Basic life support

Historical Perspective

The First Ever Guidelines

1. Warming the victim (which sometimes required transporting the body to a different location) by lighting a fire near the victim, burying him in warm sand, placing the body in a warm bath, or placing in a bed with one or two volunteers2. Removing swallowed or aspirated water by positioning the victim's head lower than feet 3. Applying manual pressure to the abdomen 4. Respirations in to the victim's mouth, either using a bellows or with a mouth to mouth method (mouth to mouth or mouth to nostril respiration is described including the advice that “a cloth or handkerchief may be

used to render the operation less indelicate”) 5. Tickling the victim's throat with a feather to induce vomiting6. ‘Stimulating’ the victim by such means as rectal and oral fumigation with tobacco smoke. This may seem very unusual in modern times; however it may have been that the nicotine was enough of a stimulant to engender a response in the “almost” dead 7. Bloodletting

AHA

CPR

Approximately 700,000 cardiac arrests per year in Europe.

Survival to hospital discharge presently approximately 5-10%.

Bystander CPR vital intervention before arrival of emergency services.

Early resuscitation and prompt defibrillation (within 1-2 minutes) can result in >60% survival.

Heart attack is the leading cause of arrest in Europe.

• EARLY recognition and management is key to survival• Survival from In- Hospital respiratory arrest 90%• Survival from In- Hospital cardiac arrest 11%• Survival from Out of Hospital cardiac arrest 7% • Less than1 in 1,000 survive – & the key factor is the

brain.

Emergency Cardiovascular Care ECC

Recognition of early warning signs of heart attack and stroke, efforts to prevent complications, reassurance of the victim, and prompt availability of monitoring equipment

Provision of immediate BLS at the scene when needed

Provision of ACLS at the scene as quickly as possible to defibrillate if necessary and stabilize the victim before transportation

Emergency Cardiovascular Care

Transfer of the stabilized victim to a hospital where definitive cardiac care can be provided

The most important link in the ECC system in the community is the layperson. Successful ECC depends on laypersons’ understanding of the importance of early activation of the EMS system, their willingness and ability to initiate effective CPR promptly, and their training in and safe use of AEDs. Accordingly, providing lifesaving BLS at this level can be considered primarily a public, community responsibility.

Emergency Cardiovascular Care

ACLS includes the use of adjunctive equipment in supporting ventilation, the establishment of intravenous access, the administration of drugs, cardiac monitoring, defibrillation or other control of arrhythmias, and care after resuscitation. In virtually every EMS system in the world a medical physician must be involved to supervise and direct ACLS efforts (1) in person at the scene, (2) by direct voice communication, or (3) by the widely used mechanism of “standing orders.” These are a set of written, condition-specific orders that instruct the nonphysician responders.

Core Objectives of BLS Training

1. Recognize unresponsiveness or other emergency situations when resuscitation is appropriate (eg, the victim does not have a “do not attempt resuscitation” order)

2. Phone the EMS number at the appropriate time within the BLS sequence

3. Provide an open airway using the head tilt–chin lift or jaw-thrust technique

4. Provide effective rescuer ventilations (breathing) that make the chest rise using the mouth-to-mouth, mouth-to-mask, or mouth-to–barrier device technique

5. Recognize and relieve FBAO in conscious victim as a part of the core breathing step (lay providers are not required to perform this step in unconscious victims)

6. Provide proper chest compressions sufficient to generate a palpable carotid pulse

7. Perform all skills in a manner that is safe for the rescuer, victim, and bystanders

If use of an AED is taught as part of the course, an additional core objective is to

8. Use an AED safely, correctly, and in the appropriate sequence

When Not to Do CPR The patient has a valid DNAR order. The patient has signs of irreversible death: rigor mortis,

decapitation, or dependent lividity. No physiological benefit can be expected because the vital

functions have deteriorated despite maximal therapy for such conditions as progressive septic or cardiogenic shock.

Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with —Confirmed gestation <23 weeks or birthweight <400 g —Anencephaly —Confirmed trisomy 13 or 18

When to Stop CPR Restoration of effective, spontaneous circulation and

ventilation Care is transferred to a more senior level of emergency

medical professional who may determine unresponsiveness to resuscitation

Recognition of reliable criteria indicating irreversible death

The rescuer is unable to continue resuscitation because exhaustion, the presence of dangerous environmental hazards, or continuation of resuscitation places other lives in jeopardy

Presentation of a valid DNAR order to the rescuers

Asystole Persists

Time to terminate resuscitative efforts? Are all BLS/ACLS interventions completed? (CPR, ventilation and

oxygenation, defibrillation, intravenous access obtained, and indicated medications given?)

Has asystole persisted for several minutes? (documented electrical silence; no specific time criteria imposed, but default approach should be shorter time requirements, not longer)

Consider opposing family attitudes toward stopping efforts.

When should more efforts be made

Young ageToxins or electrolyte abnormalities

Profound hypothermiaDrug overdose

Types of arrest

Shockable rhythm Ventricular fibrillationPulseless ventricular tachycardia

Unshockable rhythmPulseless electrical activityasystole

Correctable causes of arrest

Hypoxia Hypothermia Hypovolemia Electrolyte imbalance and acidosis Thrombosis Cardiac tamponade Tension pneumothorax Toxins

Phases of CPR Electrical phase: it is first 5 minutes of arrest on shockable rhythm. Chest

compression till defibrillator is ready is crucial in survival.

Haemodynamic phase: from 5 to 10 minutes from arrest availability of defibrillator is crucial but if patient found in VF may 90 to 180 seconds of chest compression is needed before defibrillator (controversial in AHA)

Metabolic phase: after 10 min it depends mainly on post resuscitative care after recovering of ROSC

CHAIN OF SURVIVAL

1.  Immediate recognition of cardiac arrest and activation of the

emergency response system

2. Early cardiopulmonary resuscitation (CPR) with an emphasis on

chest compressions

3. Rapid defibrillation

4. Effective advanced life support

5. Integrated post-cardiac arrest care

Recognition of cardiac arrest:

Approach to unresponsive patient to check his response by shaking his shoulders gently while asking the patient are you ok?

If no response activate emergency response. Open airway see listen and feel for breathing for 10

seconds after checking that airway is open. After 10 seconds no breathing begin CPR. Check carotid pulsation in adults and brachial pulsation

with minimal pressure in pediatric not to cause fracture humerus.

CPR

Early CPR with emphasis on chest compression. Begin by ratio 30 compression to 2 rescue breaths

as long as we are not on advanced airway if we had advanced airway we do about 100-120 chest compressions per minute to 8-10 rescue breathes per minute.

Cardiac output falls during CPR to approximately 25% of normal cardiac out put and minute volume will be around 6-8 liters per minute.

Rapid access to defibrillator

Defibrillator should be available within 4 minutes from beginning of CPR and according to AHA 3 minutes only.

While doing basic life support automated defibrillator will be use.

When begin advanced life support it is preferred to use biphasic defibrillator than monophasic defibrillator which use higher energy in delivering the shock.

Defibrillation for ventricular fibrillation and pulseless ventricular tachycardia.

If arrest for 4 or 5 min before beginning CPR and its shokable rhythm u may do CPR for 90 to 180 second before delivering the shock.

Effective advanced life support

Advanced life support should begin with in 8 minutes in a hospital.

It begin by resuscitation team with advanced airway with advanced medications as Adrenaline, Amiodarone and Magnesium sulphate.

Advance life support team:

1. Team leader: instruct during CPR2. Airway responsible3. Responsible for drugs4. Defbrillator responsible 5. 2 for chest compression6. One for documenting events

Basic airway managementBag mask ventilation is a cornerstone of basic

airway management. It is used when inadequate ventilation either

by hypoxia or hypoventilation or both. Or due to upper airway obstruction.

Classified into maneuvers like head tilt chin lift jaw thrust and airway adjuncts by oropharyngeal or nasopharyngeal.

Airway obstruction

It is diagnosed by increased respiratory effort cyanosis work of accessory muscles of respiration and adventitious sounds like snoring.

Relieved by multiple techniques 1. Abdominal thrust by encircling abdomen by both hands and the rescuer

standing in the back it is contraindicated in pregnancy sometimes it caused gastric rupture.

2. Chest thrust begin with it before abdominal if abdominal is contraindicated

3. Back slaps sometimes relieve obstruction. Usually we need combination of these maneuveres to

releive obstruction.

Airway maneuvers Head-tilt chin-lift the

manoeuvre is done by extending neck by one hand of rescuer on forehead other hand index and middle fingers tip raise chin anteriorly at the mentum which lifts tongue from posterior pharynx head tilt can not be done if cervical injury is a concern.

Jaw-thrust maneuver With the patient supine and the clinician standing at the head of the bed, it is performed by placing the heels of both hands on the parieto-occipital areas on each side of the patient's head, then grasping the angles of the mandible with the index and long fingers, and displacing the jaw anteriorly it is safe even if there is cervical spine fracture

Bag mask ventilation

Prior using bag mask ventilation use one of the airway opening maneuvers.

Used to buy time for the clinician to put a plan for definite airway management.

Success of bag mask ventilation depends on rate, volume and sealing of mask on the face.

Prior to mask placement bag should be removed from the mask to make it more successful proper placement, nasal part of the mask cover nasal bridge the rest of the mask cover maxillary eminence and the mandibular alveolar ridge of the jaw but never the eye as it may cause trauma or vagal stimulation.

Application of the maskOne hand maneuver make a web between

index and thumb around the connector of the mask then apply pressure by this web centrally on the mask the rest of hand fingers will rest on the mandible making chin lift maneuver.

Double hand maneuver requires 2 persons first care for airway by putting index and thumbs of both hands simultaneous on superior and inferior ridges of the mask and apply pressure and remaining 3 fingers rest on the jaw doing chin lift jaw thrust maneuver.

Troubleshooting of bag maskExcessive facial hair may need KY jelExcessive facial oedemaDown displaced lower lip Improper mask sizeLack of airway adjuncts Inadequate airway maneuvers Inexperienced personnel

Ventilation through bag mask Tidal volume from 8-10 ml/kgm and in CPR 6-8

ml/kgm. Respiratory rate from 10-12 breaths per minute Inspiratory time should be around 1 second This tidal volume approximate to ambubagging

using single handSellick’s maneuverPress against cricoid cartilage to prevent over distention of the stomach.

Automated external defibrillator

Automated external defibrillator

The automated external defibrillator (AED) is a computerized medical device. An AED can check a person’s heart rhythm. It can recognize a rhythm that requires a shock. And it can advise the rescuer when a shock is needed. The AED uses voice prompts, lights and text messages to tell the rescuer the steps to take.AEDs are very accurate and easy to use. With a few hours of training, anyone can learn to operate an AED safely. 

How does it operate When turned on or opened, the AED will instruct the user to

connect the electrodes (pads) to the patient. Once the pads are attached, everyone should avoid touching the patient so as to avoid false readings by the unit. The pads allow the AED to examine the electrical output from the heart and determine if the patient is in a shockable rhythm (either ventricular fibrillation or ventricular tachycardia). If the device determines that a shock is warranted, it will use the battery to charge its internal capacitor in preparation to deliver the shock. This system is not only safer (charging only when required), but also allows for a faster delivery of the electrical current.

When charged, the device instructs the user to ensure no one is touching the patient and then to press a button to deliver the shock; human intervention is usually required to deliver the shock to the patient in order to avoid the possibility of accidental injury to another person.

Many AED units have an 'event memory' which store the ECG of the patient along with details of the time the unit was activated and the number and strength of any shocks delivered. Some units also have voice recording abilities  to monitor the actions taken by the personnel in order to ascertain if these had any impact on the survival outcome.

The first commercially available AEDs were all of a monophasic type, which gave a high-energy shock, up to 360 to 400 joules depending on the model.

Now biphasic available deliver shock beginning with 200 the 300 then another 300 joules.

Time of expiry is written on the defibrillator. Recommended class I to use with in 3 minutes of

the arrest according to AHA.

AED sign put on places available

Chest recoil

Thank you