Continue CPR immediately after shock for 2 minutes before reanalysis Operator: Thank you for the reminder. Yes, CPR should be resumed immediately after shock delivery for 2 minutes before reanalysis.

1. RAKHI DAS
I YEAR MSc NURSING
JUBILEE MISSION COLLEGE OF NURSING
THRISSUR, KERALA, INDIA

2. INTRODUCTION
 THE PROVISION OF BASIC LIFE SUPPORT –
AIRWAY MAINTENANCE, VENTILLATORY
ASSISTANCE AND EXTERNAL CHEST
COMPRESSION ARE THE FIRST STEPS TOWARD
FACILITATING SURVIVAL FOR A VICTIM OF
CARDIOPULMONARY ARREST. THE VICTIM ONCE
STABILIZED WITH THESE MANEUVERS MAY NEED
THE SUPPORT OF ADVANCED LIFE SUPPORT.
 RESUSCITATION APPARENTLY MEANS –
“BRINGING BACK TO LIFE” OR “REVIVE TO
SUSTAIN”

3. DEFINITION
 CARDIOPULMONARY RESUSCITATION (CPR) 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

4. DEFINITION
 ADVANCED CARDIAC LIFE SUPPORT
(ACLS) OR ADVANCED CARDIOVASCULAR LIFE
SUPPORT (ACLS) REFERS TO A SET OF CLINICAL
INTERVENTIONS FOR THE URGENT TREATMENT
OF CARDIAC ARREST, STROKE AND OTHER LIFE-
THREATENING CARDIOVASCULAR EMERGENCIES,
AS WELL AS THE KNOWLEDGE AND SKILLS TO
DEPLOY THOSE INTERVENTIONS.

5. Difference between BLS and ACLS
BLS
 Non- invasive
 No medications
administered
 Can be done by anyone
trained
 No advanced equipments
 Two person/ technician
suffice
 No right to give basic
treatment
ACLS
 Invasive maneuvers
 Along with medications
 Medical personnel
specialized
 Defibrillator, cardiac
monitors used
 Team of workers- doctors,
nurses, paramedic,
emergency medical
technician
 Basic treatments for cuts
and injuries can be given

6. GUIDELINES FOR CPR AND ACLS

7. PRE REQUISITES FOR PERFORMING
ACLS
 ONLY QUALIFIED HEALTH CARE PROVIDERS CAN
PROVIDE ACLS, AS IT REQUIRES
 ABILITY TO MANAGE THE PERSON'S AIRWAY
 INITIATE INTRAVENOUS (IV) ACCESS
 READ AND INTERPRET ELECTROCARDIOGRAMS
 UNDERSTAND EMERGENCY PHARMACOLOGY

8. The resuscitation team
 ROLES PLANNED IN ADVANCE
 IDENTIFY TEAM LEADER
 IMPORTANCE OF NON- TECHNICAL SKILLS
 TASK MANAGEMENT
 TEAM WORKING
 SITUATIONAL AWARENESS
 DECISION MAKING
 STRUCTURED COMMUNICATION
 DEBRIEF AFTER EVENT

9. CARDIO-PULMONARY
RESUSCITATION & BASIC LIFE
SUPPORT
 SERIES OF ACTIONS AND SKILLS
 BASED ON ASSESSMENT FINDINGS
 D – R – S
 A – B – C- D

11. CPR

12. SCENARIO EXAMPLE
 YOU FIND AN ADULT LYING ON THE GROUND –
CHECK RESPONSIVENESS
 IF UNRESPONSIVE – CALL + POSITION (1PERSON,
2PERSON)
 CIRCULATION – ADULT (CAROTID), INFANT
(FEMORAL/BRACHIAL)
 IF PULSE- airway and rescue breathing
1 BREATH / 10 SECOND, RECHECK PULSE EVERY 10
MINUTES

13. SCENARIO EXAMPLE
 NO PULSE – START CPR
 100 to 120 compressions per minute
 30 compressions every 15 to 18 seconds
 Place palms midline, one over the other, on the lower
1/3 of the patient’s sternum between the nipples- lock
arms
 to 2.4 inches (5-6cm) or more – ADULT
 1.5 inches or 1/3 the depth – INFANT
 Press hard and fast

14.  Allow for full chest recoil with each compression
 Swap CPR provider(two men) every 2 minutes
 Allow for only minimal interruptions to chest
compressions
 The compression-ventailation ratio is 30:2
 CPR should continue between rhythm checks and
shocks, and until the ACLS team arrives or the victim
shows signs of movement.

15. AIRWAY MANAGEMENT
 Airway maneuvers

16. AIRWAY MANAGEMENT

17. AIRWAY MANAGEMENT
 AMBU Bag (artificial maneuver breathing unit)

18. AIRWAY MANAGEMENT
 LMA (laryngeal mask airway)

19. BREATHING
 Scan and Watch
 breathing adequately - maintain a patent airway and
place the patient in the recovery position
 not breathing or is breathing inadequately – pulse
present - rescue breaths
 no pulse - Begin CPR

20. BREATHING

21. CHOKING

22. CHOKING
If partial airway obstruction:
 Do not attempt Heimlich maneuver
If complete airway obstruction:
 Send someone to call the emergency response team
If alone:
 immediately call the emergency response team.
 Attempt Heimlich maneuver

23. CHOKING

25. RECOVERY POSITION
 lateral recumbent or 3/4 prone position

27. DEFIBRILLATE
Arrival of the AED (Automated External Defibrillator)
 Turn AED On
 early defibrillation is the single most important
therapy for survival of cardiac arrest and should be
done as soon as it arrives
 Follow verbal AED prompts

28. DEFIBRILLATE
 Attachment
 Analyze
 If the rhythm is not shockable
 If the shock is indicated-
 Assure no one is touching the patient or is in mutual
contact of a good conductor of electricity by yelling
“Clear, I’m Clear, you’re Clear!” prior to delivering a
shock
 Press the shock button when the providers are clear of
the patient
 Resume 5 cycles of CPR

29.  Defibrillation
 In ventricular fibrillation, a precordial thump is
employed by giving sternum to a height of 8-12
inch
 If rhythm reverts – inj lidocaine 0.2% is given IV
 If VF persists, proceed to BLS and defibrillation

30.  Electrical defibrillation
 Passing of electric current through a fibrillating heart
allowing for uniform depolarization and organized
cardiac activity
 Conductive jelly should be applied before placing the
paddles
 Energy level is selected in joules (100-300)
 Clear the area in contact with patient or cot
 Evaluate effectiveness and administer Inj. Epinephrine
and Sodium bicarbonate

31.  Electrocardiograph (ECG)
 essential in resuscitation
 defibrillators have in-built monitor circuit to assess ECG
 Patient ECG pattern are sensed and command follow for
shock
 For continuos monitoring, standard ECG monitors are
used

32.  THE EFFECTIVENESS OF EMERGENCY
CARDIOVASCULAR CARE (ECC)
 CHAIN OF SURVIVAL

33. links in Chain of Survival
 early access
 early CPR
 early defibrillation
 early ACLS

34. CORRECTION OF ACIDOSIS AND
FLUID REPLACEMENT
 Proper venous access
 Peripheral veins may be convenient – if
vasoconstriction and venous collapse; central venous
access made
 Correction of by adequate alveolar ventilation
 Initial dose of sodium bicarbonate is 1mEq/kg slow IV.
Further determined by ABG analysis; formula is 0.3 x
wt (kg) x based deficit
 Volume replacement – isotonic crystalloid for rapid
expansion of circulatory blood volume. Ringer lactate
or Normal Saline

35. TERMINATION OF
CARDIOPULMONARY
RESUSCITATION

36. POST-RESUSCITATION SUPPORT
 Transition from emergency service to critical care unit
 thorough assessment and examination
 Diagnostic studies should be completed
 Ventilatory support is continued at optimal level
 Cardiac support with minimal cardiac work is maintained
with appropriate drugs
 Transportation
 accompanied by a nurse and a physician with adequate
equipment
 Portable ventilators
 If not -AMBU bag with an oxygen source

38. Journal Abstract
Kah MC, Eric HC, Chih-Wei Y, Hui-
Chih W, Edward P, Yen-Pin C et al.
Advanced Cardiac Life Support
(ACLS) Is All About Airway-
Circulation-Leadership-Support (A-
C-L-S): A Novel CPR Teamwork
Model. Originally published 27 Mar
2018 Circulation. 2018; 130:A265

39. https://www.youtube.com/wat
ch?v=jQYHQr3ebLo&feature=yo
utu.be

40. A detailed view…..

41. CENTRAL OBJECTIVE
 By the end of the class, the learner will acquire
adequate technical knowledge and skill for using
defibrillator and will be able to apply this knowledge in
clinical areas skillfully and aid in nursing research with
a positive attitude

42. SPECIFIC OBJECTIVES
 Understand meaning of defibrillator and cardioversion
 Focus on indications and contraindications of defibrilation
 Learn various types of defibrillator and cardioversion
 Enumerate equipments needed for defibrilation
 Identify shockable and non- shockable rhythms
 Acquire skill in performing advanced life support and
defibrillation
 Discuss about nurses responsibilities in preparation of
patient and performing defibrillation
 Demonstrate the procedure of defibrilation
 Incorporate evidence based nursing skills in practice of
Defibrilation and cardioversion

43. Definition- Defibrillation
Defibrillation is non synchronized random
administration of shock during a cardiac
cycle performed to correct life-threatening
arrhythmias of the heart including
ventricular fibrillation and pulseless
ventricular tachycardia

44. Definition - Cardioversion
Cardioversion is a synchronized administration of shock
during the R waves or QRS complex of a cardiac cycle
During defibrillation and cardioversion, electrical
current travels from the negative to the positive
electrode by traversing myocardium
 heart cells to contract
 interrupts and terminates abnormal electrical rhythm
 allows the sinus node to resume normal pacemaker
activity

45. Indications
Indications for defibrillation:
 Pulseless ventricular tachycardia (VT)
 Ventricular fibrillation (VF)
 Cardiac arrest due to or resulting in VF

46. Indications
Indications for electrical cardioversion:
 Supraventricular tachycardia (av node reentrant
tachycardia [AVNRT] and av reentrant tachycardia [AVRT])
 Atrial fibrillation
 Atrial flutter (types I and II)
 Ventricular tachycardia with pulse
 Any patient with reentrant tachycardia with narrow or wide
QRS complex (ventricular rate >150 bpm) who is unstable
(eg, ischemic chest pain, acute pulmonary edema,
hypotension, acute altered mental status, signs of shock)

47. Contraindications
 Dysrhythmias due to enhanced automaticity
 eg: digitalis toxicity, catecholamine-induced
arrhythmia
 Multifocal atrial tachycardia

48. Equipment
 Defibrillators
 Paddle or adhesive patch
 Conductive gel or paste
 ECG monitor with recorder
 Oxygen equipment
 Intubation kit
 Emergency pacing equipment
 Blood pressure cuff
 Pulse recorder
 Oxygen saturation monitor
 Intravenous access
 Suction device
 Code Cart with ACLS medications

52. TYPES OF DEFIBRILATOR
 Advanced life support (ALS) unit

53. TYPES OF DEFIBRILATOR
 Automated external defibrillator (AED)

54. TYPES OF DEFIBRILATOR
 Implantable cardioverter defibrillators (ICDs)

55. TYPES OF DEFIBRILATOR
 Wearable defibrillators

56. TYPES OF DEFIBRILATOR
 Biphasic versus monophasic modes

58. Types of Cardioversion
 Chemical cardioversion
 Electrical cardioversion
Other considerations
 Internal cardioversion
 Cardioversion in patients with digitalis toxicity
 Cardioversion in patients with permanent
pacemakers/ICDs
 Cardioversion during pregnancy

59. NURSES RESPONSIBILITIES
 Patient preparation and sedation
 General instructions
 Patient preparation for elective procedures
 Paddle placement
 Predefibrillation care
 (preparation of defibrillation)
 Post defibrillation care

60. PATIENT PREPARATION AND
SEDATION
 emergent maneuver - promptly performed in
conjunction with or prior to administration of
induction or sedative agents
 no preparation for emergency
 ACLS measures - obtaining intravenous access and
preparing airway management equipment, sedative
drugs, and a monitoring device
 Cardioversion - under induction or sedation (short-
acting agent such as midazolam)unless patient is
hemodynamically unstable or cardiovascular collapse
is imminent

61. GENERAL INSTRUCTIONS
Prevent potential complications while using defibrillator
such as:
 Burns to the patient
 Shock to operator/ other personnel
 Fire / sparks
 Arrhythmias
 Ineffective shock

62. Patient preparation for elective
procedures
 Nil per os (NPO) for 8 hours prior to the procedure
 Stop digoxin 48 hours prior to the procedure
 Continue medications on the morning of the
procedure under the direction of the physician

63. Paddle placement
 2 conventional positions:
 Anterolateral
 a single paddle is placed on the left fourth or fifth
intercostal space on the midaxillary line.
 The second paddle is placed just to the right of the sternal
edge on the second or third intercostal space
 more effective for persistent atrial fibrillation
 Anteroposterior
 a single paddle is placed to the right of the sternum
 other paddle is placed between the tip of the left scapula
and the spine
 preferred in patients with implantable devices

64. Predefibrillation care (preparation
of defibrillation)
 Explain procedure, if patient is conscious or to the
relatives
 Position in supine without any pillow for head
 Confirm cardiac arrest (VT or VF by checking
patient’s clinical condition)
 ensure the cardiac arrest team is alerted; get ready a
defibrillator and cardiac arrest trolley
 Commence cardiopulmonary resuscitation (CPR) at 30
compressions to two ventilations

65. Predefibrillation care
 As soon as the defibrillator arrives, switch it on and prepare
the patient’s chest if necessary. Ensure CPR continues
 Ensure 'synchronize’ mode is off
 Apply self-adhesive defibrillation electrodes to the patient’s
bare chest following the manufacturer’s recommendations.
Ensure CPR continues. If paddles are used, apply
conductive gel to paddles.
 Once the electrodes are in place and are connected to the
defibrillator, ECG analysis can start; depending on the
defibrillator, this will begin automatically or the user will
be prompted to press an ECG analysis button. Briefly stop
CPR

66. Predefibrillation care
 Keep one paddle anteriorly at 2nd intercostals space right
of sternum and another paddle laterally at 5th intercostals
space to left of sternum at midaxillary line or at cardiac
apex. Ensure there is 10 cm distances between paddles
 If a shockable rhythm is detected, ensure the appropriate
shock energy has been selected. Some advisory
defibrillators will do this automatically while others require
the manual check. Most advisory defibrillators will charge
up automatically, while some – typically the older models –
require the operator to press a “charge button”
 Discontinue oxygen inhalation to prevent fire hazards.

67. Predefibrillation care
 Shout “stand clear” and perform a quick visual check
of the area to ensure that all people are clear
 Apply pressure of 25 pounds per paddle. Do not lean
forward.
 Press the shock button to discharge the shock
 Reassess cardiac monitor to determine rhythm and
subsequent action, while paddles are still on chest.
 If VF / VT is still present, reset and increase energy at
200 to 300 J and deliver

68. Predefibrillation care
 If VF/VT is not revered, deliver 360 J and reassess
cardiac rhythm
 When VF/VT persist, administer emergency drugs, e.g.
inj. adrenaline and atropine and give cardiopulmonary
resuscitation (CPR) for 1 minute
 Repeat defibrillation at 360 J for 3 times as ordered
 Discontinue procedure
 Clean and replace paddles for next use

69. Post defibrillation Care
 Assess patient responsiveness/sensorium.
 Check airway, breathing and circulation.
 Monitor cardiac rhythm continuously and assess Vital
signs including BP half hourly until stable.
 Maintain oxygenation.
 Detect arrhythmias and side effects of drugs used
during emergency
 Provide comfort and psychological support to patient
and family

70. Post defibrillation Care
 Administer analgesic as ordered if patient experiences
pain over defibrillation site.
 Document Joules, number of shocks and response of
patient.
 If defibrillation is unsuccessful, explain situation to
family with the help of doctor
 Instruct After the procedure, do not drive, operate
machinery, or sign important documents for 24 hours
and/or until sedation has worn off

71. Complications
 The most common complications are harmless
arrhythmias, such as atrial, ventricular, and junctional
premature beats.
 Serious complications include ventricular fibrillation
(VF) resulting from high amounts of electrical energy,
digitalis toxicity, severe heart disease, or improper
synchronization of the shock with the R wave.

72. Complications
 Thrombo embolization is associated with cardioversion,
especially in patients with atrial fibrillation who have not
been anticoagulated prior to cardioversion. American
Heart Association (AHA) guidelines recommend to
anticoagulate for 3-4 weeks before and after cardioversion.
 Myocardial necrosis can result from high-energy shocks. ST
segment elevation can be seen immediately and usually
lasts for 1-2 minutes.
 Myocardial dysfunction due to an absence of cardiac
output and coronary blood flow during arrest, resulting in
ischemia.

73. Complications
 Pulmonary edema is a rare complication of
cardioversion. It is probably due to transient left atrial
standstill and left ventricular systolic dysfunction. It is
more common in atrial fibrillation due to valvular
heart disease or left ventricular systolic dysfunction.
 Allergic reaction to sedation medication.

74. Complications
 Painful skin burns can occur after cardioversion or
defibrillation; they are moderate to severe in 20-25% of
patients. They most likely are due to improper
technique and electrode placement. It occurs less with
use of biphasic waveform defibrillators and use of gel-
based pads. Prophylactic use of steroid cream or
topical ibuprofen reduces pain and inflammation.

75. JOURNAL ABSTRACT
 Philip W, Kodoth V, McEneaney D, Rodrigues P, Jose
V, Waterman N et al. Towards Low Energy Atrial
Defibrillation. PMCID 2015 Sep; 15(9): 22378–22400

76. BIBLIOGRAPHY
 Sharon L. Lewis , Shannon Ruff Dirksen Margaret
McLean Heitkemper , Linda Bucher, Medical-Surgical
Nursing: Assessment and Management of 9thEdition
 Smeltzer S C, Bare B , Brunner &suddarth’s Medical
surgical nursing, edition 10th, ( 2000), Westline
Industrial drive, Missouri.
 Joyce Black , Jane Hokanson Hawks, Esther
Matassarin-JacobsMedical-Surgical Nursing: Clinical
Management for Positive Outcomes, 7th Edition

77. BIBLIOGRAPHY
 Susan Woods, Erika S Sivarajan, Sandra Underhill,
Elizabeth J Bridges, Cardiac Nursing, 5th Edition,
Lippincott William & Wilkins
 Clement I. Basic concepts of Nursing procedures.
Second edition. New Delhi: Jaypee brothers; 2006
 Johnson Priyadarshini. Clinical Nursing Procedure
manual. Chennai: KVMathew BI publications
 Soni S. Textbook of Advanced Nursing Practice. New
Delhi: Jaypee Brothers

78. BIBLIOGRAPHY
 Philip W, Kodoth V, McEneaney D, Rodrigues P, Jose
V, Waterman N et al. Towards Low Energy Atrial
Defibrillation. PMCID 2015 Sep; 15(9): 22378–22400
 Ventricular Fibrillation and Pulseless Ventricular
Tachycardia
 https://acls-algorithms.com/vfpulseless-vt/

79. EVALUATION….???

80. THANK YOU