Cardiopulmonary Resuscitation

Mechanisms of Cardiopulmonary Arrest

Cardiopulmonary arrest results from either primary
.cardiac or respiratory arrest
:Cardiac arrest may be
Primary:_due to dysrhythmia or severe myocardial failure
Secondary:_due to hypoxaemia(respiratory arrest),electrolyte
imbalance,etc

There are three fundamental (rhythms)of cardiac

:arrest
Ventricular fibrillation(VF),or pulseless ventricular tachy
cardia(VT)
Asystole,or extreme bradycardia
Electromechanical dissociation(EMD)
Factors Affecting Survival
The rhythm is VF or VT_
The arrest is witnessed_
Defibrillation and advanced life support are given early _
Basic life support
All medical, nursing and other hospital staff, as well as the
general public, should be able to perform basic life support
:Important points

Check that there is no danger to yourself or to the casuality _

.before starting resuscitation
If the casuality is unresponsive , first shout for help, then _
check airway, breathing and circulation
Airway foreign bodies may be removed under diret vision or _
.by finger sweeps, back blows or the heimlich manoeuver
If breathing and pulse are absent, get help before starting _
CPR.Survival is very unlikely without advanced life support
.and defibrillation
The ratio of chest compressions to ventilation should -
.be 15:2 with one rescuer, and 5:1 with two rescuers
Ventilation can be performed either mouth to mouth or _
.by using airway adjuncts
Be aware of the possibility of neck trauma before _
considering extending the neck in order to open the
.airway
Lifting the jaw anteriorly(jaw thrust)may be required _
.to open the airway
The technique of expired air resuscitation cannot be _
learnt from a book but only from a properly supervised
training session
:For an adult or an older child who has reached puberty
Move or remove all clothing covering the chest. You need to be able to see the chest
.move
.Kneel next to the person ,locate the lower third of sternum,avoid the xiphisternum
.
.Put the heel of one hand on the center of the person's chest between the nipples

:Positioning your hands for chest compressions

Use both hands to give compressions. Stack your other hand on top of the one that you
just put in position. Lace the fingers of both hands together, and raise your fingers so
.they do not touch the chest
Straighten your arms, lock your elbows, and center your shoulders directly over your
.hands
Positioning your arms and body for doing chest
compressions:
Press down in a steady rhythm, using your body weight.
The force from each thrust should go straight down onto the
chest, pressing it down 1.5 in. (3.8 cm) to 2 in. (5 cm). . Be
sure to let the chest re-expand at the end of each
compression.
 Is the patient Check for injuries.1
?Responsive
Reassess at regular.2
yes
no
Intervals
call for heIp Get help if needed.3

Assess breathing
And circulation

.Breathingِ .Not breathing Not breathing

?Pulse present Pulse present No Pulse

Turn to recovery.1 Give 10 breaths.1 Phone for.1

Position Phone for help.2 help
Phone for help.2 Continue.3 Perform CPR.2
expired
Air resuscitation
 Advanced Life Support 
All persons who may be called upon perform ALS should be 
familiar with these algorithms . Regular refresher courses are
.recommended
 Asystol
e
Precordial thump

VE excluded Continue CPR between shocks.1

.If no I.V. access consider adrenaline(2 mg via tracheal tube) .2
NO Yes Give adrenaline (1 mg )during each loop,give atropine only in .3
. The first loop
D.C.shock 200 -After 3 loops consider adrenaline(5 mg)i.v., calcium, alkalin .4
J .izing agent
D.C.shock 200
J
D.C.shock 360
J access
Intubate/i.v.

.Adrenaline 1mg i.v

CPR 10 sequences of 5:1

.Atropine 3mg i.v
)give only once(
?Electrical Activity

NO Yas
 VF

Precodial thump .Continue CPR between shocks.1

The interval between D.C. shocks 3 and 4 should not be more .2
1 D.C.shock 200 J
Than 2 min
2 D.C.shock 200 J .Give adrenaline (1 mg )i.v. during each loop.3
.If no i.v. access consider adrenaline (2mg) via tracheal tube .4
3 D.C.shock 360 J .After 3 loops consider alkalinizing agent,anti arhythmic(e.g .5
)Bretylium,amiodarone
Lntubate/ .i.v.accass

Adrenaline 1mg
CPR
sequences of 5:1 10

4 D.C.shock 360 J

5 D.C.shock 360 J

6 D.C.shock 360 J
 Electromechanical
dissociation
If no i.v. access, consider adrenaline(2 mg )v
Hypovolaemia
.Tracheal tube
Tensinon pneumothorax : After 3 loops consider.2
Cardiac tamponade .Adrenaline(5 mg )i.v
Pulmonary embolism Calcium chloride
Electrolyte imbalance Alkalinizing agent
Hypothermia Pressor agents
Drug verdose

Lntubate/i.v.access

Adrenaline 1 mg

CPR
sequences of 5;1 10
Important points 

A precordial thump may convert VF or VT to *

.Sinus rhythm,or stimulate a contraction in asystole
Defibrrilation is the only cure for VF or VT , but must be given as *
.soon as possible
Adrenaline is given to improve cerebral and coronary blood *
.flow,not to terminate VF or asystole
Sodium bicarbonate is no longer recommended at an early stage *
as it may worsen intracellular acidosis.It is given in early stage ,
only if the acidosis is the cause of VF or asystole.Up to 50 mmol
i.v. may be given for severe metabolic acidosis later in the
process of resuscitation,preferably guided by arterial blood
.gases
EMDis usually secondary,and CPR is unlikely to be successful *
unless the cause is treated,e.g.calcium may be useful in
hypocalcaemia,hyperkalaemia,or after use of overdose of
.calcium channel blockers
Bretylium,ligocain,or amiodarone may be considered in*
refractory VF. CPR must be continued for a further 20 – 30
.min if bretylium is given, as its effect is delyed

Drugs are best given through a central line.Central line*

insertion during CPR is hazarous if done by the
.inexperienced
If intravenous access is not possible,the endotracheal route ia
an alternative for adrenaline,atropine,lignocaine,using 2 – 3
.times the i.v. dose
Postresuscitation care

:The patient should be nursed in an ITU .The following points should be considered
:History
.Previous medical history*
Events preceding the arrest*
.Cause of the arrest*

Examination*
Respiratory(endotracheal tube position,pneumothorax, fractured ribs or sternum
Cardiovascular(pulse,BP,adequacy of perfusion, jugular venous pressure,urine out
.put
Neurological(glasgow coma score, pupil size and reactivity , neurological deficit)

Investigations
arterial blood gases , chest X-ray, 12 lead ECG, Urea and electrolytes, and *
.cosidering the invasive haemodynamic monitoring

Treatment
Oxygen, according to arterial blood gases , ,Continued ventilation,analgesia,an _
tiarrhythmic,inotropes and vasodilator,and specific organ system support, e.g.
.renal support
Paediatric Resuscitation

The principles of CPR in children are very similar to those in adult, but the
:following differences apply
Asystole or severe bradycardia are the commonest causes.They may be _
secondary to hypoxaemia or circulatory failure, and may be cured by BLS
.and oxygenation
Cardiac arrest may be due to airway obstruction(foreign bodies, epiglottitis _
or croup), near drowning, asthma ,trauma , or severe infections
The Heimlich manoevre, finger sweeps, and incisional cricothyrotomy are _
contraindication in younger children.Back blows ,chest thrusts and needle
.cricothyrotomy are alternative
External cardiac massages:The compressionrate should be 100 – 120 in_
.infants, and 80 – 100 in older children.Remember to use less force
.Defibrillation:The initial charge is 2 j/kg , increasing to 4 j /kg if necessary _
Drug doses: Adrenaline 0.1 ml/kg of 1:10000_
Atropine 0.02 mg/kg(minimum 0.1mg , maximum 0.6 mg)
.Calcium 0.1 ml/ kg of 10% calcium chloride
Lignocaine 0.1 ml/ kg of 1% lignocaine
.Sodium bicarbonate 1 mmol/kg
CARDIOPULMONARY RESUSCITATION

Dr-Basim Sudani
.F.I.B.M.S ,D.A.I.C. ,M.B.Ch.B

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