Sanjivani CPR and ECC Training

CPR AND ECC TRAINING – SANJIVANI MULTISPECIALITY HOSPITAL
CPR AND ECC TRAINING

SESSIONS
SANJIVANI MULTISPECIALITY
HOSPITAL
Prepared by: Dr Vaishakh Shyam Kumar

OBJECTIVES
- To help equip the nursing staff to handle medical emergencies, efficiently

and scientifically.
- To explain and simplify the recommended guidelines (AHA 2020, ERC 2021)
- To correctly identify a life-threatening emergency and improve
resuscitation measures, to reduce the overall mortality of patients in
Sanjivani Multi Speciality Hospital.
- To acquire knowledge of correctly managing the acutely ill, and develop
life-saving skills and practices which would be extremely useful throughout
your career.
PLAN – WHAT WE WILL COVER (PHASE I)
DAY 1
- What to do during an Emergency?!
o Assess
o Identify/Diagnose – Select the protocol
o Apply
- Systematic approach to assessing a patient
o BLS Assessment
o Primary Assessment (A, B, C, D and E)
o Secondary Assessment (SAMPLE, H’s and T’s)
- Instruments
o OPA, NPA
o Bag-valve-mask with reservoir bag
o Defibrillator
o Devices for intubation (Laryngoscope, ETT, stylet, bougie and
pillow/sheets!)
- Key points of BLS
o Chain of survival
o BLS Algorithm
o Hands-on practical – Compression, Airway, BMV, Defibrillator
o Transitioning to ACLS and Team dynamics
o Paediatric BLS
o Termination of resuscitation
o Chocking
DAY 2
- Quick recap
- ECG rhythms during a Cardiac Arrest
- ACLS – Cardiac arrest algorithm
- Hands-on practical – Team dynamics
- Assisting an intubation
- Review common errors
What to do during an emergency? – Our Goal!

1. Assess:
a. We must learn to make a basic assessment of a patient.
b. The recommended systematic approach is the best way.
2. Identify:
a. We must identify the condition of the patient correctly.
b. Is it a Cardiac arrest (SCA), symptomatic bradycardia or tachycardia,
stroke or MI.
c. Then select the right algorithm.
3. Apply:
a. Once we know the condition we must apply the algorithm the correct
way in the right order.
How can we achieve this among our staff?

- Commit
- Regular revision of CPR and ECC guidelines
- Running regular mock code, and revisions of scenarios
- Apply in the clinical scenarios
Assessment
SYSTEMATIC APPROACH TO A PATIENT
BLS Assessment
1. Responsiveness (Tap and shout. Ask loudly “ARE YOU OK?”)
2. Check Pulse (Carotid in adults & Brachial in infants) and Breathing (Look,
hear, feel technique)
- Determine whether the patient is in Cardio-pulmonary arrest, or only
Respiratory arrest!
Actions: Activate Code/Call EMS, Start CPR, Early Defibrillation
Primary Assessment (ABCDE)
1. Airway: Patent or not. Open, Maintain and Protect
2. Breathing: Type of breathing, RR, SpO2
3. Circulation: Pulse, BP, ECG, Secure IV access
4. Disability: Level of consciousness – AVPU scale, GCS, Pupils, GRBS, Limb
movement
5. Exposure: Injuries, trauma, visible or smell of substance
Secondary Assessment (SAMPLE, 5H’s and 5T’s)
1. Signs and symptoms
2. Allergies
3. Medications
4. Past medical Hx
5. Last meal
6. Events
5H’s 5T’s
Hypovolemia Tension pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen ion (acidosis) Toxins
Hypo/hyperkalaemia Thrombosis, pulmonary
Hypothermia Thrombosis, coronary
zx c
Appearance o Head bobbing

o Nasal flaring
o Tone – Too floppy/stiff
o Apnoea/Gasping
o Interactiveness – Decreased or not
o Consolability – Unable to console Circulation to skin
o Look, gaze – Fixed gaze or not
o Pallor
o Speech, cry – Abnormal or not
o Delayed capillary refill time
Work of breathing o Cyanosis
o Mottling – Sign of sepsis
o Abnormal sounds - stridor, snoring,
o Petechial or purpura
grunting, wheezing
o Abnormal positioning - sniffing, Evaluate by primary, secondary assessment
tripod, refusal to lie down and diagnostic tests
o Retractions – Chest,
supraclavicular/suprasternal
INSTRUMENTS
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1. Oropharyngeal Airway/Gudel Airway
2. Nasopharyngeal Airway
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Measurement –
OPA: From corner of mouth to
angle of mandible
NPA: From tip of nostril to tip of
earlobe
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3. Bag-valve-mask with Reservoir bag/AmbuTM bag/Self-inflating bag
Description
• Self-inflating resuscitation device
• Various sizes e.g. LaerdalTM 240ml, 500ml, 1600ml bag sizes for infants,
children and adults
• High flow oxygen (e.g.. 15L/min) is attached to the system which is in turn
attached to a mask or tube
• Place over mouth and nose in a tight fit
• Open airway using one-handed/two-handed E-C grip, or two-handed two-
thumbs down two-person technique (best if OPA and NPA’s in situ)
• Slow, small squeeze – 6-7ml/kg, over 1-2 seconds, at <12breaths/min, using
low pressure. Enough to produce normal chest rise.
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• If the patient is edentulous, then adjust the position of the mask like so:
Complications
• Easy to hyperventilate patients and limited ability to gauge tidal volumes
• Poor seal is common if one-handed E-C grip is used
• Gastric distension
• Aspiration
• Risk of barotrauma if pop off valve remain closed since we are unable to
feel for lung compliance
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4. Defibrillator
Parts –
1. Power on/off
2. Monitor screen
3. Energy select button
4. Charge button
5. Shock delivery
button (on machine
and/or paddles)
6. Synchronisation
button
7. Electrode paddles
(Sternum and apex)
8. ECG leads
9. Lead select button
10. Printer
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Instruments for intubation –

5. Laryngoscope (Macintosh and Miller)
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6. Stylet
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7. Bougie
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8. Endotracheal Tube (ETT)
The size of an ETT signifies the inner diameter of its lumen in millimetres.
Available sizes range from 2.0 to 12.0 in 0.5 mm increments.
For oral intubations,
Avg. women: Size 7.0-7.5 is generally appropriate
Avg. men: Size 7.5-8.5 is generally appropriate
For nasal intubations, a reduction in size of 0.5-1.0 mm is appropriate
The appropriate paediatric tube size can be calculated using the formula –
ID = (age in years/4) + 4
For example, a size of 6.0 ETT would generally be appropriate for an 8 year-old
patient.
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BASIC LIFE SUPPORT
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WHY GIVE LIFE SUPPORT?

- Death
- Complete, irreversible loss of brain function
- Leading cause of death: Sudden Cardiac Arrest (SCA)
o State of absent circulation, leading to absence of signs of life
- Most common cause for SCA is Ventricular fibrillation
o Defibrillation is the only definitive treatment for VF
- Survival is time dependent
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- Early defibrillation – Greater than 50-70% of SCA victims survive if

defibrillation occurs within the first 5 mins. And for each minute that
passes, there is a 10% less chance of survival.
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Chain of Survival
Cardiopulmonary Resuscitation (CPR)

CPR is the sequence of life saving interventions, which involves providing chest compressions and
delivering breaths to restart the circulation in an unresponsive patient who does not have spontaneous
breathing and doesn’t have a pulse.
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Key steps of BLS
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Chest compressions
Start chest compressions for victim who is unconscious, not breathing or not breathing
normally or gasping, without pulse.
• Position: Position the heel of your dominant hand in the centre of the chest, on the
lower half of the breastbone. Place the other hand on top of this hand and interlock the
fingers. Keep the elbows straightened and bend over the patient, to align the shoulder,
elbow and wrist in a straight line.
• Adequate rate: 100-120 compressions/min. Thinking of a song in the same tempo helps!
E.g. Staying Alive by Bee Gees or Jeevan Sanjivani (ISA, IRC)
• Adequate depth
o Adults: A compression depth of at least 2-2.4 inches (5-6 cm)
o Infants and Children: A depth of least one-third the anterior-posterior (AP)
diameter of the chest or about 1'% inches (4 cm) in infants and about 2 inches (5
cm) in children. Thumb-encircling method is better in infants that two-finger.
• Allowing complete chest recoil after each compression
• Minimizing interruptions in compressions
• Recheck for return of pulse: Not less than 5 seconds and not more than 10 seconds
• Carotid pulse in the neck is to be assessed, location - adjacent to the Adam's apple in
between the trachea and the sternocleidomastoid muscle
• If there is absence of carotid pulsation and any movement of the body, chest
compressions are to be continued.
• In babies and infants less than 1 year of age, check for brachial pulse in the arm.
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Airway
The most common cause of airway obstruction is tongue in unconscious victims, Hence, it is
necessary that the airway be opened in case of unresponsive victims.
o Head tilt and chin lift maneuver
o Jaw thrust (in trauma victims, when spine injury is suspected)
Placement of airway devices (OPA/NPA) is very useful
Breathing
Over exhaled air contains around 16% oxygen.
Delivering breaths - procedure
• Maintaining a head tilt chin lift, pinch the nose with the index finger and thumb
• Provide 2 breaths by sealing your mouth to the patient's mouth and confirm by
adequate chest rise. Pocket mask is used alternatively, or even just a handkercheif
placed over victims mouth
• For small children and infants, cover the mouth as well as the nose and deliver
• 2 rescue breaths each over 1 second looking for chest rise.
• After each rescue breath, allow for expiration; lift your mouth away from patient's
airway for complete exhalation.
Give 2 ventilations after 30 chest compressions, completing 5 cycles of CPR in 2 minutes.
• Avoid too much ventilation
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• RESCUE BREATHING: If the victim has pulse, but is not breathing, then provide rescue
breaths at one breath in every 6 seconds.
• If your breaths do not make the chest rise as in normal breathing, then before your next
attempt:
o Recheck whether there is adequate head tilt and chin lift
o Check the victim’s mouth and remove any visible obstruction carefully, only if
possible, without pushing it further down
o Do not attempt more than two breaths each time before returning to chest
compressions
• If the patient is breathing, then place him in recovery position so that the airway is not
compromised due to tongue fall or any secretions.
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Bag-Valve-Mask (BVM) Ventilation

A BMV device consists of a ventilation bag attached to a face mask
o Provide positive pressure ventilation
o Provide a volume of 6-7 ml/kg per breath.
o Ventilate at a rate of 6-10 breaths per minute
o Adult size: 2000 ml
POINTS TO REMEMBER
o Use the E-C clamp technique or two-thumbs down technique to hold the mask in place
o Two-Person BMV will ensure better sealing of the mask and thereby more effective
ventilation.
o Squeeze the bag to give breath over 1 second each.
o Give a sufficient tidal volume to produce visible chest rise.
o 1 breath every 6 second
o Avoid hypoventilation/hyperventilation
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Defibrillation
Most common cause of cardiac arrest in adults is Ventricular fibrillation:
o Shock Energy: Biphasic: 120-200J. Monophasic: 360J.
o Pediatric: First shock = 2J/kg, Second shock = 4J/kg, Subsequent = 10J/kg or adult dose.
The treatment for this condition is defibrillation, this can be done by a lay person with the help
of an Automated External Defibrillator (AED).
Recovery Position
- Remove the victim’s spectacles and other sharp objects from the pocket
- Kneel beside the victim and make sure that both his legs are straight
- Take the near side hand and place at right angle with palm facing up
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- Keeping his far side hand across the chest and pressed against his opposite cheek, pull
on the far leg to roll the victim towards you onto his side, whilst supporting their head
and neck with your other hand
- Adjust the upper leg so that both the hip and knee are bent at right angles into a
running position to stablise their body
- Ensure that they are over enough so that their tongue flops forward and any vomit can
drain out
- Tilt the head back to make sure the airway remains open. If you are worried that they
might have a neck injury, do not tilt the head. Just ensure they are rolled over enough to
drain
- Adjust the hand under the cheek, if necessary, to keep the head tilted
- Check breathing regularly
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- To put an infant into recovery position –
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Team Dynamics
Successful resuscitation requires not only medical expertise but also effective communication and team
dynamics. Whether you are a team member or a team leader during a resuscitation process, you should
understand not only your role but also the roles of the other members in the team.
Elements of Effective Team Dynamics:

• Clear roles and responsibilities
• Knowing your limitations
• Constructive interventions
• Knowledge sharing
• Summarizing and re-evaluating
• Closed-loop communications
• Mutual respect
Suggested Roles for 7 Member Team:

1. Compressor – Does 5 cycle of chest compressions and rotates every 2 minutes or sooner if fatigued.
2. Airway – Opens the airway, provides bag mask ventilation (and uses airway adjuncts as appropriate).
3. Monitor/Defibrillator – Brings and operates an AED/defibrillator.
4. Team Leader – Assigns roles and makes treatment decisions. Provides feedback (when needed) to the
rest of the team
5. Observer/Recorder – Records the time of interventions (and frequency and duration of interruptions
in compressions), communicates these to the team leader.
6. IV/1O Medications – Initiates Intravenous/Intraosseous access, administers medications.
7. CPR Coach – monitors and coordinates with the team with special emphasis on high quality CPR and
early defibrillation.
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PEDIATRIC BLS
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Paediatric Chain of Survival
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Difference between Adult, Child and Infant CPR
Rescue breaths 1 every 6 secs 1 every 2-3 secs 1 every 2-3 secs
Paediatric and infant chest compressions:
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Two finger technique:
Two thumb/Thumb encircling technique:
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- If the victim is able to cough forcefully, then encourage them to

do so. Let the person keep coughing. It might naturally remove
the stuck object.
- At any point, if the victim becomes unresponsive or has stopped
breathing – then lower the person onto the floor and start CPR.
Recheck the mouth regularly for the object.
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5 COMMON ERRORS OF CPR

1. Not getting involved.
The faster we act, the better their chances. Every second matters!
2. Not calling for help.

Not activating the Emergency Response System is a mistake, because you need your first
responders there with medication and treatment option.
3. Not prioritizing chest compression over breathing.

Hands only CPR without rescue breaths – Hands only CPR carried out by a bystander has
been shown to be as effective as CPR with breaths in the first few minutes or an out-of-
hospital SCA for an adult victim.
The AHA still recommends CPR with compressions and breaths for infants, children,
victims of drowning or drug overdose, or people who collapse due to breathing
problems.
4. Not knowing what you’re doing.

a. Wrong placement of hands: Centre of the chest on the lower half of the breast
bone.
b. Shallow chest compressions (Weak CPR): Must be 5-6cms deep. This is much
deeper than most people realise.
c. Inadequate recoil of the chest wall (Lazy CPR): This allows the heart to fill with
blood which is required for the next compression to be effective.
CPR is tiring to perform. As the rescuer becomes tired it is common to see them
‘lean’ on the victim’s chest. This means they are not allowing the chest wall to
recoil fully after each compression.
d. Long pauses in chest compressions: A pause for longer than 10 seconds has been
shown to reduce the chances of survival for the victim.
e. Over/Under-inflating the lungs
i. Poor sealing of mask in BVM ventilation
j. Excessive volume delivered: Deliver only half the bag, or enough to produce
chest rise.
k. Short delivery: Less than one second taken. Not enough to produce chest
rise.
l. Slow or fast rate: 1 in 6 seconds in adults and 1 in 2-3 seconds in children.
5. Forgetting your own safety.

Your safety comes first!
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BASICS OF ECG
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The Conduction System of the Heart
What are the parts of the cardiac conduction system?
Your cardiac conduction system contains specialized cells and nodes that
control your heartbeat. These are the:
• Sinoatrial node.
• Atrioventricular node.
• Bundle of His (atrioventricular bundle).
• Purkinje fibres.
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What are the steps of the heart conduction pathway?
Your heart is a pump that sends blood through your body. For each
heartbeat, electrical signals travel through the conduction pathway of your
heart. It starts when your sinoatrial (SA) node creates an excitation signal.
This electrical signal is like electricity traveling through wires to an
appliance in your home.
The excitation signal travels to:
1. Your atria (top heart chambers), telling them to contract.

2. The atrioventricular (AV) node, delaying the signal until your atria are
empty of blood.
3. The bundle of His (centre bundle of nerve fibres), carrying the signal
to the Purkinje fibres.
4. The Purkinje fibres to your ventricles (bottom heart chambers),
causing them to contract.
These steps make up one full contraction of your heart muscle. Your heart
conduction system sends out thousands of signals per day to keep your
heart beating.
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P – Atrial depolarization
Q – First downward deflection
R – First upward deflection Ventricular depolarization
S – Second downward deflection
T – Ventricular repolarization
U – Sometimes abnormal wave due to hypokalaemia
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Step-wise approach to interpret an ECG

1. RATE
The usual paper speed is 25mm/sec:
• 1mm (small square) = 40ms = 0.04s
• 5mm (big square) = 200ms = 0.2s
There are multiple methods to estimate the rate.
Method 1: Rate = 300/number of large squares in between two successive R
wave, provided the R-R interval is constant – Division method.
To simplify: Memorize the answers to the above formula in sequence –
300/150/100/75/60/50/42/38 bpm
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Method 2: To calculate Rate of irregular rhythm: Multiplication method –

Number of QRS complexes within 30 large squares multiplied by 10.
2. RHYTHM
• Scan rhythm strip for overall regularity and note irregular beats.
• Is it regular or irregular? Measure the R-R intervals and compare.
• Identify atrial rhythm by P waves – present or not (Sinus/not).
Normal morphology or not.
• Identify ventricular rhythm by QRS complex
• Does each P wave correspond with a QRS complex. Is there a 1:1
relationship with each QRS complex.
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3. AXIS DEVIATION
• Normal Axis = QRS axis between -30 and +90 (in normal adults)
• Left Axis Deviation (LAD) = QRS axis less than -30%
• Right Axis Deviation (RAD) = QRS axis greater than +90%
• Extreme Axis Deviation (EAD) = QRS axis between -90% and 180%
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4. P WAVES
• The P wave is the first positive deflection on the ECG.
• It represents atrial depolarisation.
• Normal P wave duration – 0.06 to 0.12 seconds (1 to 3 small
boxes)
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5. PR INTERVAL
• The PR interval is the time from the onset of the P wave to the start of
the QRS complex.
6. QRS COMPLEX
• It represents ventricular depolarization
• Increased amplitude indicates cardiac hypertrophy
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7. ST SEGMENTS
• It represents the interval between ventricular depolarization and
repolarization.
• Assess the ST segment for the presence of elevations or
depressions, together with T wave abnormalities.
• ST elevation can manifest as acute myocardial injury or myocardial
ischemia, Prinzmetal’s (variant) angina, pericarditis or ventricular
aneurysm.
Q waves is usually not present in a normal ECG. It is pathological if: >1

small square in width, > 2mm in depth and > 25% of the depth of QRS
complex.
Location of pathological Q wave is usually indicative of myocardial
infarction of a particular coronary artery territory.
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8. QT INTERVAL
• The QT interval is the time from the start of the Q wave to the end of
the T wave.
• Normally, the QT interval is 0.36 to 0.44 seconds (9-11 small boxes).
• It represents the time taken for ventricular depolarisation and
repolarisation.
• The QT interval can be prolonged secondary to metabolic disorders
and drug effects.
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9. ABNORMAL U WAVES
• The U wave is not always seen. It is small and follows the T wave.
• Prominent U waves are seen in hypokalaemia, thyrotoxicosis and
with digoxin.
REMEMBER:
Always compare a new ECG to the old or previous one. Comparison helps
to determine if changes (such as left bundle branch block or T wave
inversion) are old or new.
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LEAD REPRESENTATION
It is important to understand which leads represent which part of the
heart; this allows us to localize pathology to a particular heart region.
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REPORTING AN ECG:
Start with patient details.
Report a summary of all the major findings with a conclusion as to the
working diagnosis –
“This is an ECG of Mrs. Padmavathy, hospital number 8972529. The
ECG was taken on 06/02/2023. The heart rate is 80 beats per minute
and it appears to be in sinus rhythm. The cardiac axis is normal. P
waves are present with normal morphology. There are no pathological
Q waves and the QRS complexes appear normal and narrow. There
are no ST segment changes. There is evidence of T wave inversion in
leads aVR, V1-V2 and lead III. The QT interval is 420 ms and the
corrected QT interval is 430 ms.”
In conclusion, this ECG shows sinus rhythm with T wave inversion in

leads aVR, V1-V2 and III, which are likely normal variants”
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EXAMPLE 1:
• Rate: 65-70 bpm

• Rhythm: sinus rhythm (1:1 ratio between P wave & QRS
complexes)
• Axis: normal axis
• P waves: present, normal morphology, PR internal 140-160 ms
• QRS complexes: narrow
• ST segments & T waves: no ST changes, T wave inversion
aVR/V1 (normal variants). No pathological Q waves
• QT interval: ~360 ms (corrected ~375 ms)
• Conclusion: Normal sinus rhythm
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EXAMPLE 2:
• Rate: 60 bpm
• Rhythm: sinus rhythm (1:1 ration between wave & QRS
complexes)
• Axis: left axis deviation (Lead I positive deflection, leads II & III
negative deflection)
• P waves: present, normal morphology, PR internal ~160 ms
• QRS complexes: broad complexes (> 120 ms), right bundle
branch block morphology (positive deflection V1)
• ST segments & T waves: ST segments appear normal, T wave
inversion aVR, V1 & III in context of RBBB. No pathological Q
waves
• QT interval: QT 400 ms (corrected ~400 ms)
• Conclusion: sinus rhythm with left axis deviation and right bundle
branch block (i.e. Bifascicular block).
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IMPORTANT AND LIFE THREATENING ECG RHYTHMS
A. RHYTHMS DURING CARDIAC ARREST --->

1. VENTRICULAR FIBRILLATION
• Irregular rhythm
• No identifiable P wave
• Varying morphology of wide QRS
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2. PULSELESS VENTRICULAR TACHYCARDIA (pVT)

• Rhythm can be regular or irregular
• No identifiable P wave
• Wide QRS
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Torsade’s de Pointes is French translated as ‘twisting of peaks’
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3. PULSELESS ELECTRICAL ACTIVITY

• Any organised rhythm without a pulse
4. ASYSTOLE
• Flat line on ECG
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B. BRADYCARDIA RHYTHMS --->
1. SINUS BRADYCARDIA
• Rate: Less than 60 beats per minute
• P wave present
• PRI: 0.12-0.20 seconds and constant
• QRS: Less than 0.12 seconds
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2. FIRST DEGREE HEART BLOCK

• Constant PR interval > 0.20 seconds
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3. SECOND DEGREE HEART BLOCK

I. MOBITZ TYPE-I
o Progressive prolongation of PR interval until QRS is dropped
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II. MOBITZ TYPE-II

o Constant PR interval
o Intermittently non conducted P waves not preceded by PR
prolongation or followed by PR shortening.
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Intermittently P wave fails to conduct, but not preceded by prolongation

of PR interval.
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4. THIRD DEGREE HEART BLOCK/COMPLETE HB

• Complete disruption of AV conduction
• QRS complexes conducted at own rate totally independent of P wave
conduction
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5. JUNCTIONAL BRADYCARDIA
• Originates in AV node
• Regular rhythm
• Rate: 40-60 impulses/min (sometimes slower)
• P wave absent/inverted before; after; or hidden in QRS. PRI, if
present is normal but the ‘P’ is inverted: measure if present.
• QRS is normal. Less than 0.12 seconds.
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C. TACHYCARDIA RHYTHMS --->

1. SINUS TACHYCARDIA
• Rate >100 beats/min
• Normal P waves and PR interval
• QRS usually narrow
• Regular rhythm
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2. ATRIAL FIBRILLATION
• Irregular rhythm
• Absent P waves. Presence of f waves.
• QRS narrow <0.12 seconds
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3. ATRIAL FLUTTER
• Rate: Depends on AV conduction.
• Rhythm: Regular (Can be irregular)
• Prominent P waves/Flutter (F) waves. Saw tooth pattern.
• PR interval: F waves are consistent. 2 for every QRS (2:1 or 3:1 is
typical)
• QRS: Narrow. 0.12 sec
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4. SUPRA VENTRICULAR TACHYCARDIA
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PHARMACOLOGICAL/CHEMICAL CARDIOVERSION -
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AFTER CARDIOVERSION
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AFTER CARDIOVERSION
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AFTER CARDIOVERSION
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5. MONOMORPHIC VENTRICULAR TACHYCARDIA (VT)

• Rhythm regular
• Wide QRS with similar morphology
• Absent P waves
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6. POLYMORPHIC VT (PVT)
• Wide QRS with varying QRS morphology
• Absent P waves
(Torsade’s de Pointes - TdP is a type of polymorphic VT. For TdP to be
diagnosed, the patient must have evidence of both PVT and QT
prolongation)
- There is a run of PVT which subsequently degenerates into VF.

- QT interval is difficult to see because of artefact but appears slightly
prolonged (QTc ~480ms), making this likely to be TdP
- Initially sinus rhythm. Prolonged QTc interval of 540 ms (greater than half
the R-R interval). Ventricular ectopics arise and the second PVC initiates a
run of TdP.
- Note: The lower tracing is Arterial line pressure waveform. This is showing
how the pressure is affected by the dysrhythmia. There is a reduced volume
pulse during the first PVC as the heart has less time to fill. Subsequently the
cardiac output drops away to almost nothing during the run of TdP – this is
likely to result in syncope or cardiac arrest.
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PVT secondary to hypokalaemia:

- Sinus rhythm with inverted T waves and prominent U waves due to
severe hypokalaemia (K+ = 1.7)
- A premature atrial complex (beat #9 of the rhythm strip) lands on the
end of the T wave and initiates a paroxysm of PVT
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- Another ECG from the same patient

- A brief, self terminating paroxysm of PVT is again precipitated by a PAC.
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D. ECTOPIC BEATS/EXTRASYSTOLE’S --->

1. PREMATURE ATRIAL COMPLEX (PAC)/ATRIAL ECTOPICS
- A premature beat arising from ectopic pace-making tissue within the
atria.
- There is an abnormal P wave, usually followed by a normal QRS
complex.
- Post – extrasystolic pauses may be present
- Frequent PAC’s (arrows): Note differing P wave morphology and

post-extrasystolic pauses.
2. PREMATURE VENTRICULAR COMPLEX (PVC)/VENTRICULAR

ECTOPICS
- Broad QRS complex (>120 ms) with abnormal morphology.
- Premature – i.e.. Occurs earlier than would be expected for the next
sinus impulse.
- Appropriately Discordant ST segment and T wave changes – These
are directed opposite to the main vector of the QRS complex.
- Usually followed by a full compensatory pause – the next normal
beat arrives after an interval that is equal to double the preceding R-
R interval.
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- Sinus rhythm with PVC’s of two different morphologies (arrows) –

Multifocal PVC’s
- Note the appropriately discordant ST segments/T waves
- The pause surrounding the PVC is equal to double the preceding R-R
interval (= a full compensatory pause)
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3. PREMATURE JUNCTIONAL COMPLEX (PJC)/JUNCTIONAL ECTOPICS

- Narrow QRS complex, either without a preceding P wave (absent), or
with an inverted P wave
- Premature: Occurs sooner than would be expected for the next sinus
impulse.
- Followed by a compensatory pause.
- Typical appearance of PJC:

- Premature QRS complexes without a preceding P wave.
- The QRS morphology is very similar to the sinus complexes.
110
ACLS CASES
111
SUDDEN CARDIAC ARREST (SCA)

Cardiac arrest is the abrupt cessation of cardiac activity in a person who
may or may not have been diagnosed with heart disease.
112
113
114
ASSISTING AN ENDOTRACHEAL INTUBATION

Step 1 – Have all the necessary instruments ready (Laryngoscope, ETT, stillete,
bougie, Yankauer suction).
Step 2 – Position the patient. Sniffing position or Ramped position (In morbidly
obese patients). Just use pillow or sheets to place under the head.
Step 3 – Check Laryngoscope light.
Step 4 – Quickly open the pre-decided ETT and check cuff for leak by inflating
5-10ml of air.
Step 5 – Insert stylet and bend lower end of ETT slightly anteriorly. Lubricate
tip with 2% lignocaine gel.
Step 6 – Hand over the laryngoscope when asked.
Step 7 – Hand over suction if asked.
Step 8 – Be ready to give Cricoid pressure (Sellick’s manoeuvre) if asked.
Step 9 – Hand over the ETT (preloaded with stylet) when asked with tube
curving forwards or upwards.
Step 10 – Pull out the stylet when asked, after the performer passes ETT
through the vocal cords.
Step 11 – Remove mask from the BVM and connect to the ETT to continue
delivering breaths, now at a regular rate of 1 breath every 6 seconds in adults
and 1 in 2-3 secs in children/infants.
Intubation with bougie –
Step 9 – If bougie is asked for, then hand over with curved tip ready to enter the
mouth of the patient. Then immediately remove the stylet from the ETT.
Step 10 – Railroad the ETT through the bougie from above, with tube curving
forwards or upwards.
Advance the ETT along the bougie until reaching the hand of the performer and
he/she holds the ETT.
Hold the bougie above. Pull out the bougie when asked.
115
Positioning the patient for intubation –

1. Sniffing position:
116
2. Ramped position: For morbidly obese patients
117
Note: Because a pregnant patient is more prone to hypoxia, oxygenation and airway
management should be prioritized during resuscitation (2020 recommendation).
118
RETURN OF SPONTANEUOUS CIRCULATION (ROSC)

Return of Spontaneous Circulation (ROSC) is resumption of sustained perfusion
and cardiac activity associated with significant respiratory effort after cardiac
arrest.
Signs of ROSC include breathing, coughing or movement and a palpable pulse or
a measurable blood pressure.
• Check for response and consciousness
• Do a Primary Survey:
o Airway - maintain the airway, consider intubation
o Breathing - maintain saturation of 94%
o Circulation - check BP, take 12 lead ECG and send for blood
investigations (cardiac enzymes, ABG, CBC, electrolytes).
o Disability - assess sensorium and GCS, GRBS.
o Exposure - see for any skin colour changes, bleeding, swelling
• Do a Secondary Survey (if not done before)
• Treat for hypotension - consider 1-2 litre of NS/RL bolus, if hypotension
present or maintenance if BP is stable
• Maintain body temperature at 32-36 degree Celsius
119
120
INITIAL STABILIZATION PHASE

Resuscitation is ongoing during the post-ROSC phase and many of these
activities can occur concurrently.
However, if prioritization is necessary, follow these steps:
• Airway management with waveform capnography or capnometry
• Manage respiratory parameters: Titrate fraction of inspired oxygen for
SpO2 of 92% - 98%; start at 10 breaths/min; titrate to PaCO2 of 35-45 mm
Hg.
• Manage hemodynamic parameters: Administer crystalloid and/or
vasopressor or inotrope to maintain systolic blood pressure >90 mmHg or
mean arterial pressure >65 mmHg.
CONTINUED MANAGEMENT AND ADDITIONAL EMERGENT ACTIVITIES

These evaluations should be done concurrently so that decisions on Targeted
Temperature Management (TTM) receive high priority as cardiac interventions
• Emergent cardiac intervention: Early evaluation of 12-lead
electrocardiogram (ECG); consider hemodynamics for decision on cardiac
intervention.
• TTM: If patient is not following commands, start Targeted Temperature
Management as soon as possible; begin at 32-36"C for 24 hours by using a
cooling device with feedback loop.
• Other critical care management:
o Continuously monitor core temperature (oesophageal, rectal,
bladder)
o Maintain normoxia, normocapnia, euglycemia.
o Provide continuous or intermittent electroencephalogram (EEG)
monitoring.
o Provide lung-protective ventilation.
121
BRADYCARDIA
122
123
TACHYCARDIA
124
Synchronised Cardioversion:
• SVT – 50J to 100J
• AF – 100J to 120J
• VT – 120 to 150J
125
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127
PALS CASES
128
129
130
131
132
133
THANK YOU!
134

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CPR AND ECC TRAINING – SANJIVANI MULTISPECIALITY HOSPITAL

CPR AND ECC TRAINING

Prepared by: Dr Vaishakh Shyam Kumar

- To help equip the nursing staff to handle medical emergencies, efficiently

PLAN – WHAT WE WILL COVER (PHASE I)

What to do during an emergency? – Our Goal!

How can we achieve this among our staff?

SYSTEMATIC APPROACH TO A PATIENT

Appearance o Head bobbing

1. Oropharyngeal Airway/Gudel Airway

3. Bag-valve-mask with Reservoir bag/AmbuTM bag/Self-inflating bag

Instruments for intubation –

8. Endotracheal Tube (ETT)

BASIC LIFE SUPPORT

WHY GIVE LIFE SUPPORT?

- Early defibrillation – Greater than 50-70% of SCA victims survive if

Cardiopulmonary Resuscitation (CPR)

Key steps of BLS

• Allowing complete chest recoil after each compression

• Minimizing interruptions in compressions

Placement of airway devices (OPA/NPA) is very useful

• Avoid too much ventilation

Bag-Valve-Mask (BVM) Ventilation

- To put an infant into recovery position –

Elements of Effective Team Dynamics:

Suggested Roles for 7 Member Team:

3. Monitor/Defibrillator – Brings and operates an AED/defibrillator.

6. IV/1O Medications – Initiates Intravenous/Intraosseous access, administers medications.

Paediatric Chain of Survival

Difference between Adult, Child and Infant CPR

Paediatric and infant chest compressions:

Two finger technique:

Two thumb/Thumb encircling technique:

- If the victim is able to cough forcefully, then encourage them to

5 COMMON ERRORS OF CPR

2. Not calling for help.

3. Not prioritizing chest compression over breathing.

4. Not knowing what you’re doing.

5. Forgetting your own safety.

The Conduction System of the Heart

What are the parts of the cardiac conduction system?

What are the steps of the heart conduction pathway?

The excitation signal travels to:

1. Your atria (top heart chambers), telling them to contract.

Step-wise approach to interpret an ECG

Method 2: To calculate Rate of irregular rhythm: Multiplication method –

Q waves is usually not present in a normal ECG. It is pathological if: >1

In conclusion, this ECG shows sinus rhythm with T wave inversion in

• Rate: 65-70 bpm

IMPORTANT AND LIFE THREATENING ECG RHYTHMS

A. RHYTHMS DURING CARDIAC ARREST --->

2. PULSELESS VENTRICULAR TACHYCARDIA (pVT)

Torsade’s de Pointes is French translated as ‘twisting of peaks’

3. PULSELESS ELECTRICAL ACTIVITY

B. BRADYCARDIA RHYTHMS --->

2. FIRST DEGREE HEART BLOCK

3. SECOND DEGREE HEART BLOCK

II. MOBITZ TYPE-II