Cardio Pulmonary Resuscitation

The short what to do guide

Author : Dr F Malan
June 2012

Introduction
Why do CPR?

Basic Life Support Principels

Advance Cardiac Life Support Algorhythms

AED vs. Defib

Airway Management Devices

Drugs

Information and Graphics adapted from the BLS and ACLS Guidelines of the American Heart
Association 2010 and the South African Resuscitation Guidelines 2012

Why do CPR?
What happens during cardiac arrest?

Blood flow stops = no oxygen or substrate delivery to cells

Ischemic cell injury follows
If condition persists, cell death occurs
CNS very fragile = cell death after 3-5 minutes =
permanent neurological damage
Cardiac muscle stops contracting after 1 minute but only
dies after 40-60 minutes

Why do CPR?
Why must we start Chest compressions as soon
as possible?
Generates blood flow = less tissue ischemia
Improves survival and lessens neurological deficit
Buys time to reverse treatable conditions
The sooner CPR is started and the first shock delivered, the
better the chances of ROSC and thus survival (time = brain
+ heart)
No drug has been proven to increase survival!!

Why do CPR?
Scary Statistics
In-hospital cardiac arrest has an average survival rate of
21%
80% of patients with ROSC after cardiac arrest that are
admitted to ICU die before discharge
Survival rate is very poor for cardiac arrest associated with
rhythms other than VF/VT unfortunately >75% of inhospital arrests are due to non-VF/VT rhythms

Why do CPR?
Even Scarier Statistics
80% of patients who had a cardiac arrest had abnormal
vitals for up to 8 hours prior to arrest
Only 44% of patients urgently admitted to ICU before
cardiac arrest die before discharge

Very Important!!

Prevent Cardiac Arrest Rather

than Treating it!

What are the danger signs of a possible

cardiac arrest?

Threatened airway
Respiratory rate <6 or >30
Heart rate <40 or >140
SBP <90mmHg
Symptomatic hypertension
Significant fall in urine output
Decrease in GCS/Unexplained agitation/Seizure

And the Patient arrests.

I am alone!
What now?

Basic Life Support Principels

Step 1

Step 2

Check responsiveness
Check for absent/abnormal breathing

Get Help!!
Send for AED/Defib

Step 3

Check the carotid pulse for 5-10 seconds

If no pulse (or unsure of pulse) = start chest compressions
If pulse present = Give rescue breaths at 1 breath every 5-6 seconds and check pulse every
2 minutes

Step 4

Shock if needed
Follow each shock immediately with CPR, beginning with compressions
Check pulse and rhythm after 2 minutes

Step 1:
Check responsiveness
Are you all right

At the same time check for absent/abnormal

breathing
scan the chest for movement for 5-10 seconds

Step 2:
Get help
code blue team

Send for AED/Defib

Step 3:
Check the carotid pulse for 5-10 seconds
If no pulse (or unsure of pulse) = start chest compressions
Compress the lower half of the sternum at a rate of 100/min at a
depth of at least 5cm
Allow complete chest recoil after each compression
Minimize interruptions in compressions (10 seconds or less)
Switch compression providers every 2 minutes
Give breaths at a rate of 2 breaths for every 30 compressions if no
advanced airway is in place or at a rate of 1 breath every 5-6
seconds (8-10 breaths per minute) if advanced airway is in place
AVOID EXCESSIVE VENTILATION!

If pulse present = Give rescue breaths at 1 breath every 5-6

seconds and check pulse every 2 minutes

Step 4:
- No pulse = check for shockable rhythm with
an AED or Defib as soon as it arrives
- Shock as indicated
- Follow each shock immediately with CPR,
beginning with compressions
- Check pulse and rhythm after 2 minutes

The BLS survey

Important Points

Compressions Must be Started First!

PUSH HARD AND PUSH FAST, ALLOW FULL CHEST RECOIL
Defibrillation (if indicated) must be done ASAP!
Avoid interruption of chest compressions
Work in 2 minute cycles
If in doubt = COMPRESSIONS!!!
BLS = CAB AND NOT ABC

I have started CPR, the Defib and help

has arrived.
The patient still has no pulse!!
What next?

Advanced Cardiac Life Support

The Team

Advanced Cardiac Life Support

The universal ABCDs
Airway
Breathing
Circulation
Differential diagnosis

Advanced Cardiac Life Support

A = Airway

Is the airway
patent?

Maintain airway patency in the

unconscious patient

Is an advanced
airway
indicated?

Use advanced airway if needed

Is proper
placement of
airway device
confirmed?

Confirm placement of airway

Is the tube
secured and
placement
reconfirmed?

- Secure the airway

-Monitor airway placement with
continuous quantitative waveform
capnography

Placement of an advanced airway

device can be deferred till later if bagmask ventilation is adequate

Advanced Cardiac Life Support

A = Airway
Assess
Is the airway patent?
Is an advanced airway
indicated?
Is proper placement of the
airway device confirmed?
Is the tube secured and
placement reconfirmed?

Action
Maintain airway patency in
unconscious patients
Head tilt-chin lift/jaw thrust
OPA
NPA

Use advanced airway if

needed

ET-tube
Laryngeal mask
Laryngeal tube
Esophageal-tracheal tube

Advanced Cardiac Life Support

A = Airway
Assess

Action
If bag-mask ventilation is
adequate then the
placement of an advanced
airway device can be
deferred till ROSC or till
initial CPR and defibrillation
attempts fail. Placement
must be weighed against
the adverse effects of
interrupting compressions

Advanced Cardiac Life Support

A = Airway
Assess

Action
Confirm proper integration
of CPR and ventilation
Confirm placement of
advanced airway
Secure the device to
prevent dislodgment
Monitor airway placement
with continuous
quantitative waveform
capnography

PETCO2

A-line

PETCO2
Example of
Poor CPR

A-line

Advanced Cardiac Life Support

A = Airway

Example of
Good CPR

Advanced Cardiac Life Support

B = Breathing

Are ventilation and

oxygenation adequate?

Are quantitative
waveform capnography
and oxyheamoglobin
saturation monitored?

Give supplemental oxygen when indicated

- Monitor adequacy of ventilation and oxygenation

- Avoid excessive ventilation

Advanced Cardiac Life Support

B = Breathing
Asses
Are ventilation and
oxygenation adequate?
Are quantitative waveform
capnography and
oxyheamoglobin saturation
monitored?

Action
Give supplementary oxygen
when indicated
Cardiac arrest = 100% O2
Other = titrate O2 delivery to
achieve SATS >94%

Monitor adequacy of
ventilation and oxygenation
Clinical = chest rise and
cyanosis
Quantitative waveform
capnography
Pulse oxymetry

Avoid excessive ventilation

Advanced Cardiac Life Support

C = Circulation
Are chest
compressions
adequate?

Monitor CPR quality

What is the
cardiac
rhythm?

Attach defib/monitor and check rhythm

Is cardioversion
or defibrillation
indicated?

Provide defibrillation/ cardioversion

Has IV/IO
access been
established?

Is ROSC
present?

Obtain IV/IO access

Advanced Cardiac Life Support

C = Circulation (continued)

Is the patient
with a pulse
stable?

Are medications
needed for
rhythm or blood
pressure?

Give appropriate drugs

Does the patient

need
volume(=fluid)
for
resuscitation?

Give fluids if needed

Advanced Cardiac Life Support

C = Circulation
Assess

Action

Are chest compressions effective?

What is the cardiac rhythm?
Is cardioversion or defibrillation
indicated?
Has IV/IO access been
established?
Is ROSC present?
Is the patient with a pulse stable?
Are medications needed for
rhythm or blood pressure?
Does the patient need
volume(=fluid) for resuscitation?

Monitor CPR quality

Attach monitor/defib for arrhythmias or

cardiac arrest rhythms

Quantitative waveform capnography (aim

for Petco2>10mmHg)
Intra-arterial pressure (aim for
diastole>20mmHg)
Feel for central pulse wave during
compressions

VF/pulseless VT
Asystole/PEA

Provide defibrillation/cardioversion
Obtain IV/IO access
Give appropriate drugs
Give IV/IO fluids if needed

Advanced Cardiac Life Support

D = Differential Diagnosis

Why did the patient arrest

and is there a reversible
cause?

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
Hypothermia

Search for and treat reversible

causes
(Hs and Ts)

Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary

Advanced Cardiac Life Support

D = Differential Diagnosis
Assess
Why did the patient arrest?
Is there a reversible cause
that can be treated?

Action
Search for and treat reversible
cause (=definitive care)

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypo-/Hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary

Advanced Cardiac Life Support

Cardiac arrest rhythms
Cardiac Arrest
Rhythms

Shockable

VF

Pulseless VT

Unshockable

Asystole

PEA

Advanced Cardiac Life Support

Shockable Rhythms
VF

Advanced Cardiac Life Support

Shockable Rhythms
Pulseless VT

Advanced Cardiac Life Support

Unshockable Rhythms
PEA

Asystole

But what if the patient is unstable but

still has a pulse?

Advanced Cardiac Life Support

Dysrhythmia with pulses
Get help
and the
Defib

AIRWAY

BREATHING

Open and
maintain

Give
02/Ventilat
e if needed

Are there
signs of
instability?

ABCDEs

CIRCULATION

Check
pulse, BP
and
perfusion

Attach
monitors

What is the
pulse rate?

DRIP and
DIFFERENTIAL
DIAGNOSIS
Obtain IV
access

Treat
underlying
causes

ECG

Get rhythm
strip/12-lead
ECG

Advanced Cardiac Life Support

Dysrhythmia with pulses
What is the
pulse rate?

Fast
(>150/min)

Normal
(50-150/min)

ECG Rhythm?
ABCDEs

Narrow
QRS-complex

Broad
QRS-complex

Slow
(<50/min)

ECG Rhythm?

Bradycardia
with pulses
algorhythm

Advanced Cardiac Life Support

Tachycardia with pulses
Fast pulse
(>150/min)

Narrow QRScomplex?

Stable?

Wide QRScomplex?

Unstable?

Vagal
stimulation

Unstable?

Stable?

Synchronized
cardioversion
Adenosine
Adenosine or
Amiodarone
Amiodarone

Advanced Cardiac Life Support

Tachycardia with pulses

Normal sinus tachycardia

Advanced Cardiac Life Support

Tachycardia with pulses

Narrow complex tachycardia (SVT)

Broad complex tachycardia

Advanced Cardiac Life Support

Bradycardia with pulses
Slow pulse
(<50/min)

Unstable?

Stable?

Atropine

ABCDs
Transcutaneous
pacing or
Adrenaline

Advanced Cardiac Life Support

Bradycardia with pulses

Advanced Cardiac Life Support

Bradycardia with pulses

Advanced Cardiac Life Support

Bradycardia with pulses

Advanced Cardiac Life Support

Bradycardia with pulses

Advanced Cardiac Life Support

Bradycardia with pulses

Everything went well and the patient

has ROSC. What now?

Drugs

Adrenaline
Atropine
Amiodarone
Adenosine
MgSO4
Bicarb
Ca-chloride/gluconate
Lignocaine