Lecture Note

1. 1
Cardiopulmonary resuscitation -
An update
Author :
Venugopalan Poovathum Parambil, DA,DNB,MNAMS, MEM[GWU]
Regional Faculty , American Heart Association [AHA]
Director , Emergency Medicine , Aster DM Healthcare ,India.
drvenugopalpp@gmail.com
9847054747
What is cardiac arrest ?
Cardiac arrest​ is a sudden stop in effective blood flow due to the failure
of the heart to contract effectively.Symptoms include loss of
consciousness and abnormal or absent breathing.Some people may
have chest pain, shortness of breath, or nausea before this occurs. If not
treated within minutes, death usually occurs.
All cases of sudden collapses are cardiac arrest unless otherwise
proved
What is cardiopulmonary Resuscitation?
Cardiopulmonary resuscitation (CPR) consists of the use of chest
compressions and artificial ventilation to maintain circulatory flow and
oxygenation during cardiac arrest . Although survival rates and neurologic
outcomes are poor for patients with cardiac arrest, early appropriate
resuscitation—involving early defibrillation—and appropriate
implementation of post–cardiac arrest care lead to improved survival and
neurologic outcomes. Practically it is ​cardiopulmonary cerebral
resuscitation.
When will you start CPR ?
CPR should be performed immediately on any person who has become
unconscious and is found to be pulseless.
Absence of major pulse like carotid or femoral confirms cardiac arrest.
Assessment of cardiac electrical activity via rapid “rhythm strip” recording
can provide a more detailed analysis of the type of cardiac arrest, as well
as indicate additional treatment options.

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Loss of effective cardiac activity is generally due to the spontaneous
initiation of a nonperfusing arrhythmia, sometimes referred to as a
malignant arrhythmia.
The most common nonperfusing arrhythmias
● Ventricular fibrillation (VFib) - Shockable
● Pulseless ventricular tachycardia (VTach) - Shockable
● Pulseless electrical activity (PEA) - Non-shockable
● Asystole - Non shockable
V Fib is the most common rhythm in adult cardiac arrest
Fig1 -V fib
Fig 2-V Tach
Fig 3 -PEA

3. 3
PEA- Pulseless Electrical Activity
​Push Epi Always
Fig 4 - Asystole
CPR should be started before the rhythm is identified and should be
continued while the defibrillator is being applied and charged. Additionally,
CPR should be resumed immediately after a defibrillatory shock until a
pulsatile state is established.
What are the contraindications ?
The only absolute contraindication to CPR is a do-not-resuscitate (DNR)
order or other advanced directive indicating a person’s desire to not be
resuscitated in the event of cardiac arrest. A relative contraindication to
performing CPR is if a clinician justifiably feels that the intervention would
be medically futile.
Indian law does not permit to write DNR order in medical records
What are equipment needed ?
CPR, in its most basic form, can be performed anywhere without the need
for specialized equipment. Universal precautions (ie, gloves, mask, gown)
should be taken. However, CPR is delivered without such protections in the
vast majority of patients who are resuscitated in the out-of-hospital setting,
and no cases of disease transmission via CPR delivery have been
confirmed. Some hospitals and EMS systems employ devices to provide
mechanical chest compressions. A cardiac defibrillator provides an
electrical shock to the heart via 2 electrodes placed on the patient’s torso
and may restore the heart into a normal perfusing rhythm.

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Why defibrillation?
Defibrillation is a process in which an electronic device gives an electrical
shock to the heart. Defibrillation stops ventricular fibrillation by using an
electrical shock and allows the return of a normal heart rhythm. ​A victim’s
chance of survival decreases by 7 to 10 percent for every minute that
passes without defibrillation.
In recent years, small portable defibrillators have become available. These
devices are called automated external defibrillators, or AEDs. An AED is a
device that analyzes a heart rhythm and prompts the user to deliver a
shock when necessary. These devices only require the user to turn the
AED on and follow the audio instructions when prompted.
Fig 5- AED
Defibrillate as soon as possible in all cases of shockable rhythm. AED
enables early defibrillation in out of hospital cardiac arrest .
AHA recommendations for defibrillation include the following​ [​3​]​ ​
:
● Use defibrillators (using ,Biphasic or monophasic waveforms) to
treat atrial and ventricular arrhythmias (class I)
● Defibrillators using biphasic waveforms (Biphasic truncated
exponential - BTE or Rectilinear Biphasic - RLB) are preferred
(class IIa)
● Use a single-shock strategy (as opposed to stacked shocks) for
defibrillation (class IIa)
CPR Technique
In its full, standard form, CPR comprises the following 3 steps, performed in
order:
● Chest compressions

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● Airway
● Breathing
For lay rescuers, compression-only CPR (COCPR) is recommended.
Positioning for CPR
● CPR is most easily and effectively performed by laying the
patient supine on a relatively hard surface, which allows effective
compression of the sternum
● Delivery of CPR on a mattress or other soft material is generally
less effective
● The person giving compressions should be positioned high
enough above the patient to achieve sufficient leverage, so that
he or she can use body weight to adequately compress the
chest
Fig 6- External cardiac compression
For an unconscious adult, CPR is initiated as follows:
● Give 30 chest compressions
● Perform the head-tilt chin-lift maneuver to open the airway and
determine if the patient is breathing
● Before beginning ventilations, look in the patient’s mouth for a
foreign body blocking the airway
● Fallen back tongue is the common cause for airway obstruction in
an unresponsive victim .

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● Head tilt , Chin lift and Jaw thrust​ are the maneuvers used to
overcome airway obstruction.
● Head tilt is contraindicated in a trauma victim where Jaw thrust is
the choice
Trauma victims
● To open the airway in victims with suspected spinal injury, lay
rescuers should initially use manual spinal motion restriction (eg,
placing their hands on the sides of the patient’s head to hold it still)
rather than immobilization devices, because use of immobilization
devices by lay rescuers may be harmful (class III).
● For healthcare providers and others trained in two-person CPR, if
there is evidence of trauma that suggests spinal injury, a jaw thrust
without head tilt should be used to open the airway (class IIb)
Chest compression
The provider should do the following:
● Place the heel of one hand on the patient’s sternum and the
other hand on top of the first, fingers interlaced
● Extend the elbows and the provider leans directly over the
patient (see the image above)
● Press down, compressing the chest at least 2 in
● Release the chest and allow it to recoil completely
● The compression depth for adults should be at least 2 inches
and not more than 2.4 inches .
● The compression rate should be at least 100/min and not more
than 120/mt.
● The key phrase for chest compression is, “Push hard and fast”
● Untrained bystanders should perform chest compression–only
CPR (COCPR)
● After 30 compressions, 2 breaths are given; however, an
intubated patient should receive continuous compressions while
ventilations are given 8-10 times per minute
● This entire process is repeated until a pulse returns or the
patient is transferred to definitive care
● To prevent provider fatigue or injury, new providers should
intervene every 2-3 minutes (ie, providers should swap out,
giving the chest compressor a rest while another rescuer
continues CPR

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In the hospital setting, where patients are in gurneys or beds,
appropriate positioning is often achieved by lowering the bed, having the
CPR provider stand on a step-stool, or both. In the out-of-hospital setting,
the patient is often positioned on the floor, with the CPR provider kneeling
over him or her. Place a hard board behind the chest if patient is in a
u-foam bed .
Fig 7 - CPR board
Class I recommendations specifically for lay responders include the
following​ [​5​] ​
:
● Untrained responders should provide compression-only CPR,
with or without dispatcher assistance
● Compression-only CPR should continue until the arrival of an
AED or responders with additional training
● All responders should, at a minimum, provide chest
compressions for victims of cardiac arrest; in addition, if a trained
lay responder is able to perform rescue breaths, they should be
added in a ratio of 30 compressions to two breaths
Ventilation
If the patient is not breathing, 2 ventilations are given via the provider’s
mouth or a bag-valve-mask (BVM). If available, a barrier device (pocket
mask or face shield) should be used.
To perform the BVM or invasive airway technique, the provider does the
following:
● Ensure a tight seal between the mask and the patient’s face
● Squeeze the bag with one hand for approximately 1 second,
forcing air into the patient’s lungs.

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● Face mask should be held using E-C clamp technique for proper
and tight seal
● Provide ventilation just for adequate chest rise.
● Avoid hyperventilation.
Fig 8 - E -C clamp technique
To perform the mouth-to-mouth technique, the provider does the following:
● Pinch the patient’s nostrils closed to assist with an airtight seal
● Put the mouth completely over the patient’s mouth
● After 30 chest compression, give 2 breaths ( 30:2 cycle of CPR)
● Give each breath for approximately 1 second with enough force
to make the patient’s chest rise
● Failure to observe chest rise indicates an inadequate mouth seal
or airway occlusion
● After giving the 2 breaths, resume the CPR cycle

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Fig 9 - Mouth to mouth breathing
Fig 10 - mouth to mouth breathing using a face shield
Continue five cycles of CPR [ one cycle is 30 compressions and 2 rescue
breaths ]
No pulse check in between
Do pulse and Rhythm check in every 2 minutes or after 5 cycles of CPR
Do give shock as early as possible in a V Fib scenario
What are the complications ?
Complications of CPR include the following:
● Fractures of ribs or the sternum from chest compression (widely
considered uncommon)
● Gastric insufflation from artificial respiration using noninvasive
ventilation methods (eg, mouth-to-mouth, BVM); this can lead to
vomiting, with further airway compromise or aspiration; insertion

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of an invasive airway (eg, endotracheal tube) prevents this
problem
A comprehensive approach to manage cardiac arrest
1. Basic Life Support -BLS
2. Advanced Life Support or Advanced Cardiac Life Support -ALS
/ACLS
3. Post Cardiac Arrest Care -PCAC
Components of BLS
C-Compression
A-Airway
B- Breathing
D-Defibrillation
Components of ALS
A -Advanced airway
B- Breathing and Ventilation
C- Circulation and
pharmacotherapy
D-Differential Diagnosis
Differential Diagnosis in ALS is the reversible causes - H​s &Ts
● Hypovolemia
● Hypoxia
● Hydrogen ion (acidosis):
Consider bicarbonate
therapy
● Hyperkalemia/hypokale
mia and metabolic
disorders
● Hypoglycemia: Check
fingerstick or administer
glucose
● Hypothermia: Check
core rectal temperature
● Toxins
● Tamponade, cardiac:
Check with
ultrasonography
● Tension pneumothorax:
Consider needle
thoracostomy
● Thrombosis, coronary or
pulmonary: Consider
thrombolytic therapy if
suspected
● Trauma

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BLS Algorithm
Fig 11 BLS algorithm
Additional considerations in Pregnancy and Opioid
In ​Pregnancy​ , if uterus is at or above umbilicus perform aortocaval
decompression by manual left uterine displacement or left lateral tilt
if a wedge available .
Use Simultaneous ​C A B U approach​ in hospital arrest . U is uterine
displacement.
In ​Opioid​ -Associated life threatening emergencies Administer
Naloxone as soon as available. Dose 2 mg intranasal or 0.4mg
intramuscular .May repeat after 4 minutes- ​CAB-N approach

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Fig 12 ACLS algorithm
Airway equipment in ACLS
● Airway Adjuvants - Oropharyngeal airway , Nasopharyngeal airway
● BVM- Bag Valve mask [Ambu bag with mask ]
● Suction apparatus

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● Oxygen therapy devices, Oxygen source
● Laryngoscope , Endotracheal tube
● Gum elastic bougie ,Stylet
● Endotracheal tube fixator
● Supraglottic airway devices like LMA, Combitube , Laryngotracheal
airway
● Needle cricothyroidotomy set
● Colorimetric or Waveform capnography
Adjuncts for airway control and ventilation- recommendations
The AHA guidelines provide the following recommendations for airway
control and ventilation​ [​3​] ​
:
● Advanced airway placement in cardiac arrest should not delay
initial CPR and defibrillation for cardiac arrest
● If advanced airway placement will interrupt chest compressions,
consider deferring insertion of the airway until the patient fails to
respond to initial CPR and defibrillation attempts or
demonstrates return of spontaneous circulation
● The routine use of cricoid pressure in cardiac arrest is not
recommended (class III)
● Either a bag-mask device or an advanced airway may be used
for oxygenation and ventilation during CPR in both the
in-hospital and out-of-hospital setting (class IIb)
● For healthcare providers trained in their use, either a supraglottic
airway (SGA) device or an may be used as the initial advanced
airway during CPR (class IIb)
● Providers who perform endotracheal intubation should undergo
frequent retraining (class I)
● To facilitate delivery of ventilations with a bag-mask device,
oropharyngeal airways can be used in unconscious
(unresponsive) patients with no cough or gag reflex and should
be inserted only by trained personnel (class IIa)
● In the presence of known or suspected basal skull fracture or
severe coagulopathy, an oral airway is preferred

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● Continuous waveform capnography in addition to clinical
assessment is the most reliable method of confirming and
monitoring correct placement of an ETT (class I)
● If continuous waveform capnometry is not available, a
non-waveform carbon dioxide detector, esophageal detector
device, and ultrasound used by an experienced operator are
reasonable alternatives (class IIa)
● Automatic transport ventilators (ATVs) can be useful for
ventilation of adult patients in noncardiac arrest who have an
advanced airway in place in both out-of-hospital and in-hospital
settings (class IIb)
Pharmacotherapy in cardiac arrest
Adrenaline​ : The most important drug in Cardiac arrest irrespective of the
initial rhythm. Adrenaline ampoule available as 1:1000 dilution . Dilute it
into 10 by adding 9ml normal saline to make 1 in 10,000 dilution and give
IV push with a chaser of 20 ml saline through a peripheral line . Elevate
limb to enhance flow . If peripheral line is not available use intraosseous
route as the second prefered one .
Amiodarone​: It is the drug used in refractory VFib. When Vib is not
responding to two shocks , give Amiodarone IV 300mg. If amiodarone is
not available , use Lignocaine hydrochloride 1.5mg/kg
The ​2015 AHA guidelines ​offer the following recommendations for the
administration of drugs during cardiac arrest​ [​3​] ​
:
● Amiodarone may be considered for or pVT that is unresponsive
to CPR, defibrillation, and a vasopressor; lidocaine may be
considered as an alternative (class IIb)
● Routine use of magnesium for VF/pVT is not recommended in
adult patients (class III)
● Inadequate evidence exists to support routine use of lidocaine;
however, the initiation or continuation of lidocaine may be
considered immediately after ROSC from cardiac arrest due to
VF/pVT (class IIb)
● Inadequate evidence exists to support the routine use of a
beta-blocker after cardiac arrest; however, the initiation or
continuation of a beta-blocker may be considered after
hospitalization from cardiac arrest due to VF/pVT (class IIb)

15. 15
● Atropine during pulseless electrical activity (PEA) or asystole is
unlikely to have a therapeutic benefit (class IIb)
● There is insufficient evidence for or against the routine initiation
or continuation of other antiarrhythmic medications after ROSC
from cardiac arrest
● Standard-dose epinephrine (1 mg every 3-5 min) may be
reasonable for patients in cardiac arrest (class IIb); high-dose
epinephrine is not recommended for routine use in cardiac arrest
(class III)
● Vasopressin has been removed from the Adult Cardiac Arrest
Algorithm and offers no advantage in combination with
epinephrine or as a substitute for standard-dose epinephrine
(class IIb)
● It may be reasonable to administer epinephrine as soon as
feasible after the onset of cardiac arrest due to an initial
non-shockable rhythm (class IIb)
All drugs and equipment used in cardiac arrest management must be
organised and readily available . This can be done by setting up a crash
cart
Crash Cart
A ​crash cart​ or ​code cart​ (​crash trolley​ in UK medical jargon) or "MAX
cart" is a set of trays/drawers/shelves on wheels used in hospitals for
transportation and dispensing of emergency medication/equipment at
site of medical/surgical emergency for life support protocols (ACLS/ALS)
to potentially save someone's life. The cart carries instruments for
cardiopulmonary resuscitation and other medical supplies .
The contents of a crash cart vary from hospital to hospital, but typically
contain the tools and drugs needed to treat a person in or near cardiac
arrest. These include but are not limited to:
● Monitor/defibrillators, suction devices, and bag valve masks
(BVMs) of different sizes
● Advanced cardiac life support (ACLS) drugs such as
epinephrine, atropine, amiodarone, lidocaine, sodium
bicarbonate, dopamine, and vasopressin

16. 16
● First line drugs for treatment of common problems such as:
adenosine, dextrose, diazepam or midazolam, epinephrine for
IM use, naloxone, nitroglycerin, and others
● Drugs for rapid sequence intubation: succinylcholine or another
paralytic, and a sedative such as etomidate or midazolam;
endotracheal tubes and other intubating equipment
● Drugs for peripheral and central venous access
● Pediatric equipment (common pediatric drugs, intubation
equipment, etc.)
● Other drugs and equipment as chosen by the facility
Fig 13 - Crash Cart
Adult immediate post‒cardiac arrest care[PCAC] after ROSC[Return
of spontaneous circulation]​ [​3​] ​
:
● Optimize ventilation and oxygenation
● Treat hypotension
● Perform a 12-lead ECG to determine whether acute ST elevation
or ischemia is present
● For ST-elevation myocardial infarction (STEMI), perform
coronary reperfusion with PCI
● TTM-Targeted temperature management

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Fig 14 PCAC algorithm
Termination of resuscitation in OHCA may be considered:
● Arrest was not witnessed by EMS personnel
● No return of spontaneous circulation (ROSC) prior to transport
● No AED shock delivered prior to transport
In addition, in intubated patients, ​failure to achieve an end-tidal carbon
dioxide (ETCO​2​) level of greater than 10 mm Hg by waveform
capnography after 20 minutes of CPR​ may be considered as one
component of a multimodal approach to decide when to end resuscitative
efforts.
What are the Chains of Survival
The 2015 update differentiates in-hospital cardiac arrests (IHCAs) from
out-of-hospital cardiac arrests (OHCAs), with separate adult chain of
survival recommendations that identify the different pathways for IHCA and
OHCA and the successful outcome of cardiac arrest survival is depending
on the successful integration of the links of chain of survival

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Fig 15 OHCA chain of survival
OHCA- Out of hospital cardiac arrest chain of survival links
● Recognition of cardiac arrest and activation of emergency response
system
● Immediate high quality CPR
● Rapid defibrillation
● Basic and advanced emergency medical services [EMS]
● Advanced life support and Post arrest care
Fig 16 IHCA chain of survival
IHCA- In hospital cardiac arrest chain of survival - Links
● Surveillance and Prevention - ​[ Rapid Response Team]
● Recognition of cardiac arrest and activation of emergency response
system ​[ Code blue system ]
● Immediate high quality CPR
● Rapid defibrillation
● Advanced life support and Post arrest care

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What is meant by Rapid Response Team
A ​rapid response team​ (​RRT​), also known as a ​medical emergency
team​ (​MET​) is a team of health care providers that responds to
hospitalized patients with early signs of clinical deterioration on
non-intensive care units to prevent respiratory or cardiac arrest. The
health care providers are trained in early resuscitation interventions and
advanced life support and often include a physician, ​nurse​, and
respiratory therapist. The RRT, medical emergency team (MET), critical
care outreach team (CCOT), and rover team are all different forms of the
efferent component of the rapid response system. The team responds to
calls placed by clinicians or families at the bedside who have detected
deterioration.
What is Code blue
"Code Blue" is generally used to indicate a patient requiring resuscitation
or in need of immediate medical attention, most often as the result of a
respiratory arrest or cardiac arrest. When called overhead, the page
takes the form of "Code Blue, (floor), (room)" to alert the resuscitation
team where to respond. Every hospital, as a part of its disaster plans,
sets a policy to determine which units provide personnel for code
coverage. In theory any medical professional may respond to a code, but
in practice the team makeup is limited to those with advanced cardiac
life support or other equivalent resuscitation training. Frequently these
teams are staffed by physicians (from anesthesia and internal medicine
in larger medical centers or the Emergency physician in smaller ones),
respiratory therapists, pharmacists, and nurses. A code team leader will
be a physician in attendance on any code team; this individual is
responsible for directing the resuscitation effort and is said to "run the
code".
What are the CPR and ECC Guidelines available ?
Updated cardiopulmonary resuscitation (CPR) and emergency
cardiovascular care (ECC) guidelines were issued in 2015 by the following
organizations:
● American Heart Association (AHA)
● European Resuscitation Council (ERC)
● The International Liaison Committee on Resuscitation (ILCOR)

20. 20
Cardiac arrest management - A Nutshell
● Scene safety, Personal safety
● Surveillance and Prevention , RRT
● Check responsiveness
● Scan for breathing / Major pulse
● Activate emergency response system, Code blue , Get AED
● Start 30 compression @ 100- 120/mt ,Push hard and Push fast ,
with minimum interruption
● Open airway Head tilt,Chin lift
● Use Jaw thrust in Trauma victims plus protect C spine , No head
tilt
● Give two rescue breaths , Inflate for adequate chest rise , Do not
hyperventilate
● Continue CPR cycle 30 compression and 2 ventilation for 2 minutes
or 5 cycle
● Reassess in every 2 minutes or after 5 cycle for pulse and Rhythm
● Defibrillate at any point when AED or Defibrillator is available
● V Fib and V Tach are the shockable rhythm .
● Use maximum available joules or energy to defibrillate
● PEA and Asystole are the non- shockable rhythms
● Use quality CPR-Shock-Drugs in shockable rhythms
● Use CPR quality CPR and Drug in shockable rhythms
● The drug is Epinephrine in all arrest scenarios
● Use Amiodarone or Lignocaine in refractory V Fib or V Tach
● Use advanced airway and airway adjuvants appropriately
● Search for reversible causes for cardiac arrest in all cases
● Initiate early post cardiac arrest care once ROSC attained
References
1. https://eccguidelines.heart.org/wp-content/uploads/2015/10/2015-AH
A-Guidelines-Highlights-English.pdf
2. http://emedicine.medscape.com/article/1344081-overview?pa=1YqR
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8bN%2BcxO7EpOPaIuPvmnMeZfhJ1pesD9LOwhd8Mdk7tVO%2Fdk
scsGC4%3D#a1

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3. [Guideline] American Heart Association. American Heart Association.
Web-based Integrated Guidelines for CPR & ECC. Available at
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/​.
October 15, 2015; Accessed: November 21, 2015.
4. [Guideline] Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive
summary: 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. ​Circulation​. 2010 Nov 2.
122 (18 Suppl 3):S640-56. ​[Medline]​.
5. [Guideline] Neumar RW, Shuster M, Callaway CW, et al. Part 1: Executive
Summary: 2015 American Heart Association Guidelines Update for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Circulation​. 2015 Nov 3. 132 (18 Suppl 2):S315-67. ​[Medline]​.