First aid

1. Dr Aggy S. Valentine MD, DA
Senior Consultant in Anaesthesia
Kerala State Health Services

2. CARDIO PULMONARY RESUSCITATION
 Symptomatic therapy aimed at sustaining vital organ
function until natural cardiac function is restored
 Basic Life Support (BLS)
 Advanced Cardiac Life Support (ACLS)
 Post Resuscitation Support

3.  BLS is to maintain cardiac output and vital organ
perfusion.
 ACLS is to diagnose cause of arrest and proceed
to the cause specific treatment while
continuining BLS.

4.  Basic Life Support is the
foundation for saving lives
following cardiac arrest.

5. TIME IS CRITICAL
 4 – 6 min, Irreversible neurological deficit.
 RESUSCITATE HEART , RESTORE
BRAIN
 Move quickly, calmly, do a systematic and
effective resuscitation

6. BLS includes
Recognition of signs of sudden cardiac
arrest.
Cardio pulmonary resuscitation
Defibrillation

7. Adult Chain of Survival

8. Code Blue
To provide immediate life
saving measures in case of life
threatening emergencies.

9. Scope of Code Blue
 It is an event of utmost emergency, a
mode of alerting all medical, nursing,
paramedical and allied health-care
services and other personnel (house-
keeping, bio-medical, transport,
maintenance, security, etc)

10.  Victims of cardiac arrest need immediate CPR.
 Start CPR within 10 seconds of finding a patient
in cardiac arrest.
 Inform and then start CPR
 Trolley should reach within 2 minutes.

11. Adult BLS Sequence
 Before approaching the victim, the rescuer must
ensure that the scene is safe.
 Immediate recognition and activation of the
emergency response system.
 Tap the victim on the shoulder and ask “Are you
alright?”
 If victim responds but is injured, leave victim to
phone for help.

12.  Then come back as soon as possible to check on
the patient.
 If a lone rescuer finds an unresponsive patient ( no
movement in response to stimulation, gasping, no
breathing ) alert emergency services.
 Return to patient, provide CPR, defibrillation if
needed.
 If two or more rescuers present, one begins CPR
while the other phones for help.

13. Pulse Check
 Should take not more than 10 seconds.
 If no pulse felt
within that
period, start
chest
compression.

14. “A-B-C” to “C-A-B”
 This development came in the 2010 CPCR
guidelines
 Adults and Pediatric patients

16. Chest Compressions
 Consists of forceful, rhythmic application of pressure
over lower half of sternum.
 All patients in cardiac arrest should receive
chest compressions

17. How does chest compression
work?
 Chest compressions increase intrathoracic pressure
and directly compresses the heart. This generates
blood flow and oxygen delivery to the heart and
brain.

22. Effective Chest Compressions
 Push hard and push fast.
 100-120 compressions per minute.
 Compression depth – 5cms.
 Allow complete recoil of chest after each
compression to allow heart to fill completely.
 Avoid interruptions in compression.
 Rotate compressor every two minutes.

23.  Compression/Ventilation ratio – 30:2
 Two breaths should take no less than
10 seconds.
 One breath should take just over 1
second.

24. Airway
 To open the airway,
Head tilt
Chin lift.

25. Head tilt, chin lift.

26. Rescue Breaths
 Mouth to mouth or Bag mask.
 Deliver each rescue breath over 1 second.
 Give a sufficient tidal volume to produce
visible chest rise.
 Use a compression/ventilation ratio of 30
chest compressions to 2 ventilations

27. Pocket Mask

28. Ambu bag

30. Early Defibrillation
 Early Defibrillation with AED
Follow AED prompts.
 Interval from collapse to defibrillation is one of the
most important determinants of survival from cardiac
arrest.
 Resume chest compressions immediately after the
shock.

31. Defibrillation
 Defibrillation stuns the heart, briefly stopping cardiac
electrical activity.
 If the heart if still viable, its normal pace maker may
resume firing and produce an effective rhythm.

33. Steps for using AED
• Switch power On.
• Attach paddles.
• Analyze rhythm ( done by AED ).
• Deliver shock ( if advised by AED ).
• Biphasic: 120 – 200J
Monophasic: 300J
• Resume CPR immediately after shock.

35. Conventional Defibrillation
 Power on.
 Attach paddles.
 Analyze rhythm.
 Select joules.
 Charge.
 All clear.
 Deliver shock.

36. To Summarize BLS
 Person collapses
 Confirm Unresponsiveness : Shake &Shout
Scan for breathing
If normal breathing absent
 Activate EMS / Call for help
 Check pulse
 Position the patient & yourself

37. To Summarize BLS
 Start Chest Compression
 After 30 chest compression Open Airway by
Triple maneuver
 Two rescue breaths
 Continue Chest Compression & Ventilation
(30:2) till AED / Manual Defibrillation

38. To Summarize BLS
 Defibrillation ( 360J monophasic or 120-200J
biphasic)
 5 cycles of Compression & Ventilation
 Analyze rhythm
 ACLS

39. ACLS-2015
 Advanced cardiac life support 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
medical emergencies, as well as the knowledge and
skills to deploy those interventions.

40. IMPORTANCE OF BLS IN ACLS
 ACLS is built heavily upon the foundation of BLS

42. Shockable Rhythms
 Ventricular Tachycardia (VT)
 Ventricular Fibrillation(VF)

43. Unshockable Rhythms
 Asystole
 Pulseless electrical activity

44. Ventricular Tachycardia

45. Ventricular Fibrillation

46. Ventricular Fibrillation
 Rate: Rapid- no effective cardiac rhythm
 Rhythm: Irregular
 P, QRS, T- waves: Absent
 No blood pressure

47. Asystole

48. Asystole
 P, QRS, T- waves: Complete absent of
cardiac electrical activity
 Complete absent of effective cardiac
pumping function

49. Pulseless Electrical Activity (PEA)
 PEA rhythm occurs when any organized heart
rhythm that is observed on the electrocardiogram
(ECG) does not produce a pulse.
 Performing a pulse check after a rhythm/monitor
check will ensure that you identify PEA in every
situation

50. Causes of Cardiac Arrest

52.  Failure of a single adequate shock to restore a pulse
should be followed by continued CPR and second
shock delivered after five cycles of CPR
 If cardiac arrest still persist- patient is intubated and
IV/IO access achieved

53. Intubation

54. LMA

55. i-gel

56. i-gel

57. Routes of administration
Peripheral IV – easiest to insert during CPR, must
followed by 20 ml NS push
Central IV – fast onset of action, but do not wait or
waste time for CV line
Intraosseous – alternative IV route in peds, also in
adult
Intratracheally (down an ET tube)- not recommended
now a days

59. Epinephrine (Adrenaline)
• It increases heart rate, stroke volume and blood
pressure
• May help in asystole, PEA and symptomatic
bradycardia
• IV Dose: 1 mg every 3-5 minutes

60. Amiodarone
• Indications: Vtach, Vfib
• IV Dose:
300 mg in 20-30 ml of N/S or D5W
Supplemental dose of 150 mg in 20-30 ml of N/S
Followed with continuous infusion of 1 mg/min
for 6 hours then 0.5mg/min to a maximum daily
dose of 2 grams
• Contraindications:
Cardiogenic shock, profound Sinus Bradycardia,
2nd and 3rd degree blocks that do not have a
pacemake

61. Lidocaine
• Indications:
PVCs, Vtach, Vfib
Can be toxic so no longer given
prophylactically
• IV dose :
1-1.5 mg/kg bolus then continuous infusion
of 2-4mg/min
Can be given down ET tube
• Signs of toxicity:
slurred speech, seizures, altered
consciousness

62.  Oxygen
• FIO2 100%
• Assist Ventilation
• O2 Toxicity should not be a concern during ACLS
IV Fluids
Volume Expanders
• crystalloids , e.g. Ringer’s lactate, N/S

63.  Vasopressin (ADH)- is out according to 2015
guidelines for ACLS
 Sodium Bicarbonate
• Used for METABOLIC acidosis / hyperkalemia
• IV Dose: 1 mEq/kg
• Side effects:
Metabolic alkalosis
Increased CO2 production

64. Monitoring during CPR
Physiologic parameters
 Monitoring of PETCO2 (35 to 40 mmHg)
 Abrupt and sustained increase is a sensitive
indicator of ROSC that can be monitored without
interrupting chest compressions

65. ROSC
 Abrupt and sustained increase in ETCO2 (typically
greater than 40mm Hg)
 Palpable pulse.
 Assess BP. Maintain BP with fluids and vasopressor
 Obtain 12- lead ECG.
 Maintain SpO2 greater than 94%

67.  Does the patient follow commands ?
No – Consider induced hypothermia
Yes – STEMI or high suspicion of AMI
Advanced critical care
Coronary reperfusion

70. HAVE A HEART... SAVE A LIFE !!

72. THANK YOU