2. OBJECTIVES
• How to perform BLS procedures
• How to use AED.
• Know when to stop and when not to initiate CPR.
• Principles of ALS.
• Performing some procedures that may improve
the out come as (ET tube, cricothyroidtomy ,etc..)
• Arrested pregnant,drowing,chocking
• Diagnosing death.

3. BACK GROUND
• Two factors were found to be crucial determinants of survival
from cardiac arrest. The first was the presence of bystanders
able to perform basic life support. The second was the speed
with which defibrillation was performed.
• Early Resuscitation and defibrilation increase survival to 60%.
• Approximately 700,000 cardiac arrest cases seen in eurpe /y.

5. CHAIN OF SURVIVAL

6. Causes of cardiac arrest
• More than 70 % refering to cardiac problems
MI,ACS. ”in europe”.
• REST refering to non
Cardiac as CVA ,electrolyt
Disturbance ,hypothermia

8. Jaw thrust picture

9. breathing

11. Agonal Breathing
• Heavy , noisy and gasping breath.
• It is recognized as a sign of cardiac arrest.
CAROTID PULSE
CHECK IF PRESENT THEN DO RESCUE BREATH 10/MIN
RECHECK BREATH AND PULSE AFTER 1 MIN.

12. • Don’t over ventilate.
• Pericordial thump:
if the onset is witnessed and defibrilator not available
immediately and cardiac arrest confirmed.
• It has a good out come in the first 10 seconds of the
time of the arrest .
• No evidence confirm that HIV may be transferred by
mouth to moth breathing

13. AUTOMATED EXTERNAL DEFIBRILATOR

15. RECOVERY POSITION

16. IN HOSPITAL CARE
• 1- DON’T INTERRUPT CPR.
• 2- SECURE AIR WAY
• 3- IV ACCESS.
• 4- ATTACH VITAL SIGNS MONITOR TO ANALYS
ECG TRACE.
• 5- START ALS .
• 6-FINDOUT AND TREAT THE REVersibles

17. Methods of securing the air way
• tracheal intubation is the optimal method of
providing and maintaining a clear and secure
airway.(should not take more than 30 sec. and if 2
trials failed turn to other methode of airway
securing.
• Gudele air way
• LMA, Combi tube
• Cricothyroidotomy : delivery of oxygen through a
cannula or surgical cricothyroidotomy may be life
saving.

18. Give O2 80-100% 10-12 ml/min and do Spo2
(normal 93%)
We should not forget removing denture and do
suction as needed

19. IV ACCESS
• PERIPHERAL VEIN
• CENTRAL
VEIN(JUGULAR,SUBCLAVIAN,FEMORAL)
• INTEROSSEOUS
• INTRA TRACHEAL

20. APPLY ECG electrodes

21. ALS ALGORITHM

23. VENTRICULAR TACHYCARDIA

24. SHOCKABLE STATE
• VF/VT
1-Attempt defibrillation (one shock - 150-200 J
biphasic or 360 Jmonophasic).
2-Immediately resume chest compressions
(30:2) without reassessing the rhythm or
feeling for a pulse.
3-Continue CPR for 2 min, then pause briefly to
check the monitor:

25. • IF STILL VT/VF.
1-Give a further (2nd) shock (150-360 J biphasic
or 360 J monophasic).
2- PROCEED CPR for 2 min (5 cycle)
CHECK THE MONITOR:
If still VT/VF
1-give adrenalin 1 mg iv
2-give 3rd shock (150-360 J biphasic or 360 J
monphasic)
3- proceed CPR for 2 min

26. • CHECK THE MONITOR
• If still VF?VT
1- give amiodaron 300mg iv
2- give 4th shock (150-360 J biphasic or 360 J
monphasic)
3- proceed CPR
THEN AFTER CHECK EVERY 2 MIN AND GIVE
SHOCK IF STILL VT/VF.
Give adrenalin with alternate shockes (i.e.every
3-5 minutes)

27. • IF BRIEF ELECTRICAL ACTIVITY SEEN IN
PAUSING PERIOD THEN: check the pulse if
pulseless shift to unshockable algorithm.
• If pulse felt thet post resucitation care.
• If asystole develop then non shockable
algorythm.
• Fine VF that is difficult to distinguish from
asystole is very unlikely to be shocked
successfully into a perfusing rhythm

29. NON SHOCKABLE STATE
• Asystole/PEA
Pulseless electrical activity (PEA) is defined as cardiac electrical activity in the absence of
any palpable pulse. These patients often have some mechanical myocardial contractions
but they are too weak to produce a detectable pulse or blood pressure. PEA may be
caused by reversible conditions that can be treated
• 1-start CPR
• 2-give adrenalin 1mg IV.
• 3- check pulse every 2 min
• 4-give adrenalin then every 5 min
• 5- in asystole or PEA 60 bpm give atropin 1 mg IV.
IF VT/VF appear then shift to shockable algorythm
IF pulse palpated and regular rhythm them post res. care

30. Pregnant Resuscitation
• The causes of pregnant arrest: Embolus post
C.Section “amniotic embolism” , sepsis ,
• The problems of CPR in pregnancy; hypertrophied
breast ,enlarged uterus,uterus obstruct IVC.
• We have to put pt. in
Lateral position and dis-
Place uterus laterally. And
Raise pt. legs.

31. • Don’t put paddles into the breast tissues.
• If BLS and ALS not succed in 5 min EMPTY
UTERUS to safe fetus life and decompress IVC.

32. chocking

35. PEDIATRIC CHOCKING

37. DROWING AND PEDIATRIC CPR
• GIVE 5 RESCUE BREATH IN THE BEGINNING.
• AED CAN USED IF PT. BECAME DRY.
• IN PEDIATRIC DO 5 RESCUE BREATH FIRST
THEN PROCEED CPR 15:2 FOR 1 MIN THEN
REASSES SIGNS OF LIFE.

38. REVIRSABLE STATUS
• 4Ts , 4Hs
• HYPOVOLEMIA
• HYPOTHERMIA
• HYPOXIA
• HYPO/HYPER KALEMIA
• TENSION PNEUMOTHORAX
• TEMPONAD
• TOXINES
• THROMBOSIS(coronary,pulmonary)

39. Managing Reversible conditions
• HYPORVOLEMIA:
Usually caused by hemorrhage(trauma as rupture spleen or
rupture aortic anurysm)
excessive diarrhoea and vomiting.
Treated by stop bleeding and fluid replacments:
2000ml NS (PEDIATRICS 100ml/kg) then
start colloids(volume expanders):except in cardiogenic shock
Hemagel , Hypertonic saline7.5% , Dextran.
Blood (if urgent = O -ve)
If still no response start inotrpes.
(BP required for brain perfusion systolic 80 mmHg)

40. • Excessive IV fluid cause : Hypothermia that
precipitate coma and arrythmia, dilutional
coagulopathy and pulmonary edema.
• Aim for systolic = 90
• Raising the foot improve venous return.

41. HYPOXIA
• ENSURE adequate ventilation 100% O2.
• Check chest raise and breath sound.
• Ensure no tracheal disposition as being
inserted into the esophagus.
• Check Spo2 and ABG.

42. HYPOTHERMIA
• Core rectal Temp less than 35 degree Cent.
• Suspect in DRAWING.or excess expose to cold.
• Also in impaired level of conseciousness(eg.
Following alcohole or drug overdose as diuretics
and anti depressants)
• Do axilary thermometry if less than 36.5 Use low
grade thermometer for rectal.
• Ecg may shoe j wave.
Treated by external heating. Or internal heat. Slowly
aiming 1/2 degree C/hour

43. HYPERKALEMIA
• Plasma K more than 6.5mmol/L need urgent tt
• History will make you predict it.as RF,drugs.
• ECG tall tented t wave,wide QRS,VF
• Treated by:
1-10%Ca gluconate 10ml IV over 2 min. repeated as
necesay according to ecg change.
2-insulin + glucose (20units+50ml of 50% glucos)
3-salbutamol inhaler can be used 2.5mg(1/2 ml)
4-calsium resonium.

44. HYPOKALEMIA
• K below 2.5mmol/L need urgent ttt.
• ECG inverted t, st depresion, prolonged PR int.
• IF K more than 2.5 then oral replacment

45. TENSION PNEUMOTHORAX
• May follow attemp for central venous line.
• Diagnosis done clinically
• Thoracocentesis then chest tube.
Temponad
Deficult to diagnose clinically in arrest
victim
Suspected in chest trauma
Do urgent pericardiocentesis

46. THROMBOEMBOLIC
The commonest cause is Masive pulmonary
emboplism.
Treated by thrombolytic drugs immediately.
Give heparin 10000 unit iv bolous if sys BP more than
90 then start warafrin 10mg/24h
If BP less than 90 consider hypovolemia ttt regimen
TOXINES
Rvealed by Lab study.
Treat it by antidots if available or either gastric
aspiration with charcoal.

47. POST RESUSCITATION CARE
• The pt. should be transferred to ICU or CCU.
• If not then put the pt. on Recovery Position.
1-airway and breathing: intubate if not done.
Adjust ventilation by monitoring co2 by ABG.
2- NGT to decompress stomach.
3-CXR: to ensure ET tube position and ensure no
pneumothorax happen by rib fracture at CPR.
4-monitor BPlPR and give IV fluids.
5-inotropes to achive optimal BP and UOP
6-diuretics if HF

48. 7-if coronary thrombus consider thrombolysis or
angioplasty.
8- treat electrolyte disturbance mainly K.
9-control seizure which common in post CPR.
10- sedation if required.
11-treat hyperthermia that commonly occur
post resuscitation by cooling and antipyretics.
12-blood glucose control: by Insulin
There is a strong association between high
blood glucose levels after resuscitation from
cardiac arrest and poor neurological outcome.

49. WHEN NOT START CPR
• Valid DNAR order or advanced directive
• Signs of irreversible death (eg, rigor mortis,
decapitation, decomposition)
• Futility--No expected physiologic benefit(eg,
deterioration of vital functions despite
maximal therapy, pre-hospital blunt trauma
arrest)
• EMS: Danger to the rescuer

50. WHEN STOP CPR
1-Interval B/W BLS and ALS more than 30 min.
(except hypothermia and drug toxicity)
2- asystole who not resond to CPR after 20 min.
3- advance directive by physecian.
4-fatigue.
- If interval B/W arrest and ALS more than 5 min
poor prognosis
- If the pt. received sedatives or hypnotics CPR
time will increased.

52. DIAGNOSING DEATH
• 1-brain stem absence of reflexes
• 2-coma (unresponsiveness) i.e.absence of
motor reflexes
• 3-Determin Etiology and irreversibility of
condition .
• 4-. apnoea with Pco2 more than 60mmHg
• 5- lab tests ; as ECG confirmation.
(source ; American Academy of Neurology 1994)

53. WHO CAN CONFIRM DEATH
These tests should be carried out on two occasions,
the time interval between the tests being a matter of
clinical judgement. The tests should be carried out by
two medical practitioners registered for more than fi ve
years, at least one of whom should be a consultant.
They should be competent in the field and not members
of the transplant team.
• SOURCE (APPLIED BASIC SCIENCE FOR BASIC SURGICAL TRAINING BY Andrew
T. Raftery 2ND Edition)

54. MULTIMEDIA
• CPR DEMO 1
• CPR DEMO2
• ENTUBATION NEJM
• ENTUBATION DEMO
• ABG SAMPLING
• PERICARDIOCENTESIS
• FEMORAL VENOUS CAULATION
• INTERNAL JUGULAR CANULATION

55. References
REFERENCES
* Resuscitation council UK 2005 guidelines
* American Heart Assosciation 2005
guidelines
*ABC of resuscitation by 2004 5thedition
1- By M C Colquhoun, A J Handley and T R
2- *American Academy of Neurology
*Oxford hand book of clinical medicine
3- edition 6.
*APPLIED BASIC SCIENCE FOR BASIC
4- SURGICAL TRAINING BY Andrew T. Raftery
2008 2ND Edition)

56. DR.MOHAMMAD EZADEEN NASSR
HOUSE PHYSECIAN - AL NAW HOSPITAL- SUDAN
(MOHEZDNSR@HOTMAIL.COM)-