This document provides information about cardiopulmonary resuscitation (CPR) and the basic life support (BLS) and advanced cardiac life support (ACLS) protocols. It begins with definitions of CPR and its purposes to support life through circulation and prevent brain damage from lack of oxygen. The history of developments in CPR techniques from chest compressions to defibrillation are outlined. Adult and pediatric BLS protocols are described, including assessing responsiveness, calling for help, performing high-quality chest compressions, opening the airway, rescue breathing, and using an automated external defibrillator. Differences in CPR for adults, children and infants are also summarized.

1. PRESENTED BY:
DR ARYA DASMAHAPATRA
POSTGRADUATE TRAINEE
DEPARTMENT OF ANAESTHESIOLOGY
MEDICAL COLLEGE AND HOSPITAL, KOLKATA
GUIDED BY:
DR DEBASISH GHOSH
ASSISTANT PROFESSOR
DEPARTMENT OF ANAESTHESIOLOGY
MEDICAL COLLEGE AND HOSPITAL, KOLKATA
CARDIO-PULMONARY
RESUSCITATION:
BASIC LIFE SUPPORT
&
ADVANCED CARDIAC LIFE SUPPORT
1

2. W
H
A
T
I
S
C
P
R
 CPR or Cardiopulmonary Resuscitation, is an emergency lifesaving
procedure performed when the heart stops beating.
 Cardiopulmonary resuscitation and emergency cardiac care(CPR-
ECC) should be considered any time an individual cannot
adequately oxygenate or perfuse vital organs- not only following
cardiac or respiratory arrest.
 Cardiopulmonary resuscitation is an emergency procedure that
combines chest compressions often with artificial ventilation in an
effort to manually preserve intact brain function until further
measures are taken to restore spontaneous blood circulation and
breathing in a person who is in cardiac arrest.
2

3. P
U
R
P
O
S
E
O
F
C
P
R
 To support life by the means of haemodynamics, through
chain of activities.
 To reverse the initiating pathophysiological event.
 To prevent irreversible cerebral damage from anoxia.
3

4. 1732: First medical BLS by Willian Tossach
1780: First attempt of newborn resuscitation by blowing
1858: Method of restoring natural breathing by Dr H. R. Silvester
1892: First attempt of external chest compression to a cardiac arrest
victim by Friedrich Maass
1906: Use of epinephrine in treating cardiac arrest by Crile and Dolley
1947: First successful internal defibrillation of ventricular fibrillation in
human by Claude Beck
1949: First report of mouth-to-mouth ventilation to a cardiac arrest victim
by James Elam
1955: First successful external defibrillation of ventricular fibrillation in
human by Paul Zoll
1960: Application of external chest compression to patients with cardiac
arrest by William Kouwenhoven group
The birth of cardiopulmonary resuscitation by Safar, Jude,
Kouwenhoven
1966: First CPR guidelines by American Academy of Science
1979: Development of the prototype of AED
1991: Introduction of Chain of Survival by AHA
1993: Foundation of International Liaison Committee On Resuscitation
2000: First International CPR Guidelines by ILCOR
T
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4

5. C
A
R
D
I
A
C
A
R
R
E
S
T
• Sudden cessation of mechanical activity of heart with some or no
electrical activity
• Cessation of normal circulation of blood due to failure of heart to
contract effectively.
• Maybe reversible by a rapid intervention but will lead to death in its
absence.
5

6. C
A
U
S
E
S
O
F
S
C
A
Acute Myocardial Infarction
Cardiomyopathy
Rhythm disturbances(VT/VF/PEA/Asystole)
Congestive Heart Failure
Cardiac Tamponade
Acute Coronary Syndrome
Hypoxia
Pulmonary Embolism
Tension Pneumothorax
Respiratory Failure
Airway Obstruction
Sepsis Trauma
Electrolyte Imbalance Hypothermia or Hyperthermia
Hypoglycemia Drugs
Anaphylaxis Blood transfusion reaction
Hypovolemia Intracranial Catastrophe
6

7. AHA CHAIN OF SURVIVAL FOR ADULTS
2020 AHA CPR and ECC Highlights
2015 AHA CPR and ECC Highlights
7

8. 2020 AHA CPR and ECC Highlights
2015 AHA CPR and ECC Highlights
8

9. BASIC LIFE SUPPORT
• Cardiopulmonary resuscitation is a spectrum from recognising
a cardiac arrest to BLS to ACLS to post cardiac arrest care.
• BLS is the foundation of saving lives after cardiac arrest.
• A level of medical care which is used for victims of life
threatening illnesses or injuries until they can be given full
medical care at a hospital. It can be provided by trained
medical personnel, including emergency medical technicians,
paramedics, and by qualified bystanders.
• Includes psychomotor skills to perform high quality CPR, using
an automated external defibrillator(AED) and relieving an
obstructed airway
9

10.  BLS is the primary medical aid provided in an emergency
medical situation.
 Objective here is not to “treat” the person but to buy some
valuable time until the emergency medical team arrives.
 BLS can be performed by anyone who knows how to do it,
anywhere, immediately without any other equipment.
 To support life by the means of haemodynamics, through
chain of activities.
 To reverse the initiating pathophysiological event.
 To “save hearts too good to die” while preventing irreversible
cerebral damage from anoxia.
O
B
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I
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E
S
10

11. When to give CPR?
BLS is needed when the individual:
• is unconscious
• is not breathing
• has an abnormal pulse rate
When not to give CPR?
• Neither scene nor the victim and the rescuer is safe
• Patient has already developed rigor mortis
• Patient has normal pulse and breathing
11

12. S
E
Q
U
E
N
C
E
S
C- Compression
A- Airway
B- Breathing
A- Airway
B- Breathing
C- Compression
Why C-A-B?
• To emphasize the simplest but the most important step
• To increase survival rate in sudden cardiac arrest
• Patient’s blood stays oxygenated for 4-6minutes after last breath
but circulation should be restarted at the earliest
• Rescue breathing almost always delays chest compressions.
12

13. C
O
M
P
O
N
E
N
T
S
Ensure scene safety
Check for response and assessment
Call for help
Activate EMS
Chest compressions
13

14. A
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A
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D
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T
B
L
S
A
L
G
O
R
I
T
H
M
14

15. SCENE SIZE-UP
 Goal is to affirm your safety, the safety of your team,
as well the patient and bystanders.
 Sizing up the scene to find the answers of these questions:
 Is it safe?
 Is immediate danger involved?
 What is the nature of the illness or mechanism of injury?
 How many patients are involved?
 Is anyone else available to help?
 What is your initial impression?
DO NOT MOVE THE VICTIM UNTIL CPR IS GIVEN AND
QUALITY HELP
ARRIVES, UNLESS SCENE DICTATES OTHERWISE.
15

16. RESPONSE AND ASSESSMENT
Level of consciousness:
• To check for responsiveness, tap the patient gently
on the shoulder and shout, “Are you okay?”
• Monitor if reciprocated, otherwise summon additional
resources.
Circulation and breathing:
• Check for carotid pulsation for not more than 10seconds
but atleast for 5seconds.
• Check for respiration, if there is at all any sign of it.
• Agonal breaths.
16

17. CALL FOR HELP
Seek help from bystanders, other providers or from
any trained individual.
ACTIVATE EMS
• Dial up 102/108 for EMS.
• Activate CODE BLUE for in-patients.
• Kolkata Accident Response and Medical
Assistance(KARMA).
17

18. OUTCOME OF ASSESSMENT
Normal breathing,
Pulse felt
No normal breathing,
Pulse felt
No normal breathing,
Pulse absent
Rescue breaths
Monitor Start CPR
immediately
18

19. CHEST COMPRESSIONS
• 2020 AHA guidelines for CPR and ECC has re-emphasised early
initiation of CPR(compression) by rescuers.
• Chest compression is foundation of CPR.
• Continued emphasis on providing high quality CPR.
• Push hard, push fast.
• Hands-only CPR.
19

20. • Rescuer should be at victim’s side.
• Patient should be supine on a flat, firm surface.
• Chest is exposed adequately.
• Heel of the hand is placed in the
centre of the chest on the lower
half of sternum.
• Other hand is placed on top.
• Fingers are interlaced.
T
E
C
H
N
I
Q
U
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•Arms are kept as straight as
possible. Shoulder directly over the
hands. Elbows are locked.
• Movement of the rescuer should
be from the hip joint.
20

21. HOW DOES COMPRESSION WORK?
21

22. HIGH QUALITY CPR
•Push hard (at least 2inches [5 cm]) and fast (100-120/min)
•Allow complete chest recoil.
•Minimise interruptions in compressions.
•Avoid excessive ventilation.
•Change compressor every 2 minutes, or sooner if fatigued.
•If no advanced airway, 30:2 compression-ventilation ratio.
•Push hard (≥⅓ of anteroposterior diameter of chest) and fast
(100-120/min)
•Allow complete chest recoil.
•Minimise interruptions in compressions.
•Change compressor every 2 minutes, or sooner if fatigued.
•If no advanced airway, 15:2 compression-ventilation ratio.
•If advanced airway, provide continuous compressions and
give a breath every 2-3 seconds.
A
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22

23. AIRWAY ASSESSMENT
AND
BREATHING
23

24. H EA D TI LT CH I N LI FT
JAW TH RU ST
T
O
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N
A
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R
W
A
Y
NEVER PERFORM A BLIND FINGER SWEEP
24

25. R
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S
C
U
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B
R
E
A
T
H
MOUTH-TO-MOUTH:
Open airway-Pinch the nose-Seal mouth to mouth contact-Blow
MOUTH-TO-NOSE:
Lockjaw-Seal mouth to nose
contact-blow with more force
Tidal Volume: 500-600ml
Each breath over 1seconds
with enough volume to rise
victim’s chest. 25

26. MOUTH-TO-BARRIER DEVICE BREATHING:
Head tilt chin lift-Seal from nasal bridge to chin in a ‘C’ pattern-Blow
Protects rescuer from contact with a victim’s blood, vomitus and saliva, and
from breathing the air that the victim exhales.
26

27. BAG-VALVE-MASK RESUSCITATOR:
Open airway-First rescuer seals the mask in ‘E-C’ pattern-Second
rescuer provide ventilation
27

28. 28
THE KISS OF LIFE
Award winning 1967 photo was
taken by Rocco Morabito. Two
electrical operators, Champion
Randall(hanging down after a
cardiac arrest following
electrocuted) and
JD Thompson(giving mouth-to-
mouth ventilation). CPR was given
when Champion was brought
down and he survived and died of
heart failure in 2002 at the age of
64.
This photograph was published
and won the Pulitzer Prize in 1968.

29. EARLY
DEFIBRILLATION
29

30. AUTOMATED
EXTERNAL
DEFIBRILLATOR
 AED is a portable electronic device that automatically analyses the
patient’s rhythm and can provide defibrillation, an electrical shock
that may help the heart re-establish a perfusing rhythm.
 AED is an integral component of BLS protocol.
 Early defibrillation has been re-emphasised in all updates.
 AEDs deliver defibrillations to specific two shockable dysrhythmias
Ventricular fibrillation(V-fib)
Ventricular tachycardia(V-tach)
30

31. HOW TO USE AN AED?
31

32. A
E
D
S
A
F
E
T
Y
 Make sure the patient is as dry as possible. Rescuers should not be
in contact with water.
 Avoid getting AED or AED pads wet, if possible.
 Make sure pads are not touching metal surface.
 Position the pads at least an inch away from metal piercings, 3cm
away from pacemakers.
 Be cautious with medication patches. Remove the patch beforehand.
 Excessive chest hair can affect pad-to-skin contact.
 When advised ‘CLEAR’, make sure no one is in contact.
 Do not use alcohol to wipe.
 Do not defibrillate around inflammable materials.
32

33. AHA CHAIN OF SURVIVAL FOR PAEDIATRICS
33

34. BLS Healthcare
Provider
Paediatric
Cardiac
Arrest
Algorithm.
Single Rescuer.
34

35. BLS Healthcare
Provider
Paediatric
Cardiac
Arrest
Algorithm.
2 or more
Rescuer.
35

36. DIFFERENCES IN ADULT, CHILD AND INFANT
36

37. DIFFERENCES IN ADULT, CHILD AND INFANT
37

38. DIFFERENCES IN ADULT, CHILD AND INFANT
38

39. AHAALGORITHM
FOR
OPIOID
ASSOCIATED LIFE
THREATENING
EMERGENCY
39

40. R
E
C
O
V
E
R
Y
P
O
S
I
T
I
O
N
For patient who is unconscious
and breathing with no head, neck
or spinal injury.
MODIFIED H.A.IN.E.S. POSITION
‘High Arm IN Endangered Spine’ Position
For patients with
suspected spine injury.
40

41. 41

42. 42
If CPR is started
Within 4minutes
and defibrillation
provided within
10minutes a
person has a 40%
chance of survival
Bad CPR is better than No
CPR
Impedance
Threshold
Device is used
to decrease
intrathoracic
pressure
“Stayin’ Alive” by
The Bee Gees is
termed as the ‘CPR
Song’ as it has
104beats/ min
Resusci Anne(L’Inconnue
de la Seine is the face
of mannequin. Unknown
French girl who was
drowned in Paris in
19th century
Good Samaritan Laws
protect those giving CPR
from lawsuits

43. 43
ADULT
CARDIAC
ARREST ALGORITHM

44. 44
CARDIAC RHYTHMS IN CARDIAC ARREST
Ventricular Tachycardia Ventricular Fibrillation
Shockable
1. Monomorphic
2. Polymorphic
1. Fine
2. Coarse
Nonshockable
Asystole
Pulseless Electrical Activity
Other shockable rhythms are: Atrial Fibrillation, Atrial Flutter,
Supraventricular Tachycardia

45. 45
VENTRICULAR TACHYCARDIA
≥3 heartbeats in a row, at
a rate of more than
100beats/minute.
A-V dissociation with
P-wave marching
forward.
Wide QRS-complex
≥0.12s

46. 46
VENTRICULAR FIBRILLATION
Coarse Ventricular Tachycardia
Fine Ventricular Tachycardia
•Chaotic irregular deflections of varying amplitude
•No identifiable P waves, QRS complexes, or T waves
•Rate 150 to 500 per minute
•Amplitude decreases with duration (coarse VF -> fine VF)

47. 47
WIDE COMPLEX TACHYCARDIA
•150 beats/min or more with a QRS duration of 0.12s or more.
•SVT, A-fib, A-flutter, Ectopic A-tach.
•There may be accessory pathway or due to VT or a rapid ventricular paced
rhythm with pacemaker.
•In stable patients, IV Adenosine may be considered when the cause of regular,
monomorphic rhythm cannot be determined. Not in unstable patients with
irregular, or polymorphic wide-complex tachycardias.
•IV Amiodarone, Procainamide, Sotalol.
•Cardioversion, if pharmacological therapy failed.

48. 48
TORSADES DE POINTES
•Twisting of points.
•Wide complex tachycardia of ventricular origin with differing configurations of
the QRS complex from beat to beat. TdP is associated with heart rate-corrected QT
interval when the rhythm is normal and VT is not present.
•Catecholaminergic polymorphic VT, Genetic exercise induced polymorphic VT in
the absence of QT prolongation, ‘Short QT’ syndrome, Unusually short QT
interval polymorphic VT, Bidirectional VT in digitalis toxicity.
•Immediate defibrillation for sustained, unstable polymorphic VT.
•Magnesium may be considered for polymorphic VT with long QT interval.
•IV Lidocaine, Amiodarone and measures to treat MI may be considered for
polymorphic VT in the absence of prolonged QT interval.

49. 49
REGULAR NARROW COMPLEX TACHYCARDIA
• Narrow complex tachycardia represents a range of tachyarrythmias originating
from a circuit or focus involving the atria or the AV node.
• Synchronised cardioversion is recommended for acute treatment in patients
with haemodynamically unstable SVT.
• For haemodynamically stable VT, Vagal maneuvers, Pharmacological therapy,
then Cardioversion.
• Choices of drugs accordingly:
• IV Adenosine
• IV Diltiazem or Verapamil
• IV β-adrenergic blockers

50. 50
ATRIAL FIBRILLATION OR FLUTTER WITH RAPID
VENTRICULAR RESPONSE
•Atrial fibrillation is an SVT consisting of disorganised atrial electric
activation and uncoordinated atrial contractions.
•Atrial flutter is an SVT with a macroreentrant circuit resulting in rapid atrial
activation but intermittent vetricular response.
•Cardioversion is recommended for haemodynamically unstable atrial
fibrillation or flutter.
•Initial biphasic energy of 120-200 J for atrial fibrillation
•Initial biphasic energy of 50-100 J for atrial flutter.
•Pharmacological therapy
•IV β-adrenergic, Diltiazem or Verapamil
•IV Amiodarone

51. 51
BRADYCARDIA
• Heart rate less than 60/min.
• Physiological or pathological.
• In acute symotomatic bradycardia evaluation should be done and reversible
causes should be treated.
• IV Atropine to be given in haemodynamically compromised acute
bradycardia.
• IV Epinehrine can be considered in bradycardia unresponsive to Atropine.
• Transcutaneous pacing is effective prior to transvenous temporary pacing.
• Immediate pacing in unstable patients with high-degree AV block.

52. 52
ALTERNATIVE CPR TECHNIQUES
•Mechanical CPR devices
Load distributing compression band
Pneumatic piston device
•Impedance threshold devices
•Active compression-decompression CPR
•Interposed abdominal compression CPR
•Extracorporeal CPR

53. 53
ADVANCED AIRWAY
•Bag mask ventilation or
advanced airway(SGA or ET
intubation)
•Continuous waveform
capnography to confirm and
monitor correct placement of
ET tube.

54. 54
D
E
F
I
B
R
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L
L
A
T
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O
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• Defibrillator is a device that deliver a therapeutic dose of electrical
energy to the affected heart to force the heart to produce more normal
cardiac rhythm.
• Shock energy:
Adult
Biphasic: Manufacturer recommendation; if unknown, use
maximum available. Second and subsequent doses
should be equivalent, and higher doses maybe
required.
Monophasic: 360 J
Paediatric: First shock 2 J/kg
Second shock 4 J/kg
Subsequent shocks ≥4 J/kg
Maximum 10 J/kg or adult dose
• Cardioversion is synchronised administration of shock on the peak of
R-wave.

55. 55
DRUGS
IN
ACLS
PROTOCOL

56. 56
• With respect to timing, for cardiac arrest with a non-shockable
rhythm, it is reasonable to administer Epinephrine as soon as
feasible.
• With respect to timing, for cardiac arrest with a shockable rhythm,
it may be reasonable to administer Epinephrine after initial
defibrillation attempts have failed.
• Dose: IV/IO
Adult: 1 mg every 3-5 minutes.
Paediatric: 0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL concentration).
Max dose 1mg.
Repeat every 3-5 minutes.
ET dose: 0.1 mg/kg (0.1 mL/kg of the 1 mg/mL
concentration)

57. 57
• Class III antiarrhythmic agent.
• For refractory VF/pulseless VT, IV/IO dose is:
Adult:
First dose: 300 mg bolus
Second dose: 150 mg
Paediatric:
5 mg/kg bolus during cardiac arrest. May repeat upto
3 total doses.

58. 58
• Class IB antiarrhythmic agent.
• IV/IO dose:
Adult:
First dose: 1-1.5 mg/kg
Second dose: 0.5-0.75 mg/kg
Paediatric:
Initial dose: 1 mg/kg loading dose

59. 59
PAEDIATRIC CARDIAC
ARREST ALGORITHM

60. 60
PAEDIATRIC
TACHYCARDIA
WITH A PULSE
ALGORITHM

61. 61
PAEDIATRIC
BRADYCARDIA WITH A
PULSE ALGORITHM

62. 62
NEW RECOMMENDATIONS FOR PAEDIATRIC ALGORITHM
•It is reasonable to use cuffed ETTs over uncuffed for intubating infants and children. Cuff
inflation pressure should be <20-25 cm H2O.
•Routine use of cricoid pressure is not recommended.
•Invasive blood pressure monitoring to assess CPR quality. Survival with favourable
neurologic outcome are improved if the diastolic blood pressure is atleast 25 mm Hg in
infants and 30 mm Hg in children.
•In patients with septic shock, it is reasonable to administer fluid in 10 mL/kg or 20 mL/kg
aliquots with frequent reassessment.
•Use of either epinephrine or norepinephrine as an initial vasoactive infusion in fluid-
refractory septic shock. It may be reasonable to consider stress-dose corticosteriods.
•After ROSC, evaluation for seizures.
•Blood products instead of crystalloid in hypotensive haemorrhagic shock following
trauma.
•Inhaled nitric oxide or prostacyclin as the initial therapy for pulmonary hypertensive
crises.

63. 63
CARDIAC
ARREST
IN
PREGNANCY
IN-HOSPITAL
ACLS ALGORITHM

64. 64
Team planning between the concerned
departments.
Priorities for pregnant women including high
quality CPR and relief of aorto-caval compression
with lateral uterine displacement.
Perimortem ceaserean delivery to be performed.
Difficult airway.
ET intubation and supraglottic airway.
Use of waveform capnography.
Through advanced airway, 1 breath every 6
seconds with continuous chest compressions.
CARDIAC ARREST IN PREGNANCY

65. 65
RETURN OF SPONTANEOUS CIRCULATION
•Return of palpable pulse and measurement of blood
pressure.
•Abrupt sustained increase in PETCO2. Typically ≥40 mm Hg.
•Spontaneous arterial pressure waves with intra-arterial
monitoring.
ACLS TERMINATION OF RESUSCITATION

66. 66
POST CARDIAC ARREST
CARE ALGORITHM
Initial stabilisation:
Capnography and ET tube placement
Respiratory parameters
Haemodynamic parameters
Continued management:
Cardiac intervention
Targeted temperature management
Critical care management

67. 67
TARGETED TEMPERATURE MANAGEMENT
Recommendation of TTM for adults who do not follow
commands after ROSC in OHCA and IHCA.
TTM between 32°C and 36°C for atleast 24hours is currently
recommended.
PCI AFTER CARDIAC ARREST
Coronary angiography should be performed emergently for all
cardiac arrest patients with suspected causes and ST elevation.
For select OHCA patients who are comatose and without ST
elevation.
Independent of mental status.

68. 68
MULTIMODAL NEUROPROGNOSTICATION
AFTER CADIAC ARREST

69. 69
NEUROPROGNOSTICATION
• Neuroprognostication involves multimodal approach.
• Neuroprognostication to be delayed to ensure avoidance of confounding by
medication effect. Atleast 72hours after normothermia.
• Regular and transparent multidisciplinary discussions about time course and
uncertainties.
Use of clinical examination.
Use of serum biomarkers.
Use of electrophysiological tests.
Use of neuroimaging.

70. 70
 Approximately one third of cardiac arrest survivors experience anxiety,
depression, or posttraumatic stress.
 Cognitive impairments after cardiac arrest include difficulty with memory,
attention, and executive function.
 Early evaluation for cardiac rehabilitation and physical, occupational, and
speech language therapy may be helpful to adapt to impairments.
 Community reintegration and return to work or other activities.
 Rescuers may experience anxiety or posttraumatic stress about providing or
not providing BLS.
 Team debriefings may allow a review of team performance as well as
recognition of the natural stressors.
RECOVERY AND SURVIVORSHIP

71. 71
ROADMAP TO
RECOVERY

72. Thank you.
72