1. bls & als for adults

Basic Life Support for Adults
Prof. Dr. Ram Sharan Mehta, MSND, CON
1
Prof. Dr. RS Mehta, BPKIHS
BLS & ALS

How many times does the human
Heart beat in a day ?
1,00,800 beats per day
(70 beats x 60 minutes x 24
hours = 1,00,800 beats)
2 Prof. Dr. RS Mehta, BPKIHS

BRAIN TISSUE = ?
HEART TISSUE =?
KIDNEY TISSUE=?
CPR=CPCR
CARDIO PULMONARY CEREBRAL RESUSCITATION
Death of Tissue after cutoff oxygen

BLS ALS: steps
A
B
C
D
 D
 E
 F
 G
 H
 I

DEFINITIONS
 CARDIAC ARREST: Abrupt cessation
of cardiac pump function which may
be reversible by a rapid intervention
but will lead to death in its absence.
 DEATH: Irreversible cessation of all
biologic functions

CARDIAC:
 Coronary artery disease
 M.I.
 Arrhythmia
 Low C.O.,failure,shock
 Cardiomyopathy
 Myocarditis
 Massive pulmonary
emboli
OTHERS
 Severe anaphylaxis
 Suffocation
 Electrocution
 Trauma
 Stroke
 Exsanguinations
 Drowning
CAUSES OF CARDIAC ARREST

REVERSIBLE CAUSES OF
CARDIAC ARREST:
4 Ts:
 Thromboembolism
Tension
pneumothorax
Tamponade
Toxicity(TCAs,b-
blockers,ca channel
blocker,dogoxin)
4Hs:
Hypoxia
Hypovolemia
Hypo/hyperkalemia
Hydrogen ions

Introduction:
 Lack of resuscitation skills of nurses and doctors
in basic life support (BLS) and advanced life
support (ALS) has been identified as a contributing
factor to poor outcomes of cardiac arrest victims.
 The hypothesis was that nurses’ knowledge on
BLS and ALS would be related to their
professional background as well as their
resuscitation training.

Introduction...
 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 – double or triple survival
from sudden cardiac arrest (SCA).
 Early resuscitation and prompt defibrillation
(within 1-2 minutes) can result in >60% survival

CHAIN OF SURVIVAL

BASIC LIFE SUPPORT
 Sequences of procedures performed to restore
the circulation of oxygenated blood after a
sudden pulmonary and/or cardiac arrest
 Chest compressions and pulmonary ventilation
performed by anyone who knows how to do it,
anywhere, immediately, without any other
equipment
Protective devices

BLS
 Its Cardiopulmonary Resuscitation (CPR).
 Combines rescue breathing and chest
compressions
 Revives heart (cardio) and lung
(pulmonary) functioning
– Use when there is no breathing and no pulse
 Provides O2 to the brain until ACLS
arrives
12Prof. Dr. RS Mehta, BPKIHS

How CPR Works
 Effective CPR provides 1/4 to
1/3 normal blood flow
 Rescue breaths contain 16%
oxygen (exhaled).

Start CPR Immediately
 Better chance of survival
 Brain damage starts in 4-6
minutes
 Brain damage is certain after
10 minutes without CPR

Do Not Move the Victim Until CPR is
Given and Qualified Help Arrives…
 unless the scene dictates
otherwise
– threat of fire or explosion
– victim must be on a hard surface
– Place victim level or head slightly
lower than body

Even With Successful CPR, Most
Won’t Survive Without ACLS
 ACLS (Advanced
Cardiac Life
Support)
 ACLS includes
defibrillation,
oxygen, drug
therapy

17
BLS = CPR = ABC?
DRS CAB D

Basic Life Support (BLS)
ABCs - Airway, Breathing, Circulation
 Steps to follow in BLS
– Approach Safely
– 1. Check the responsiveness of the victim
– 2. Call for Help
– 3. Position victim on his or her back
– 4. Open the airway
– 5. Assess breathing
– 6. Assess circulation
– 7. Stay with the victim until help arrives.

Details of the Steps:

APPROACH SAFELY!
Scene
Rescuer
Victim

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

SHOUT FOR HELP

Open the airway with the head tilt-
chin lift method to check for
breathing.
Check for Breathing

OPEN AIRWAY
Head tilt and chin lift
- lay rescuers
- non-healthcare rescuers
No need for finger sweep
unless solid material can be
seen in the airway

Look, listen and feel for breathing
for not over 10 seconds.
Check for Breathing

OPEN AIRWAY
Head tilt, chin lift + jaw thrust
- healthcare professionals

Head Tilt–Chin Lift Maneuver
Step 1 Step 2
Step 3 Step 4

Jaw-Thrust Maneuver
Step 1 Step 2
Step 3

Use a barrier device of some type
while giving breaths.
Giving Breaths

Give 2 breaths, each for about 1
second, watching the chest rise
and fall.
Giving Breaths

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

RESCUE BREATHS
RECOMMENDATIONS:
- Tidal volume
500 – 600 ml
- Respiratory rate
give each breaths over about 1s with enough
volume to make the victim’s chest rise
- Chest-compression-only
continuously at a rate of 100 min

Pocket mask vs bag-valve mask
• Easy to use and
easily available
• One way valve
• Can give O2 up to
50%
Pocket
mask
• Takes more skill and
requires 2 people in
most cases
• Can give O2 up to
85%
Bag-
valve
Mask

Give 30 chest compressions, hard
and fast, positioning hand
midway between breasts.
Giving Chest Compressions

Use cycles of 2 breaths and 30
compressions.
Cycles of
Breaths/Compressions
2 breaths +
30 compressions

• Place the heel of one hand in the
centre of the chest
• Place other hand on top
• Interlock fingers
• Compress the chest
– Rate 100 min-1
– Depth 4-5 cm
– Equal compression : relaxation
• When possible change CPR
operator every 2 min
CHEST COMPRESSIONS

CONTINUE CPR
30 2

DEFIBRILLATION

Date
East of England Ambulance Service
NHS Trust
BLS & AED
12/02/201540
Understanding Defibrillation
 The heart’s pumping
action controlled by
electrical system
 Electrical rhythm normally
very organized
 Normal heart’s rhythm is
called “Sinus Rhythm”
 Normal heart rate of 60 -
100 beats per minute
Sinus Rhythm

Date
NHS Trust
BLS & AED
12/02/201541
Understanding Defibrillation:
Ventricular Fibrillation (VF)
 VF is the most common
rhythm in Sudden
Cardiac Arrest (90%)
 Electrical Problem in
Nature
 Chaotic rhythm results in
“quivering of heart” and
results in loss of pulse
 VF will result in brain
damage within 5 minutes
and death in 10-15
minutes

Date
NHS Trust
BLS & AED
12/02/201542
Understanding Defibrillation
 Defibrillation may correct VF
 Uses DC current delivered
across the heart
 A successful defibrillation
“depolarizes” the heart’s
cells
 Depolarization allows the
cells to “reorganize”
 Defibrillation is the ONLY
effective cure for VF!

DC Shock: Joules
AED OR Defibrillation Machine
 150-360 Joules: Monophasic
 150-270 Joules: Biphasic

Use the AED as soon as it is
available and ready to use.
Use of an AED
Automated External Defibrillator44 Prof. Dr. RS Mehta, BPKIHS

Follow the AED prompts to give a
shock, then give CPR again
while the AED is analyzing the
victim’s rhythm.
Using AED and CPR

First turn it on.
Then simply follow instructions.
Using an AED

AUTOMATED EXTERNAL
DEFIBRILLATOR (AED)
 Some AEDs will
automatically switch
themselves on when
the lid is opened

ATTACH PADS TO
CASUALTY’S BARE CHEST

ANALYSING RHYTHM
DO NOT TOUCH VICTIM

SHOCK INDICATED
 Stand clear
 Deliver shock

SHOCK DELIVERED
FOLLOW AED INSTRUCTIONS
30 251 Prof. Dr. RS Mehta, BPKIHS

NO SHOCK ADVISED
FOLLOW AED INSTRUCTIONS
30 252 Prof. Dr. RS Mehta, BPKIHS

IF VICTIM STARTS TO
BREATHE NORMALLY PLACE
IN RECOVERY POSITION

DEFIBRILLATION SAFETY !
 THE PATIENT.
 5 point check
 Pacemaker
 Jewellery
 Hair on chest
 Damp/Wet skin
 Patches (GTN)
 THE AED.
 In good working order
 Do Not use in Heavy
rain
 Do Not use if they lay in
a pool of water
 Do Not use in an
explosive environment !

If the victim responds, position him
in the recovery position and
monitor breathing until help
arrives.
The Recovery Position
Infant Recovery Position

Complications of CPR
 Skeletal injuries especially rib#
 Visceral injuries- myocardial and pulmonary
contusions, blood in pericardial sac,
pneumothorax, liver and spleen rupture, gastric
perforation
 Airway injuries- tracheal & laryngeal injuries
 Skin and integument damage

Immediately after CPR…
 Laryngoscopy; 100% oxygen
 Urinary catheter
 NG tube
 establish or verify existing intravenous
access; start with NS
 Transfer to a special care unit for
continuous monitoring and therapy.

After CPR…
Complete exam including
– serial vitals
– urine output
– 12-lead ECG
– Chest x-ray
– Blood glucose
– Serum urea,
creatinine
– serum electrolytes
(+Mg++ and Ca++)
– Cardiac markers

Atropine, Adrenaline, CaCl2,
Digoxin
 Atropine: 5 amp (3 mg) single bolus dose to
increase heart rate
 Adrenaline: 1 ml=1mg, 1amp=1:1000 dilution,
1gm=1000mg, 1000mg=1000ml 1mg every 2-3
min till B P is maintained
 Cacl 2= 5-10 mmol
 Digoxin = 0.5 mg stat then 0.25 mg 6hrly

Factors contributing to cardiac arrest or complicating
resuscitation or post-resuscitation care
H’s
 Hypovolemia
 Hypoxia
 H+ (acidosis)
 hyper-/hypokalemia
 Hypoglycemia
 hypothermia
T’s
 Toxins
 tamponade (cardiac)
 tension pneumothorax
 thrombosis of coronary or
pulmonary vasculature
 trauma

Prognosis
5 clinical signs strongly predicting death or
poor neurological outcome:
No corneal reflex at 24 hours
No pupillary response at 24 hours
No withdrawal response to pain at 24hours
No motor response at 24 hours
No motor response at 72 hours

 Stroke (first 2 hours are critical)
 Asthma (check for inhalers)
 Fainting (look for injuries from fall)
 Seizures (check for medication)
 Diabetic emergencies
 Chocking
 Poisoning
First Aid Management for Common Problems:

CONTINUE RESUSCITATION UNTIL
– Qualified help arrives and takes over
– Victim revives: The victim starts
breathing normally
– Rescuer becomes exhausted
– Cardiac arrest of longer than 30 minutes
(controversial)

Summary

Simplified adult BLS algorithm.
Robert A. Berg et al. Circulation. 2010;122:S685-S705
Copyright © American Heart Association, Inc. All rights reserved.66 Prof. Dr. RS Mehta, BPKIHS

BLS healthcare provider algorithm.
Robert A. Berg et al. Circulation. 2010;122:S685-S705
Copyright © American Heart Association, Inc. All rights reserved.67 Prof. Dr. RS Mehta, BPKIHS

• “Look, listen, and feel for breathing” has been
removed from the algorithm.
• Continued emphasis has been placed on high-
quality CPR (with chest compressions of
adequate rate and depth, allowing complete
chest recoil after each compression minimizing
interruptions in compressions, and avoiding
excessive ventilation).
Key Issues and Major Changes

 To initiate chest compressions before giving
rescue breaths (C-A-B rather than A-B-C).
 Compression rate should be at least 100/min
(rather than “approximately” 100/min).
 Compression depth for adults has been
changed from the range of 1½ to 2 inches to at
least 2 inches (5 cm).

 BLS only provides 15 to 20% of normal cardiac
output and should be regarded as “buying time”
until the commencement of ALS.
 If there is more than one rescuer present ,
another should take over the CPR every 1 to 2
minute to prevent fatigue.

ALS
Prof. Dr. RS Mehta, BPKIHS73

ALS ALGORITHM

 Circulation by cardiac compression
Airway management by equipments
 Breathing by advanced techniques
 Defibrillation by manual defibrillator
 Drugs.
75
ALS includes:

Chest compression:
- rate- 100/min
- Place- mid of sternum
- Depth- at least 5 cm
(2inches)
- or 1/3rd of AP diameter of chest
- No synchrony with respiration
Circulation

• The precordial thump should not be used for
unwitnessed out-of-hospital cardiac arrest.
• The precordial thump may be considered for
patients with witnessed, monitored, unstable
VT (including pulseless VT) if a defibrillator is
not immediately ready for use, but it should not
delay CPR and shock delivery.
Precordial Thump

1) Guedel’s airways- Most commonly used
78
A. Airway management

2) Laryngeal Mask Airways
Airway management

3) Endotracheal tube
Airway management

 Breathing can be accomplished by
1.Bag and mask ventilation
2.Ventilation by advanced method:
a.ET tube: Intubation is most definitive
and best method for ventilation.
b.LMA
c.Tracheostomy tube
3. Ventilation by automatic ventilators.
81
B. Breathing:

Bag and Mask Ventillation

It consists of self inflating bag made up of
rubber or silicon, connector, safety valve,
mouth piece.100% oxygen can be delivered
by AMBU bag by attaching oxygen source
and oxygen reservoir.
83
Artificial Manual Breathing
Unit(AMBU)

 These are the treatment for tachydysrhythmias.
 Defibrillation depolarize the critical mass of
myocardial cell at once. When they repolarize the
sinus node recapture its role as the pacemaker .
 Is treatment of choice for pulseless VT/VF.
Defibrillation

85
Ventricular tachycardia

86
Ventricular fibrillation

Defibrillators can be classified as :
Monophasic(delivers current
of one polarity only and
Biphasic (deliver current of 2
polarity)
Defibrillator

Position of defibrillator paddle:
88
 1st paddle - on the
right side of the chest
just below the
clavicle
 2nd at precordial,
region.
 Paddle should be
applied with pressure
equivalent to 10 kg.

 Adult: 13cm
 Children:8cm
 Infants:4.5cm
Latest Recommendation for shock protocol ;
Previous recommendation of 3 successive shock
(200,300,360J)
Now a days only single shock is recommended .i.e.
360J by monophasic
150-200J by biphasic
89
Paddle size

 Apply conducting jelly between the paddle and the skin.
 Place the paddle so that they don't touch patient’s
clothing and bed linen and aren't near medication and
direct oxygen flow.
 Ensure that defibrillator is not in synchronized mode.
 Don't charge the device until ready to shock; then keep
the thumbs and fingers off discharge button until paddle
are on the chest.
90
Nurses role while performing
defibrillation

 Before pressing the discharge button call “ all
clear” 3 times
1st clear: Ensures you aren’t touching
patient,bed, equipment
2nd clear: Ensures no one is touching patient,
bed , equipment
3rd clear: Ensures you and everyone else are
clear off the patient and anything touching the
patient.
91
Nurses role in defibrillation

 Record the delivered energy and the
results (cardiac rhythm and pulse).
 After the event is complete inspect
the skin under the pads and paddles
for burns , and if any detected
consult about the treatment.
92
Nurses role in defibrillation

1. Adrenaline(all types of cardiac arrest)- 1mg
every 3-5 mins
2. Amidarone(VF,VT)- 1st dose:300mg IV bolus,
2nd dose 150 mg
3. Lidocaine(If Amidarone isn’t available)
4. Sodium bicarbonate(only if cardiac arrest is
associated with hyperkalemia or tricyclic anti-
depressent overdose)
5. Calcium gluconate
93
DRUGS

 Class : Adrenergic
 MOA : Causes Cardiac stimulation
 Indication : cardiac arrest
 Dose : Adults – 0.5-1 mg IV
- repeat every 5min
- Children – 10 mcg/kg
 Adverse reaction : nervousness , tremor, headache,
drowsiness , palpitation , tachycardia , dyspnea .
94
Adrenaline (Epinephrine):

 Class : Ventricular antiarrhythmic
 MOA : abolishes ventricular arrhythmia
 Indication : recurrent VF , unstable VT , atrial
fibrillation
 Dose : 300mg IV ; further 150mg may be
given , followed by an infusion of 900mg for
24 hour.
95
Amiodarone:

FLOWCHART OF ACLS

Unresponsive
Call for
help(monitor/defribillator)
Start BLS algorithm
Attach monitor & defibrillator
when available
Check rhythm

Shockable
VT
VF
Non-
shockable
Asystole
PEA
98
Rythm

VF and VT

10
0
Asystole and PEA

SHOCKABLE(pulseless VF/VT)
1stShock (150-200 biphasic, 360 monophasic)
CPR 30:2(2min)
If VF,VT persists
2nd Shock( 150-360 biphasic, 360 monophasic)
CPR30:2(2 min)
10

Check monitor(if
VT,VF persists)
Adrenaline 1mg
IV every 3-5min
3rd
Shoc
k
CPR 30:2(2 min)
Check monitor(if
VT,VF persists)
Amidarone(300
mgIV)
4th Shock
CPR 30:2 (2 min)
Adrenaline 1mg IV102 Prof. Dr. RS Mehta, BPKIHS

5th shock
Further shock after each
2 min period of CPR
If organised electrical
activity seen,check for
pulse
If pulse present:start post resuscitation care
If no pulse and asystole seen :continue CPR and
switch on to non shockable rhythm

 Start CPR 30:2
 Give adrenaline 1mg as soon as intravascular
access is achieved.
 Continue CPR 30:2 until the airway is secured,
then continue chest compressions without
pausing during ventilation
 Consider possible reversible causes and
correct any that are identified
Management of Asystole and PEA
10

 Recheck the patient after 2 min:
 If there is still no pulse and no achange in the ECG
appearance:
- Continue CPR.
- Recheck the patient after 2 min and proceed
accordingly.
- Give further adrenaline 1 mg every 3-5 min (alternate
loops).
- If VF/VT, change to the shockable rhythm algorithm.
- If a pulse is present, start post-resuscitation care.
Management of Asystole and PEA
10

WHEN TO STOP RESUSCITATION
10

 Optimizing vital organ perfusion
 Maintain o2 saturation more than or equal to 94%
 Transport to comprehensive post arrest system of care
 Emergent coronary reperfusion for high suspicion of
STEMI or AMI
 Temperature control
 Aniticipation, treatment and prevention of multi organ
dysfunction
10
7
POST RESUSCITATION CARE

Thank you
10
8
The woods are lovely dark and
deep but, I have promises to keep
and miles to go before I sleep and
miles to go before I sleep
-Robert Frost

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