLY recognition and management is key to
survival
• Survival from In- Hospital respiratory arrest 90%
• Survival from In- Hospital cardiac arrest 11%
• Survival from Out of Hospital cardiac arrest 7%
• Less than1 in 1,000 survive – & the key factor is the
brain.

4. History
• Elam and Safar described the technique and
benefits of mouth-to-mouth ventilation in
1958.
• Kouwenhoven, Knickerbocker, and Jude
subsequently described the benefits of
external chest compressions
• Kouwenhoven first described External
defibrillation in 1957

5. Types of arrest
• Shockable rhythm
• Ventricular fibrillation
• Pulseless ventricular tachycardia
• Unshockable rhythm
• Pulseless electrical activity
• asystole

6. Correctable causes of arrest
• Hypoxia
• Hypothermia
• Hypovolemia
• Electrolyte imbalance and acidosis
• Thrombosis
• Cardiac tamponade
• Tension pneumothorax
• Toxins

7. Phases of CPR
• Electrical phase: it is first 5 minutes of arrest on
shockable rhythm. Chest compression till defibrillator
is ready is crucial in survival.
• Haemodynamic phase: from 5 to 10 minutes
from arrest availability of defibrillator is crucial but if
patient found in VF may 90 to 180 seconds of chest
compression is needed before defibrillator
(controversial in AHA)

8. CHAIN OF SURVIVAL
1. Immediate recognition of cardiac arrest and activation of the
emergency response system
2. Early cardiopulmonary resuscitation (CPR) with an emphasis on
chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care

9. Recognition of cardiac arrest:
• Approach to unresponsive patient to check his response
by shaking his shoulders gently while asking the patient
are you ok?
• If no response activate emergency response.
• Open airway see listen and feel for breathing for 10
seconds after checking that airway is open.
• After 10 seconds no breathing begin CPR.
• Check carotid pulsation in adults and brachial pulsation
with minimal pressure in pediatric not to cause fracture
humerus.

10. CPR
• Early CPR with emphasis on chest compression.
• Begin by ratio 30 compression to 2 rescue breaths as
long as we are not on advanced airway if we had
advanced airway we do about 100-120 chest
compressions per minute to 8-10 rescue breathes per
minute.
• Cardiac output falls during CPR to approximately
25% of normal cardiac out put and minute volume will
be around 6-8 liters per minute.

11. Rapid access to defibrillator
• Defibrillator should be available within 4 minutes from
beginning of CPR and according to AHA 3 minutes only.
• While doing basic life support automated defibrillator will
be use.
• When begin advanced life support it is preferred to use
biphasic defibrillator than monophasic defibrillator which
use higher energy in delivering the shock.
• Defibrillation for ventricular fibrillation and pulseless
ventricular tachycardia.
• If arrest for 4 or 5 min before beginning CPR and its
shokable rhythm u may do CPR for 90 to 180 second
before delivering the shock.

12. Effective advanced life support
• Advanced life support should begin with in 8 minutes
in a hospital.
• It begin by resuscitation team with advanced airway
with advanced medications as Adrenaline,
Amiodarone and Magnesium sulphate.

13. • Advance life support team:
1. Team leader: instruct during CPR
2. Airway responsible
3. Responsible for drugs
4. Defbrillator responsible
5. 2 for chest compression
6. One for documenting events

14. Indicators Inadequate Blood Flow During CPR
• Systemic venous oxygen saturation below 40%
• Coronary perfusion pressure below 15 mmHg
• Diastolic blood pressure below 40 mmHg
• Unpalpable carotid and femoral pulsation
• End tidal carbon dioxide below 10 mmHg

15. Integrated post-cardiac arrest care
• Important as CPR as it is responsible with adequate CPR for
brain resuscitation which is the main concern in effective CPR.
• Therapeutic hypothermia by the idea of decreasing metabolic
rate and oxygen needs of brain and other body organs.
– Cooling is done to 34 degree Celsius and maintained for 12 to 24
hours then gradual rewarming over 12-24 hours.
– Achieved through using
1. Infusion of 1 to 2 liters of cold intravenous fluids.
2. Turn off warming system in mechanical ventilator.
3. Surface cooling blankets or automated devices
4. Use sedation and neuromuscular blockers to prevent shivering
5. Ice packs on neck, inguinal and axilla
6. Cooling fans
7. Automated endovascular cooling devices more safe prevent rebound
hyperthermia need a feed back loop through a catheter inserted in inferior vena
cava.

16. Surface cooling blanket

17. Automated endovascular cooling devices
Transfemoral IVC insersion

18. Contraindication to hypothermia:
1. severe cardiogenic Shock
2. life- threatening dysrhythmias
3. Uncontrolled bleeding
4. Preexisting Coagulopathy
5. Pregnancy
6. another obvious reason for coma (e.g., drug overdose
or status epilepticus), known end-stage
7. Terminal illness, and a preexisting do-not-resuscitate
status

19. • Look for a 12 lead ECG with right and posterior leads of there is
ST elevation or left bundle either go for PCI or thrombolytic with
better chance of survival in with primary PCI.
• Antiplatelet and anticoagulation should be given to all patient
with ROSC provided no hemorrhage or profound hypertension
• Beta blockers and nitroglycerin use post CPR in ACS patients.
• Patients attached to EEG and convulsions should be treated
promptly.
• Pacemaker insertion in patients who had
1. Complete heart block
2. Second degree heart block
3. Right bundle branch block with anterior or posterior hemiblock
4. Left bundle branch block

20. • Prevent hypoxia or hyperoxia keep Fio2 to
keep oxygen saturation 94% over
oxygenation causes oxidative effect on brain
tissue as hypoxia.
• Care for CPR trauma as pneumothorax,
tension pneumothorax, flail chest and
fracture ribs.

21. Post cardiac arrest goals
1. Mean arterial pressure: 70-90 mmHg
2. CVP/PCWP 10-15/15-18 mm Hg
3. Hemoglobin 10 g/dL
4. Lactate <2.0 mM
5. Temperature 32-34.0 C for 12-24 hrs then 36-37 C
6. SaO2 94-98%
7. ScvO2 65%
8. DO2 400-500 mL/min/m2
9. VO2 >90 mL/min/m2
10. Avoid flow-dependent consumption

22. Basic airway management
• Bag mask ventilation is a cornerstone of basic
airway management.
• It is used when inadequate ventilation either by
hypoxia or hypoventilation or both. Or due to upper
airway obstruction.
• Classified into maneuvers like head tilt chin lift jaw
thrust and airway adjuncts by oropharyngeal or
nasopharyngeal.

23. Airway obstruction
• It is diagnosed by increased respiratory effort
cyanosis work of accessory muscles of respiration
and adventitious sounds like snoring.
• Relieved by multiple techniques
1. Abdominal thrust by encircling abdomen by both hands and the
rescuer standing in the back it is contraindicated in pregnancy
sometimes it caused gastric rupture.
2. Chest thrust begin with it before abdominal if abdominal is
contraindicated
3. Back slaps sometimes relieve obstruction.
• Usually we need combination of these maneuveres
to releive obstruction.

26. Airway maneuvers
• Head-tilt chin-lift the
manoeuvre is done by
extending neck by one
hand of rescuer on
forehead other hand index
and middle fingers tip
raise chin anteriorly at the
mentum which lifts tongue
from posterior pharynx
head tilt can not be done if
cervical injury is a
concern.

27. • Jaw-thrust maneuver With
the patient supine and the
clinician standing at the
head of the bed, it is
performed by placing the
heels of both hands on the
parieto-occipital areas on
each side of the patient's
head, then grasping the
angles of the mandible with
the index and long
fingers, and displacing the
jaw anteriorly it is safe even
if there is cervical spine
fracture

28. • Cervical spine
immobilization if
cervical spine
fracture is
anticipated cervical
spines must be kept
aligned by another
rescuer if patient is
on collar anterior
part should be
removed to do basic
airway management

29. Airway adjuncts
• They will prevent the tongue from occluding the
airway and provide an open conduit for air to pass.
• Oropharyngeal airway must be inserted to any patient
on Bag mask ventilation will be prolonged.
• They do not prevent aspiration of gastric content or
salivation.

30. Oropharyngeal airway
• Used only in deep unresponsive patients or it may induce
vomiting.
• Multiple sizes we measure it approximately equals distance
between mandibular angle (tip) and the mouth (flange).
• Inserted by introducing it to the mouth inverted then return it to
upright position to prevent displacing the tongue posteriorly.
• Complications of insersion
1. Posterior displacement of the tongue
2. Trauma to the lips
3. Induce vomiting
4. Incorrect size

32. Oropharyngeal airway insertion

33. Nasopharyngeal airway
• Soft rubber or plastic hollow tube that is passed through the
nose into the posterior pharynx. Patients tolerate NPAs more
easily than OPAs, so NPAs can be used when the use of an
OPA is difficult, such as when the patient's jaw is clenched or
the patient is semiconscious and cannot tolerate an OPA.
• Comes with different sizes the length affected by internal
diameter of the NPA young adult 6-7 cm, medium adult 7-8 cm
and large adult 8-9 cm.
• Measure the proper size by putting flare end in front of the tip of
the nose the tip will just reach angle of the mandible.
• Lubricated with anesthetic gel before insertion through floor of
naris gently press posteriorly to reach its place.

34. Complications
1. Too long will enter oesphagus causing gastric distension
2. Nasal mucosa injury
3. If there is fracture base it is contraindicated as it may
precipitate infection

35. Nasopharyngeal airway insertion

36. Bag mask ventilation
• Prior using bag mask ventilation use one of the airway
opening maneuvers.
• Used to buy time for the clinician to put a plan for definite
airway management.
• Success of bag mask ventilation depends on rate, volume
and sealing of mask on the face.
• Prior to mask placement bag should be removed from the
mask to make it more successful proper placement, nasal
part of the mask cover nasal bridge the rest of the mask
cover maxillary eminence and the mandibular alveolar
ridge of the jaw but never the eye as it may cause trauma
or vagal stimulation.

37. Application of the mask
• One hand maneuver make a web between
index and thumb around the connector of the mask
then apply pressure by this web centrally on the
mask the rest of hand fingers will rest on the
mandible making chin lift maneuver.
• Double hand maneuver requires 2 persons first
care for airway by putting index and thumbs of both
hands simultaneous on superior and inferior ridges of
the mask and apply pressure and remaining 3 fingers
rest on the jaw doing chin lift jaw thrust maneuver.

38. Troubleshooting of bag mask
• Excessive facial hair may need KY jel
• Excessive facial oedema
• Down displaced lower lip
• Improper mask size
• Lack of airway adjuncts
• Inadequate airway maneuvers
• Inexperienced personnel

39. Ventilation through bag mask
• Tidal volume from 8-10 ml/kgm and in CPR 6-8
ml/kgm.
• Respiratory rate from 10-12 breaths per minute
• Inspiratory time should be around 1 second
• This tidal volume approximate to ambubagging using
single hand
Sellick’s maneuver
Press against cricoid cartilage to prevent over distention
of the stomach.

40. Applying bag mask

41. Basic life support

42. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

43. APPROACH SAFELY!
Scene
Rescuer
Victim
Bystanders
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

44. Approach safely
• The safety of both the rescuer and victim are paramount
during a resuscitation attempt.
• There have been few incidents of rescuers suffering
adverse effects from undertaking CPR, with only isolated
reports of infections such as Tuberculosis (TB) and
Severe Acute Respiratory Distress Syndrome (SARS).
• Transmission of HIV during CPR has never been
reported.
• Moving & Handling Risks
• Beware of Environmental Dangers

45. CHECK RESPONSE
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

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

47. SHOUT FOR HELP
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

48. OPEN AIRWAY
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

49. • If the person does not respond:
• Shout for help.
• Turn the victim onto his back and then check inside the mouth
for objects that could block the airway, then open the airway
using head tilt and chin lift jaw thrust
• Place your hand on his forehead and gently tilt the head back.
• With your fingertips under the point of the victim's chin, lift the
chin to open the airway.

50. CHECK BREATHING
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

51. CHECK BREATHING
• Look, listen and feel
for NORMAL
breathing
• Do not confuse
agonal breathing with
NORMAL breathing

52. AGONAL BREATHING
• Occurs shortly after the heart stops
in up to 40% of cardiac arrests
• Described as barely, heavy, noisy or gasping
breathing
• Recognise as a sign of cardiac arrest

53. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

54. 30 CHEST COMPRESSIONS
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

55. •Start chest compression as follows:
1. Kneel by the side of the victim.
2. Place the heel of one hand in the centre of the
victim’s chest (which is the lower half of the victim’s
sternum).
3. Place the heel of your other hand on top of the first
hand.
4. Interlock the fingers of your hands and ensure that
pressure is not applied over the victim's ribs. Do not
apply any pressure over the upper abdomen or the
bottom end of the sternum.

56. 5. Position yourself vertically above the victim's chest
and, with your arms straight, press down on the
sternum 5 - 6 cm.
6. After each compression, release all the pressure on
the chest without losing contact between your hands
and the sternum.
7. Repeat at a rate of 100 – 120 compression per min.
8. Compression and release should take an equal
amount of time.
9. When possible change CPR operator every 2 min

57. CHEST COMPRESSIONS

58. RESCUE BREATHS
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

59. 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

60. CONTINUE CPR
30 2

61. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths

62. DEFIBRILLATION

63. Call 123
Approach safely
Check response
Shout for help
Open airway
Check breathing
Attach AED
Follow voice prompts

64. SWITCH ON AED
• Some AEDs will
automatically switch
themselves on when
the lid is opened

65. ATTACH PADS TO
CASUALTY’S BARE CHEST

66. ANALYSING RHYTHM
DO NOT TOUCH VICTIM

67. SHOCK INDICATED
• Stand clear
• Deliver shock

68. SHOCK DELIVERED
FOLLOW AED INSTRUCTIONS
30 2

69. NO SHOCK ADVISED
FOLLOW AED INSTRUCTIONS
30 2

70. IF VICTIM STARTS TO BREATHE NORMALLY
PLACE IN RECOVERY POSITION

72. CPR IN CHILDREN
• Adult CPR
techniques can be
used on children
• Compressions 1/3 of
the depth of the chest

73. AED IN CHILDREN
• Age > 8 years
• use adult AED
• Age 1-8 years
• use paediatric pads /
settings if available
(otherwise use adult
mode)
• Age < 1 year
• use only if

74. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
30 chest compressions
2 rescue breaths
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 123
Attach AED
Follow voice prompts

75. Basic life support

76. Automated external
defibrillator

77. Automated external defibrillator
The automated external defibrillator (AED) is a
computerized medical device. An AED can check a
person’s heart rhythm. It can recognize a rhythm that
requires a shock. And it can advise the rescuer when a
shock is needed. The AED uses voice prompts, lights
and text messages to tell the rescuer the steps to take.
AEDs are very accurate and easy to use. With a few
hours of training, anyone can learn to operate
an AED safely.

78. How does it operate
• When turned on or opened, the AED will instruct the
user to connect the electrodes (pads) to the patient.
Once the pads are attached, everyone should avoid
touching the patient so as to avoid false readings by
the unit. The pads allow the AED to examine the
electrical output from the heart and determine if the
patient is in a shockable rhythm (either ventricular
fibrillation or ventricular tachycardia). If the device
determines that a shock is warranted, it will use the
battery to charge its internal capacitor in preparation
to deliver the shock. This system is not only safer
(charging only when required), but also allows for a

79. • When charged, the device instructs the user to
ensure no one is touching the patient and then to
press a button to deliver the shock; human
intervention is usually required to deliver the shock to
the patient in order to avoid the possibility of
accidental injury to another person.
• Many AED units have an 'event memory' which store
the ECG of the patient along with details of the time
the unit was activated and the number and strength
of any shocks delivered. Some units also have voice
recording abilities to monitor the actions taken by the

80. • The first commercially available AEDs were all of a
monophasic type, which gave a high-energy shock,
up to 360 to 400 joules depending on the model.
• Now biphasic available deliver shock beginning with
200 the 300 then another 300 joules.
• Time of expiry is written on the defibrillator.
• Recommended class I to use with in 3 minutes of
the arrest according to AHA.

82. AED sign put on places
available

83. Thank you
Dr. Islam Ellakany
Emergency medicine specialist
Alexandria university