CARDIOPULMONARY

RESUSCITATION
Wiwi Jaya
SMF Anesthesiology & Intensive
Treatment
RS Saiful Anwar Malang - East Java

CARDIAC ARREST
Abrupt loss of consciousness caused
by lack of adequate cerebral blood
flow due to failure of cardiac pump
function.

CARDIAC ARREST
Survival depends on
The setting in which arrest occurs
Electrical mechanisms
Underlying clinical status

Electrical mechanisms

Ventricular fibrillation
Pulseless VT
Asystole
Pulseless electrical activity

PHASES OF VF
ELECTRICAL (0-4 min)
o adequate myocardial ATP store
o defibrillation alone restore perfusing
o rhythm(without chest compressions)
o duration of this phase can be
prolonged
by bystander CPR.

PHASES OF VF
Circulatory phase(4-10 min)
depletion of ATP store, lactic acidosis
defibrillation without chest
compression
rarely successful, may result in PEA
ECG fine fibrillatory wave.

PHASES OF VF
Metabolic phase(>10 min)
terminal phase
irreversible damage
less chance of successful
defibrillation
mild therapeutic hypothermia delay
the
onset.

Pulseless electrical activity

H S

Hypoxia

Hypovolemia

Hydrogen ion(acidosis)

Hypo/hyperkalemia
Hypothermia.

TS

Toxins
Tamponade
Tension pneumothorax
Thrombosis(pulmonar
y)
Thrombosis(coronary)

Asystole
No cardiac electrical and mechanical
activity of heart.
Terminal rhythm in non intervened
PEA or VF
Same causes of PEA can also
sometimes present initially as
asystole

AHA 2010 GUIDELINE

Recognition of SCA based on
unresponsiveness and absence of
normal breathing( ie the victim is
not breathing or gasping)
Look ,listen, and feel removed
ABC Sequence
CAB
Encourage hands only CPR

AHA 2010 GUIDELINE

Continue effective chest
compressions/CPR until return of
spontaneous circulation (ROSC) or
termination of resuscitative efforts
Continued de-emphasis on pulse
check

AHA 2010 GUIDELINE

Ensure high-quality CPR
compressions of adequate rate and
depth
Allowing full chest recoil between
compressions
Minimizing interruptions in chest
compressions
Avoiding excessive ventilation

Chain
Chain of
of Survival
Survival

Immediate recognition and activation, early CPR, rapid

defibrillation, effective advanced life support and integrated
post-cardiac arrest care.

ADULT BLS SEQUENCE

Recognition of SCA
unresponsive
no breathing or only gasping
Pulse checknot recommended for lay rescuer
Healthcare provider not more
than 10 sec
Early CPR

Early CPR

Chest
Compressions
Chest compressions consist of forceful rhythmic
applications of pressure over the lower half of the
sternum.
These compressions create blood flow by
increasing intrathoracic pressure and directly
compressing the heart.
This generates blood flow and oxygen delivery to
the myocardium and brain.

Effective chest compressions

push hard and push fast
rate of at least
100 compressions per
minute
compression depth of at
least 2 inches/5 cm.
Allow complete recoil of the chest after each
compression, to allow the heart to fill completely
before the next compression
Minimizing interruptions in compressions

A compression-ventilation ratio of 30:2 is

recommended

HANDS ONLY CPR

Initially during SCA with VF rescue
breath are not important
Oxygen level remains adequate.
Gasping and passive chest recoil
allow gas exchange.
Improves survival in OHCA

Airway Control and Ventilation

During low blood flow states such as CPR,
oxygen delivery to the heart and brain is
limited by blood flow rather than by arterial
oxygen content.
Advanced airway placement in cardiac arrest
should not delay initial CPR and defibrillation
Empirical use of 100% inspired oxygen
during CPR optimizes arterial
oxyhemoglobin content and in turn oxygen
delivery.

Airway and Ventilations

Opening the airway (with a head tiltchin
lift or jaw thrust) followed by rescue breaths
Untrained rescuer will provide Hands-Only
(compression-only) CPR and the lone
rescuer who is able, should open the airway
and give rescue breaths with chest
compressions.
Ventilations should be provided if the
victim has a high likelihood of an asphyxial
cause of the arrest.

Rescue Breaths
by mouth-to-mouth or bag-mask
Deliver each rescue breath over 1
second
Give a sufficient tidal volume to
produce visible chest rise.
Use a compression to ventilation
ratio of 30:2

Mouth-to-Mouth Rescue Breathing

Open the victims airway, pinch the
victims nose
Create an airtight mouth-to-mouth
seal.
Give 1 breath over 1 second, take a
regular (not a deep) breath
A second rescue breath over next 1
second

Ventilation With Bag and Mask

With room air or oxygen.
Positive-pressure ventilation without an
advanced airway
Produce gastric inflation and its
complications
To deliver approximately 600mL tidal
volume.
Squeezing a 1-L adult bag about two thirds
of its volume or a 2-L adult bag about one
third.

Ventilation With Bag & Mask

Cycles of 30compressions and 2
breaths.
Delivers ventilations during pauses in
compressions and each breath over 1
second.
Can use supplementary oxygen
(O2concentration 40%, at a minimum
flow rate of 10 to 12 L/min) when
available.

Ventilation
When an advanced airway (ie, endotracheal
tube, combitube,or laryngeal mask airway
[LMA]) is in place during 2-person CPR,
give 1 breath every 6 to 8 seconds without
attempting to synchronize breaths between
compressions
This will result in delivery of 8 to 10
breaths/minute
There should be no pause in chest
compressions for delivery of ventilations

Cricoid Pressure
Applying pressure to the victims cricoid
cartilage to push the trachea posteriorly
and compress the esophagus against
the cervical vertebrae
Used in a few special circumstances (eg,
to aid in viewing the vocal cords during
tracheal intubation,
The routine use of cricoid pressure in
adult cardiac arrest is not recommended

 During CPR cardiac output is 25% to

33% of normal
Oxygen uptake from the lungs and
CO2 delivery to the lungs are also
reduced
low minute ventilation (lower than
normal tidal volume and respiratory
rate) can maintain effective
oxygenation and ventilation

 Excessive ventilation is unnecessary and can

cause gastric inflation and its resultant,
regurgitation and aspiration
Excessive ventilation can be harmful because it
increases
Intrathoracic pressure
decreases venous return to the heart
diminishes cardiac output
Rescuers should avoid excessive ventilation (too
many breaths or too large a volume) during CPR

Universal Adult Basic Life Support

(BLS) Algorithm

Adult Advanced Cardiovascular

Life Support
Advanced cardiovascular life support (ACLS)
includes interventions to treat cardiac arrest,
and improve outcomes of patients who achieve
return of spontaneous circulation (ROSC).
Includes:
-airway management,
-ventilation support, and
-Rhythm based management of cardiac arrest

Advanced airways
Advantages
Improved ventillation and
oxygenation
Eliminate pauses in chest
compressions
1 breath every 6-8 sec(8-10
breath/min)
Reduce risk of aspiration

Supraglotic airways
Laryngeal mask airways
regurgitation less
when ET is difficult
neck injury
positioning of patient is difficult for ET
Provides equivalent ventillation comp.
ET.
Esophageal tracheal tube
Laryngeal tube

DEFIBRILLATION
Initial shock
360j for monophasic , same dose for
subsequent shocks
120-200j for biphasic defibrillator,
subsequent dose same or higher.
If VF recurs use previously successful
energy level

Medication for arrest

rhythms
Vasopressors
Epinephrine 1 mg IV/IO every 3-5 min
Alpha-adrenergic receptor
stimulation
produces
vasoconstriction.
Increases coronary perfusion
pressure,
Cerebral perfusion pressure.

Vasopressin
Non adrenergic
Coronary vasoconstrictor
Dose:40 units IV/IO

ANTI ARRYTHMICS
AMIODARONE
For VF/Pulseless VT unresponsive to
CPR,
defibrillation ,vasopressor
Initial 300mg IV/IO can be followed
by 150mg

Lidocaine
if amiodarone not available
initial dose 1 to 1.5 mg/kg IV
addl. Dose 0.5 to 0.75 mg/kg if not
responding

Magnesium sulphate
Used in torsades de pointes
Dose 1-2gm diluted in 5% D

Post - cardiac arrest care

Objective
Optimise cardio pulmonary function
Try to identify precipitating causes
Control body temperature to
optimise
Neurological recovery
Identify and treat ACS

Induced hypothermia
In comatose (lack of meaningful
response to verbal commands) adult
patients
With ROSC after out of hospital VF
arrest
(class 1)
In hospital arrest with any rhythm
(class2 b)
Cooled to 32-340C for 12 -24 hrs

 Inhibitory effect on adverse

enzymatic and chemical reactions
initiated by ischemia
Inhibits the release of glutamic and
dopamine
Induces brain derived neurotropic
factors

Cooling blanket
Ice packs
Direct immersion in ice water
IV ice-cold fluids (500 ml to 30 ml/kg
NS or Ringers lactate)
Monitor with esophageal
thermometer
or bladder catheters in nonanuric
patients

THANK
U
THANK U

1.current recommendation for

compression ventilation ratio
a) 15:2
b) 30:2
c) 15:1
d) 1:5

2.initial dose of amiodarone in ACLS

a)300 mg bolus
b)150 mg bolus
c)450 mg
d)200 mg

3) Therapeutic hypothermia
a)32-34
b)30-32
c)27-30
d)35

4)1st shock for VF with monophasic

defibrillator is
a)300 j
b)360 j
c)250 j
d)200 j

5)Breath/min with advanced airway in

CPR is
a)8-10
b)5
c)7
d)2

6)Max .rate of defibrillation success is

in which phase of VT
a)Circulatory phase
b)Electrical phase
c)Metabolic phase
d)Equal in all phase

7) rate of chest compression /min at

least
A)60
b)80
c)100
d)120

8)drug not used routinely in adult

ACLS
a)Epinephrine
b)Amiodarone
c)Vasopressin
d)atropine

9)depth of chest compression

A)3 cm
b)5 cm
c)4 cm
d)6 cm

10)not a part of BLS

A)Chest compression
b)Bag and mask ventillation
c)Manual defibrillation
d)AED