BASIC LIFE SUPPORT

Dr. Negoita Silvius

Elias Hospital, Bucharest
November 2018
WHY?
Who care?
 Epidemiology

• The exact incidence of sudden cardiac arrest (SCA) in the United

States is unknown, but estimates vary from 180,000 to over 450,000
• In North America and Europe, the estimated incidence falls between
50 to 100 per 100,000 in the general population.
• The most common etiology of SCA is ischemic cardiovascular disease
resulting in the development of lethal arrhythmias.
• Resuscitation is attempted in up to two-thirds of people who sustain
SCA.
 Survival
• Despite the development of cardiopulmonary resuscitation (CPR), electrical
defibrillation, and other advanced resuscitative techniques over the past 50 years,
survival rates for SCA remain low.
• In the out-of-hospital setting, studies have reported survival rates of 1 to 6 percent.
Survival-to-hospital discharge from out-of-hospital SCA reported 5 to 10 percent
survival among those treated by emergency medical services (EMS) and 15 percent
survival when the underlying rhythm disturbance was ventricular fibrillation (VF) . In-
hospital SCA reported a 17 percent survival to discharge.
• While early, properly performed CPR improves outcomes, not performing CPR or low-
quality performance are important factors contributing to poor outcomes. Multiple
studies assessing both in-hospital and prehospital performance of CPR have shown
that trained health care providers consistently fail to meet basic life support
guidelines.
Algorithm
 Cardiac arrest
• Shockable
1. Ventricular fibrillation
2. Pulseless ventricular tachycardia

• Non–shockable
1. Asystole
2. Pulseless electrical activity
 Important concepts
• In most communities, the median time from emergency call to emergency medical
service arrival (response interval) is 5–8 min, or 8–11 min to a first shock.

• Immediate recognition of sudden cardiac arrest (SCA) by noting unresponsiveness

or absent/gasping breathing

• Immediate initiation of excellent CPR – "push hard, push fast" (but not too hard nor
too fast) – with continuous attention to the quality of chest compressions, and to
the frequency of ventilations

• Minimizing interruptions in CPR

 Important concepts
• For health care professional rescuers, taking no more than 10 seconds
to check for a pulse

• For single untrained rescuers, encouraging performance of excellent

chest compression-only CPR

• Using automated external defibrillators as soon as available

• Activating emergency medical services as soon as possible

 The chain of survival
• Early recognition and call for help
Chest pain should be recognized as a symptom of myocardial ischemia. Cardiac arrest occurs in a quarter to a third of patients with myocardial ischemia
within the first hour after onset of chest pain

• Early bystander CPR

The immediate initiation of CPR can double or quadruple survival from cardiac arrest

• Early defibrillation
Defibrillation within 3–5 min of collapse can produce survival rates as high as 50–70%. This can be achieved by public access
and onsite AEDs.

• Early advanced life support and standardized post-resuscitation care

Advanced life support with airway management, drugs and correcting causal factors may be needed if initial attempts at resus-
citation are un-successful.
 Phases of resuscitation
• Electrical phase — The electrical phase is defined as the first 4 to 5 minutes of arrest
due to ventricular fibrillation (VF). Immediate DC cardioversion is needed to optimize
survival of these patients. Performing excellent chest compressions while the
defibrillator is readied also improves survival
• Hemodynamic phase — The hemodynamic or circulatory phase, which follows the
electrical phase, consists of the period from 4 to 10 minutes after SCA, during which the
patient may remain in VF. Early defibrillation remains critical for survival in patients
found in VF. Excellent chest compressions should be started immediately upon
recognizing SCA and continued until just before defibrillation is performed.
• Metabolic phase — Treatment of the metabolic phase, defined as greater than 10
minutes of pulselessness, is primarily based upon postresuscitative measures, including
hypothermia therapy. If not quickly converted into a perfusing rhythm, patients in this
phase generally do not survive.
 Recognition of cardiac arrest
• Recognizing cardiac arrest can be challenging. Both bystanders and emergency call
handlers (emergency medical dispatchers)have to diagnose cardiac arrest promptly in
order to activate the chain of survival. Checking the carotid pulse (or any other pulse)has
proved to be an inaccurate method for confirming the presence or absence of circulation.
• Agonal breaths are slow and deep breaths, frequently with a characteristic snoring sound.
They originate from the brain stem, the part of the brain that remains functioning for
some minute when deprived of oxygen.
• The presence of agonal breathing can be erroneously interpreted as evidence that there
is a circulation and CPR is not needed. Agonal breathing may be presenting up to 40% of
victims in the first minutes after cardiac arrest, and if responded to as a sign of cardiac
arrest, is associated with higher survival rates.
• Bystanders should suspect cardiac arrest and start CPR if the victim is unresponsive and
not breathing normally.
 Recognition of cardiac arrest
• Immediately following cardiac arrest, blood flow to the brain is
reduced to virtually zero, which may cause seizure-like episodes that
can be confused with epilepsy.
• Bystanders should be suspicious of cardiac arrest in any patient
presenting with seizures.
• Although bystanders who have witnessed cardiac arrest events report
changes in the victims’ skin color, notably pallor and bluish changes
associated with cyanosis, these changes are not diagnostic of cardiac
arrest.
Performance of excellent chest compressions
• Chest compressions are the most important element of cardiopulmonary resuscitation (CPR) . Coronary
perfusion pressure and return of spontaneous circulation (ROSC) are maximized when excellent chest
compressions are performed.

• The following goals are essential for performing excellent chest compressions:

• Maintain the rate of chest compression at 100 to 120 compressions per minute

• Compress the chest at least 5 cm but no more than 6 cm with each down-stroke

• Allow the chest to recoil completely after each down-stroke (it should be easy to pull a piece of paper from
between the rescuer's hand and the patient's chest just before the next down-stroke)

• Minimize the frequency and duration of any interruptions

Performance of excellent chest compressions
• To perform excellent chest compressions, the rescuer and patient must be in optimal position. The
patient must lie on a firm surface. This may require a backboard if chest compressions are performed on
a bed. All efforts to deliver excellent CPR must take precedence over any advanced procedures, such as
tracheal intubation.
• The rescuer places the heel of one hand in the center of the chest over the lower (caudad) portion of
the sternum and the heel of their other hand atop the first. The rescuer's own chest should be directly
above their hands. This enables the rescuer to use their body weight to compress the patient's chest,
rather than just the muscles of their arms, which may fatigue quickly.
• Animal and observational clinical studies suggest that chest compressions of proper depth (at least 5
cm) play an important role in successful resuscitation. In addition, full chest recoil between down-
strokes promotes reduced intrathoracic pressures, resulting in enhanced cardiac preload and higher
coronary perfusion pressures.
• Inadequate compression and incomplete recoil are more common when rescuers fatigue, which can
begin as soon as 1 minute after beginning CPR. The AHA Guidelines suggest that the rescuer performing
chest compressions be changed every 2 minutes whenever more than one rescuer is present.
 Minimizing interruptions
• Interruptions in chest compressions during CPR, no matter how brief, result in unacceptable
declines in coronary and cerebral perfusion pressure and worse patient outcomes.
• Once compressions stop, up to 1 minute of continuous, excellent compressions may be
required to achieve enough perfusion pressures.
• Two minutes of continuous CPR should be performed following any interruption.
• When preparing for defibrillation, rescuers should continue performing excellent chest
compressions while charging the defibrillator until just before the single shock is delivered
and resume immediately after shock delivery without taking time to assess pulse or
breathing.
• No more than three to five seconds should elapse between stopping chest compressions
and shock delivery. If a single lay rescuer is providing CPR, excellent chest compressions
should be performed continuously without ventilations.
 Compression-only CPR (CO-CPR)
• When multiple trained personnel are present, the simultaneous
performance of continuous excellent chest compressions and proper
ventilation using a 30:2 compression to ventilation ratio is
recommended.
• If a sole lay rescuer is present, should not interrupt excellent chest
compressions to palpate for pulses or check for the return of
spontaneous circulation, and should continue CPR until an AED is ready
to defibrillate, EMS personnel assume care, or the patient wakes up
• For many would-be rescuers, the requirement to perform mouth-to-
mouth ventilation is a significant barrier to the performance of CPR
 Compression-only CPR (CO-CPR)
• This reluctance may stem from anxiety about performing CPR correctly or fear
of contracting a communicable disease, despite scant reports of infection
contracted from the performance of mouth-to-mouth ventilation, none of
which involve HIV .
• CO-CPR circumvents these problems, potentially increasing the willingness of
bystanders to perform CPR.
• Evidence directly comparing bystander CO-CPR with conventional CPR using a
30:2 ratio of compressions to ventilation is limited to one large observational
study which suggests improved survival when conventional CPR is performed .
• Nevertheless, we support CO-CPR when personnel to perform conventional
CPR with a 30:2 ratio are not available.
 Ventilations
• During the initial phase of SCA, when the pulmonary alveoli are likely to
contain adequate levels of oxygen and the pulmonary vessels and heart
likely contain sufficient oxygenated blood to meet markedly reduced
demands, the importance of compressions supersedes ventilations.
• Consequently, the initiation of excellent chest compressions is the first
step to improving oxygen delivery to the tissues. This is the rationale
behind the compressions-airway-breathing (C-A-B) approach to SCA.
• Properly performed ventilations become increasingly important as
pulselessness persists. In this, the metabolic phase of resuscitation,
clinicians must continue to ensure that ventilations do not interfere with
the cadence and continuity of chest compressions.
 Ventilations
• Give two ventilations after every 30 compressions for patients
without an advanced airway
• Give each ventilation over no more than one second
• Provide only enough tidal volume to see the chest rise (approximately
500 to 600 mL, or 6 to 7 mL/kg)
• Avoid excessive ventilation
• Give one asynchronous ventilation every 8 to 10 seconds (6 to 8 per
minute) to patients with an advanced airway (eg, supraglottic device,
endotracheal tube) in place
 Defibrillation
• The effectiveness of early defibrillation in patients with ventricular fibrillation (VF) and short "downtimes"
is well supported by the resuscitation literature and early defibrillation is a fundamental
recommendation.
• As soon as a defibrillator is available, providers should assess the cardiac rhythm and, when indicated,
perform defibrillation as quickly as possible. For BLS, a single shock from an automated external
defibrillator (AED) is followed immediately by the resumption of excellent chest compressions.
• Biphasic defibrillators are preferred because of the lower energy levels needed for effective
cardioversion. Biphasic defibrillators measure the impedance between the electrodes placed on the
patient and adjust the energy delivered accordingly. Rates of first shock success are reported to be
approximately 85 percent.
• All defibrillations for patients in cardiac arrest be delivered at the highest available energy in adults
(generally 360 J for a monophasic defibrillator and 200 J for a biphasic defibrillator). This approach
reduces interruptions in CPR.
• Controversy exists about the possible benefit of delaying defibrillation in order to perform excellent chest
compressions for a predetermined period (eg, 60 to 120 seconds).
ADVANCED LIFE
SUPPORT
 Principles
• Excellent cardiopulmonary resuscitation (CPR) and early defibrillation
for treatable arrhythmias remain the cornerstones of basic and ACLS
• Early recognition of the deteriorating patient and prevention of
cardiac arrest is the first link in the chain of survival.
• Once cardiac arrest occurs, only about 20% of patients who have an
in-hospital cardiac arrest will survive to go home.
• Current ALS Guidelines strongly recommend that every effort be
made NOT to interrupt CPR; other less vital interventions (eg, tracheal
intubation or administration of medications to treat arrhythmias) are
made either while CPR is performed
Do not attempt cardiopulmonary resuscitation
• Does not wish to have CPR

• Is very unlikely to survive cardiac arrest even if CPR is attempted.

 Resuscitation team management
• Leadership

• Communication
In hospital resuscitation
 Starting in-hospital CPR
• One person starts CPR as others call the resuscitation team and collect the resuscitation equipment and
a defibrillator. If only one member of staff is present, this will mean leaving the patient.
• Give 30 chest compressions followed by 2 ventilations.
• Compress to a depth of at least 5 cm but not more than 6 cm.
• Perform chest compressions should be performed at a rate of100–120 min−1.
• Allow the chest to recoil completely after each compression; do not lean on the chest.
• Minimize interruptions and ensure high-quality compressions.
• Undertaking high-quality chest compressions for a prolonged time is tiring; with minimal interruption,
try to change the persondoing chest compressions every 2 min.
• Maintain the airway and ventilate the lungs with the most appropriate equipment immediately to hand.
Pocket mask ventilation or two-rescuer bag-mask ventilation, which can be supplemented with an oral
airway, should be started. Alternatively, use a supraglottic airway device (SGA) and self-inflating bag.
Tracheal intubation should be attempted only by those who are trained, competent and experienced in
this skill.
 Starting in-hospital CPR
• Waveform capnography must be used for confirming tracheal tube placement and monitoring
ventilation rate. Waveform capnography can also be used with a bag-mask device and SGA.
• Use an inspiratory time of 1 s and give enough volume to produce a normal chest rise. Add
supplemental oxygen to give the highest feasible inspired oxygen as soon as possible.
• Once the patient’s trachea has been intubated or a SGA has been inserted, continue
uninterrupted chest compressions (except for defibrillation or pulse checks when indicated)
at a rate of 100–120 min and ventilate the lungs at approximately 10 breaths min. Avoid
hyperventilation (both excessive rate and tidal volume).
• If there is no airway and ventilation equipment available, con-sider giving mouth-to-mouth
ventilation.
• When the defibrillator arrives, apply self-adhesive defibrillation pads to the patient whilst
chest compressions continue and then briefly analyze the rhythm.
• Continue resuscitation until the resuscitation team arrives or the patient shows signs of life.
Advanced Life Support
Advanced Life Support
 Advanced Life Support
• The first monitored rhythm is VF/pVT in approximately 20% bothfor in-hospital
and out-of-hospital cardiac arrests.
• Minimize the delay between stopping chest compressions and delivery of the
shock (the pre shock pause); even a 5–10 s delay will reduce the chances of the
shock being successful.
• If IV/IO access has been obtained, during the next 2 min of CPR give adrenaline 1
mg and amiodarone 300 mg.
• The use of waveform capnography may enable ROSC to be detected without
pausing chest compressions and may be used as a way of avoiding a bolus
injection of adrenaline after ROSC has been achieved. Several human studies have
shown that there is a significant increase in end-tidal CO2when ROSC occurs.
 Advanced Life Support
• In animal studies, peak plasma concentrations of adrenaline occur at
about 90 s after a peripheral injection and the maximum effect on
coronary perfusion pressure is achieved around the same time (70 s).

• When VF is present for more than a few minutes, the myocardium is

depleted of oxygen and metabolic substrates.

• A single precordial thump has a very low success rate for

cardioversion of a shockable rhythm.
 Advanced Life Support
• Tracheal intubation provides the most reliable airway, but should be
attempted only if the healthcare provider is properly trained and has
regular, ongoing experience with the technique.
• Tracheal intubation must not delay defibrillation attempts. Personnel
skilled in advanced airway management should attempt laryngoscopy and
intubation without stopping chest compressions; a brief pause in chest
com-pressions may be required as the tube is passed through the vocal
cords, but this pause should be less than 5 s.
• In the absence of personnel skilled in tracheal intubation, a supraglottic
airway (SGA) (e.g. laryngeal mask airway, laryngeal tube or i-gel) is an
acceptable alternative.
 Intravenous access and drugs
• Establish intravenous access if this has not already been achieved. Although peak drug
concentrations are higher and circulation times are shorter when drugs are injected into a
central venous catheter compared with a peripheral cannula
• A central venous catheter requires interruption of CPR and can be technically challenging and
associated with complications.
• Peripheral venous cannulation is quicker, easier to perform and safer.
• Drugs injected peripherally must be followed by a flush of at least 20 ml of fluid and elevation of
the extremity for 10–20 s to facilitate drug delivery to the central circulation.
• If intravenous access is difficult or impossible, consider the Intra Osseus route. Injection of drugs
achieves adequate plasma concentrations in a time comparable with injection through a vein.
• Multiple studies have demonstrated that lidocaine, epinephrine, atropine, vasopressin, and
naloxone are absorbed via the trachea; however, the serum drug concentrations achieved using
this route are unpredictable.
 Adrenaline
• During cardiac arrest, the initial IV/IO dose of adrenaline is 1 mg. There are no studies
showing improvement in survival or neurological outcomes with higher doses of
adrenaline for patients in refractory cardiac arrest.
• There is an increasing concern about the potential detrimental effects of adrenaline.
While its alpha-adrenergic, vasoconstrictive effects cause systemic vasoconstriction,
which increases macrovascular coronary and cerebral perfusion pressures, its beta-
adrenergic actions (inotropic, chronotropic) may increase coronary and cerebral blood
flow, but with concomitant increases in myocardial oxygen consumption, ectopic
ventricular arrhythmias (particularly when the myocardium is acidotic), transient
hypoxemia from pulmonary arteriovenous shunting, impaired microcirculation, and
worse post-cardiac arrest myocardial dysfunction.
• The optimal dose of adrenaline is not known, and there are no human data supporting
the use of repeated doses.
 Amiodarone
• Amiodarone is a membrane-stabilising anti-arrhythmic drug that
increases the duration of the action potential and refractory period in
atrial and ventricular myocardium
• Following three initial shocks, amiodarone in shock-refractory VF
improves the short-term outcome of survival to hospital admission
compared with placebo or lidocaine.
• Appears to improve the response to defibrillation when given to humans
or animals with VF or hemodynamically unstable ventricular tachycardia.
• Amiodarone 300 mg is recommended if VF/pVT persists after three
shocks.
 Lidocaine
• Is recommended for use during ALS when amiodarone is unavailable.
Lidocaine is a membrane-stabilizing anti-arrhythmic drug that acts by
increasing the myocyte refractory period. It decreases ventricular
automaticity, and its local anaesthetic action suppresses ventricular
ectopic activity.
• Lidocaine is indicated in refractory VF/pVT (when amiodarone is
unavailable).
 Intravenous fluids
• Hypovolemia is a potentially reversible cause of cardiac arrest.
• Infuse fluids rapidly if hypovolemia is suspected. In the initial stages of
resuscitation there are no clear advantages to using colloid, so use
balanced crystalloid solutions, Hartmann’s solution or 0.9% sodium
chloride.
• Avoid glucose, which is redistributed away from the intravascular
space rapidly and causes hyperglycaemia, and may worsen
neurological outcome after cardiacarrest.
 Duration of resuscitation attempt
• Duration of resuscitative effort >30 minutes without a sustained
perfusing rhythm
• Initial electrocardiographic rhythm of asystole
• Prolonged interval between estimated time of arrest and initiation of
resuscitation
• Patient age and severity of comorbid disease
• Absent brainstem reflexes
• Normothermia