Basic life support


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Basic life support

  1. 1. Basic life support
  2. 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. 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. 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. 5. Types of arrest • Shockable rhythm • Ventricular fibrillation • Pulseless ventricular tachycardia • Unshockable rhythm • Pulseless electrical activity • asystole
  6. 6. Correctable causes of arrest • Hypoxia • Hypothermia • Hypovolemia • Electrolyte imbalance and acidosis • Thrombosis • Cardiac tamponade • Tension pneumothorax • Toxins
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 16. Surface cooling blanket
  17. 17. Automated endovascular cooling devices Transfemoral IVC insersion
  18. 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. 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. 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. 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. 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. 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.
  24. 24. 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.
  25. 25. • 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
  26. 26. • 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
  27. 27. 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.
  28. 28. 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
  29. 29. Oropharyngeal airway insertion
  30. 30. 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.
  31. 31. 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
  32. 32. Nasopharyngeal airway insertion
  33. 33. 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.
  34. 34. 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.
  35. 35. 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
  36. 36. 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.
  37. 37. Applying bag mask
  38. 38. Basic life support
  39. 39. Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  40. 40. 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
  41. 41. 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
  42. 42. CHECK RESPONSE Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  43. 43. 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
  44. 44. SHOUT FOR HELP Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  45. 45. OPEN AIRWAY Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  46. 46. • 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.
  47. 47. CHECK BREATHING Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  48. 48. CHECK BREATHING • Look, listen and feel for NORMAL breathing • Do not confuse agonal breathing with NORMAL breathing
  49. 49. 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
  50. 50. Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  51. 51. 30 CHEST COMPRESSIONS Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  52. 52. •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.
  53. 53. 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
  55. 55. RESCUE BREATHS Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  56. 56. 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
  57. 57. CONTINUE CPR 30 2
  58. 58. Approach safely Check response Shout for help Open airway Check breathing Call 123 30 chest compressions 2 rescue breaths
  60. 60. Call 123 Approach safely Check response Shout for help Open airway Check breathing Attach AED Follow voice prompts
  61. 61. SWITCH ON AED • Some AEDs will automatically switch themselves on when the lid is opened
  64. 64. SHOCK INDICATED • Stand clear • Deliver shock
  68. 68. CPR IN CHILDREN • Adult CPR techniques can be used on children • Compressions 1/3 of the depth of the chest
  69. 69. 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
  70. 70. 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
  71. 71. Basic life support
  72. 72. Automated external defibrillator
  73. 73. 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.
  74. 74. 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
  75. 75. • 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
  76. 76. • 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.
  77. 77. AED sign put on places available
  78. 78. Thank you Dr. Islam Ellakany Emergency medicine specialist Alexandria university