1. bls & als for adults

Basic Life Support for Adults

Prof. Dr. Ram Sharan Mehta, MSND, CON1 Prof. Dr. RS Mehta, BPKIHS

BLS & ALS

HOW MANY TIMES DOES THE HUMAN HEART BEAT IN A DAY ?

1,00,800 beats per day

(70 beats x 60 minutes x 24 hours = 1,00,800 beats)

2 Prof. Dr. RS Mehta, BPKIHS

BRAIN TISSUE = ?HEART TISSUE =?KIDNEY TISSUE=?

CPR=CPCR CARDIO PULMONARY CEREBRAL RESUSCITATION

Death of Tissue after cutoff oxygen


BLS ALS: steps

ABCD

DEFGHI


DEFINITIONS

CARDIAC ARREST: Abrupt cessation of cardiac pump function which may be reversible by a rapid intervention but will lead to death in its absence.

DEATH: Irreversible cessation of all biologic functions


CARDIAC: Coronary artery disease M.I. Arrhythmia Low C.O.,failure,shock Cardiomyopathy Myocarditis Massive pulmonary

emboli

OTHERS Severe anaphylaxis Suffocation Electrocution Trauma Stroke Exsanguinations Drowning

CAUSES OF CARDIAC ARREST


REVERSIBLE CAUSES OF CARDIAC ARREST:

4 Ts: Thromboembolism Tension

pneumothoraxTamponadeToxicity(TCAs,b-

blockers,ca channel blocker,dogoxin)

4Hs:Hypoxia HypovolemiaHypo/hyperkalemiaHydrogen ions


Introduction:

Lack of resuscitation skills of nurses and doctors in basic life support (BLS) and advanced life support (ALS) has been identified as a contributing factor to poor outcomes of cardiac arrest victims.

The hypothesis was that nurses’ knowledge on BLS and ALS would be related to their professional background as well as their resuscitation training.


Introduction...

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 – double or triple survival from sudden cardiac arrest (SCA).

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


CHAIN OF SURVIVAL


BASIC LIFE SUPPORT

Sequences of procedures performed to restore the circulation of oxygenated blood after a sudden pulmonary and/or cardiac arrest

Chest compressions and pulmonary ventilation performed by anyone who knows how to do it, anywhere, immediately, without any other equipment

Protective devices


BLS Its Cardiopulmonary Resuscitation (CPR).Combines rescue breathing and chest

compressionsRevives heart (cardio) and lung

(pulmonary) functioning– Use when there is no breathing and no pulse

Provides O2 to the brain until ACLS arrives

12Prof. Dr. RS Mehta, BPKIHS

How CPR WorksEffective CPR provides 1/4 to

1/3 normal blood flowRescue breaths contain 16%

oxygen (exhaled).


Start CPR Immediately

Better chance of survivalBrain damage starts in 4-6

minutesBrain damage is certain after

10 minutes without CPR


Do Not Move the Victim Until CPR is Given and Qualified Help Arrives…

unless the scene dictates otherwise– threat of fire or explosion– victim must be on a hard surface– Place victim level or head slightly

lower than body15 Prof. Dr. RS Mehta, BPKIHS

Even With Successful CPR, Most Won’t Survive Without ACLS

ACLS (Advanced Cardiac Life Support)

ACLS includes defibrillation, oxygen, drug therapy


17

BLS = CPR = ABC?

Prof. Dr. RS Mehta, BPKIHS

DRS CAB D

Basic Life Support (BLS)ABCs - Airway, Breathing, Circulation

Steps to follow in BLS– Approach Safely– 1. Check the responsiveness of the victim– 2. Call for Help– 3. Position victim on his or her back– 4. Open the airway– 5. Assess breathing– 6. Assess circulation– 7. Stay with the victim until help arrives.


Details of the Steps:


APPROACH SAFELY!

Scene

Rescuer

Victim


CHECK RESPONSE

– Shake shoulders gently– Ask “Are you all right?”– If he responds• Leave as you find him.• Find out what is wrong.• Reassess regularly.


SHOUT FOR HELP


Open the airway with the head tilt-chin lift method to check for

breathing.

Check for Breathing


OPEN AIRWAY

Head tilt and chin lift- lay rescuers- non-healthcare

rescuers

No need for finger sweep unless solid material can be

seen in the airway


Look, listen and feel for breathing for not over 10 seconds.

Check for Breathing


OPEN AIRWAY

Head tilt, chin lift + jaw thrust- healthcare professionals


Head Tilt–Chin Lift ManeuverStep 1 Step 2

Step 3 Step 4


Jaw-Thrust ManeuverStep 1 Step 2

Step 3


Use a barrier device of some type while giving breaths.

Giving Breaths


Give 2 breaths, each for about 1 second, watching the chest rise

and fall.

Giving Breaths


RESCUE BREATHS

Pinch the nose Take a normal breath Place lips over mouth Blow until the chest rises Take about 1 second Allow chest to fall Repeat


RESCUE BREATHS

RECOMMENDATIONS:- Tidal volume 500 – 600 ml

- Respiratory rate give each breaths over about 1s with enough volume to make the victim’s chest rise

- Chest-compression-only continuously at a rate of 100 min


Pocket mask vs bag-valve mask

•Easy to use and easily available

•One way valve•Can give O2 up to

50%

Pocket mask

•Takes more skill and requires 2 people in most cases

•Can give O2 up to 85%

Bag-valve Mask


Give 30 chest compressions, hard and fast, positioning hand midway between breasts.

Giving Chest Compressions


Use cycles of 2 breaths and 30 compressions.

Cycles of Breaths/Compressions

2 breaths + 30 compressions


• Place the heel of one hand in the centre of the chest

• Place other hand on top • Interlock fingers• Compress the chest

– Rate 100 min-1

– Depth 4-5 cm– Equal compression : relaxation

• When possible change CPR operator every 2 min

CHEST COMPRESSIONS


CONTINUE CPR

30 2


DEFIBRILLATION


Date

East of England Ambulance ServiceNHS Trust

BLS & AED

12/02/201540

Understanding Defibrillation The heart’s pumping

action controlled by electrical system

Electrical rhythm normally very organized

Normal heart’s rhythm is called “Sinus Rhythm”

Normal heart rate of 60 - 100 beats per minute

Sinus Rhythm

Date


BLS & AED

12/02/201541

Understanding Defibrillation:Ventricular Fibrillation (VF)

VF is the most common rhythm in Sudden Cardiac Arrest (90%)

Electrical Problem in Nature

Chaotic rhythm results in “quivering of heart” and results in loss of pulse

VF will result in brain damage within 5 minutes and death in 10-15 minutes

Date


BLS & AED

12/02/201542

Understanding Defibrillation Defibrillation may correct VF Uses DC current delivered

across the heart A successful defibrillation

“depolarizes” the heart’s cells

Depolarization allows the cells to “reorganize”

Defibrillation is the ONLY effective cure for VF!

DC Shock: Joules

AED OR Defibrillation Machine

150-360 Joules: Monophasic 150-270 Joules: Biphasic


Use the AED as soon as it is available and ready to use.

Use of an AED

Automated External Defibrillator44 Prof. Dr. RS Mehta, BPKIHS

Follow the AED prompts to give a shock, then give CPR again

while the AED is analyzing the victim’s rhythm.

Using AED and CPR


First turn it on.Then simply follow instructions.

Using an AED


AUTOMATED EXTERNAL DEFIBRILLATOR (AED)

Some AEDs will automatically switch themselves on when the lid is opened


ATTACH PADS TO CASUALTY’S BARE CHEST


ANALYSING RHYTHM DO NOT TOUCH VICTIM


SHOCK INDICATED

Stand clear Deliver shock


SHOCK DELIVEREDFOLLOW AED INSTRUCTIONS

30 251 Prof. Dr. RS Mehta, BPKIHS

NO SHOCK ADVISEDFOLLOW AED INSTRUCTIONS

30 252 Prof. Dr. RS Mehta, BPKIHS

IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN RECOVERY POSITION



DEFIBRILLATION SAFETY !

THE PATIENT. 5 point check Pacemaker Jewellery Hair on chest Damp/Wet skin Patches (GTN)

THE AED. In good working order Do Not use in Heavy

rain Do Not use if they lay in

a pool of water Do Not use in an

explosive environment !


If the victim responds, position him in the recovery position and monitor breathing until help

arrives.

The Recovery Position

Infant Recovery Position56 Prof. Dr. RS Mehta, BPKIHS

http://upload.wikimedia.org/wikipedia/commons/3/34/Recovery_position.jpg

Complications of CPR Skeletal injuries especially rib# Visceral injuries- myocardial and pulmonary

contusions, blood in pericardial sac, pneumothorax, liver and spleen rupture, gastric perforation

Airway injuries- tracheal & laryngeal injuries Skin and integument damage


Immediately after CPR…

Laryngoscopy; 100% oxygenUrinary catheterNG tubeestablish or verify existing intravenous

access; start with NSTransfer to a special care unit for

continuous monitoring and therapy.58 Prof. Dr. RS Mehta, BPKIHS

After CPR…Complete exam including– serial vitals– urine output– 12-lead ECG– Chest x-ray

– Blood glucose– Serum urea,

creatinine– serum electrolytes

(+Mg++ and Ca++)– Cardiac markers


Atropine, Adrenaline, CaCl2, Digoxin

Atropine: 5 amp (3 mg) single bolus dose to increase heart rate

Adrenaline: 1 ml=1mg, 1amp=1:1000 dilution, 1gm=1000mg, 1000mg=1000ml 1mg every 2-3 min till B P is maintained

Cacl 2= 5-10 mmol Digoxin = 0.5 mg stat then 0.25 mg 6hrly


Factors contributing to cardiac arrest or complicating resuscitation or post-resuscitation care

H’s Hypovolemia Hypoxia H+ (acidosis) hyper-/hypokalemia Hypoglycemia hypothermia

T’s

Toxins tamponade (cardiac) tension pneumothorax thrombosis of coronary or

pulmonary vasculature trauma


Prognosis

5 clinical signs strongly predicting death or poor neurological outcome:

No corneal reflex at 24 hoursNo pupillary response at 24 hoursNo withdrawal response to pain at 24hoursNo motor response at 24 hoursNo motor response at 72 hours


Stroke (first 2 hours are critical)Asthma (check for inhalers)Fainting (look for injuries from fall)Seizures (check for medication)Diabetic emergencies ChockingPoisoning

First Aid Management for Common Problems:


CONTINUE RESUSCITATION UNTIL

– Qualified help arrives and takes over– Victim revives: The victim starts

breathing normally– Rescuer becomes exhausted– Cardiac arrest of longer than 30 minutes

(controversial)


Summary


Simplified adult BLS algorithm.

Robert A. Berg et al. Circulation. 2010;122:S685-S705Copyright © American Heart Association, Inc. All rights reserved.66 Prof. Dr. RS Mehta, BPKIHS

BLS healthcare provider algorithm.

Robert A. Berg et al. Circulation. 2010;122:S685-S705Copyright © American Heart Association, Inc. All rights reserved.67 Prof. Dr. RS Mehta, BPKIHS

Algorithm of ALS 2015


• “Look, listen, and feel for breathing” has been removed from the algorithm.

• Continued emphasis has been placed on high-quality CPR (with chest compressions of adequate rate and depth, allowing complete chest recoil after each compression minimizing interruptions in compressions, and avoiding excessive ventilation).

Key Issues and Major Changes


To initiate chest compressions before giving rescue breaths (C-A-B rather than A-B-C).

Compression rate should be at least 100/min (rather than “approximately” 100/min).

Compression depth for adults has been changed from the range of 1½ to 2 inches to at least 2 inches (5 cm).


BLS only provides 15 to 20% of normal cardiac output and should be regarded as “buying time” until the commencement of ALS.

If there is more than one rescuer present , another should take over the CPR every 1 to 2 minute to prevent fatigue.


ALSProf. Dr. RS Mehta, BPKIHS73

ALS ALGORITHM


Circulation by cardiac compression Airway management by equipments Breathing by advanced techniques Defibrillation by manual defibrillator Drugs.

75

ALS includes:


Chest compression:- rate- 100/min- Place- mid of sternum- Depth- at least 5 cm (2inches)- or 1/3rd of AP diameter of chest- No synchrony with respiration

Circulation


• The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest.

• The precordial thump may be considered for patients with witnessed, monitored, unstable VT (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery.

Precordial Thump


1) Guedel’s airways- Most commonly used

78

A. Airway management


2) Laryngeal Mask Airways

Airway management


3) Endotracheal tubeAirway management


Breathing can be accomplished by 1.Bag and mask ventilation2.Ventilation by advanced method:

a.ET tube: Intubation is most definitive and best method for ventilation.

b.LMA c.Tracheostomy tube

3. Ventilation by automatic ventilators.

81

B. Breathing:


Bag and Mask Ventillation


It consists of self inflating bag made up of rubber or silicon, connector, safety valve, mouth piece.100% oxygen can be delivered by AMBU bag by attaching oxygen source and oxygen reservoir.

83

Artificial Manual Breathing Unit(AMBU)


These are the treatment for tachydysrhythmias.

Defibrillation depolarize the critical mass of myocardial cell at once. When they repolarize the sinus node recapture its role as the pacemaker .

Is treatment of choice for pulseless VT/VF.

Defibrillation


85

Ventricular tachycardia


86

Ventricular fibrillation


Defibrillators can be classified as : Monophasic(delivers current

of one polarity only and

Biphasic (deliver current of 2 polarity)

Defibrillator


Position of defibrillator paddle:

88

1st paddle - on the right side of the chest just below the clavicle

2nd at precordial, region.

Paddle should be applied with pressure equivalent to 10 kg.


Adult: 13cm Children:8cm Infants:4.5cmLatest Recommendation for shock protocol ;Previous recommendation of 3 successive shock

(200,300,360J)Now a days only single shock is recommended .i.e. 360J by monophasic

150-200J by biphasic 89

Paddle size


Apply conducting jelly between the paddle and the skin. Place the paddle so that they don't touch patient’s

clothing and bed linen and aren't near medication and direct oxygen flow.

Ensure that defibrillator is not in synchronized mode. Don't charge the device until ready to shock; then keep

the thumbs and fingers off discharge button until paddle are on the chest.

90

Nurses role while performing defibrillation


Before pressing the discharge button call “ all clear” 3 times

1st clear: Ensures you aren’t touching patient,bed, equipment

2nd clear: Ensures no one is touching patient, bed , equipment

3rd clear: Ensures you and everyone else are clear off the patient and anything touching the patient.

91

Nurses role in defibrillation


Record the delivered energy and the results (cardiac rhythm and pulse).

After the event is complete inspect the skin under the pads and paddles for burns , and if any detected consult about the treatment.

92

Nurses role in defibrillation


1. Adrenaline(all types of cardiac arrest)- 1mg every 3-5 mins

2. Amidarone(VF,VT)- 1st dose:300mg IV bolus, 2nd dose 150 mg

3. Lidocaine(If Amidarone isn’t available)4. Sodium bicarbonate(only if cardiac arrest is

associated with hyperkalemia or tricyclic anti-depressent overdose)

5. Calcium gluconate

93

DRUGS


Class : Adrenergic MOA : Causes Cardiac stimulation Indication : cardiac arrest Dose : Adults – 0.5-1 mg IV - repeat every 5min - Children – 10 mcg/kg Adverse reaction : nervousness , tremor, headache,

drowsiness , palpitation , tachycardia , dyspnea .

94

Adrenaline (Epinephrine):


Class : Ventricular antiarrhythmic MOA : abolishes ventricular arrhythmia Indication : recurrent VF , unstable VT , atrial

fibrillation Dose : 300mg IV ; further 150mg may be

given , followed by an infusion of 900mg for 24 hour.

95

Amiodarone:


FLOWCHART OF ACLS


Unresponsive

Call for help(monitor/defribillator)

Start BLS algorithm

Attach monitor & defibrillator when available

Check rhythm97 Prof. Dr. RS Mehta, BPKIHS

Shockable

VT

VF

Non-shockable

Asystole

PEA

98

Rythm


VF and VT


100

Asystole and PEA


SHOCKABLE(pulseless VF/VT)

1stShock (150-200 biphasic, 360 monophasic)

CPR 30:2(2min)

If VF,VT persists

2nd Shock( 150-360 biphasic, 360 monophasic)

CPR30:2(2 min)

101


Check monitor(if VT,VF persists)

Adrenaline 1mg IV every 3-5min

3rd Shoc

kCPR 30:2(2 min)

Check monitor(if VT,VF persists)

Amidarone(300 mgIV)

4th Shock

CPR 30:2 (2 min)

Adrenaline 1mg IV102


5th shock

Further shock after each 2 min period of CPR

If organised electrical activity seen,check for

pulse

If pulse present:start post resuscitation care

If no pulse and asystole seen :continue CPR and switch on to non shockable rhythm10


Start CPR 30:2 Give adrenaline 1mg as soon as intravascular

access is achieved. Continue CPR 30:2 until the airway is secured,

then continue chest compressions without pausing during ventilation

Consider possible reversible causes and correct any that are identified

Management of Asystole and PEA

104


Recheck the patient after 2 min: If there is still no pulse and no achange in the ECG

appearance:- Continue CPR.- Recheck the patient after 2 min and proceed

accordingly.- Give further adrenaline 1 mg every 3-5 min (alternate

loops).- If VF/VT, change to the shockable rhythm algorithm.- If a pulse is present, start post-resuscitation care.

Management of Asystole and PEA

105


WHEN TO STOP RESUSCITATION

106


Optimizing vital organ perfusion Maintain o2 saturation more than or equal to 94% Transport to comprehensive post arrest system of care Emergent coronary reperfusion for high suspicion of

STEMI or AMI Temperature control Aniticipation, treatment and prevention of multi organ

dysfunction

107

POST RESUSCITATION CARE


Thank you

108

The woods are lovely dark and deep but, I have promises to keep and miles to go before I sleep and miles to go before I sleep

-Robert FrostProf. Dr. RS Mehta, BPKIHS

Date post:	15-Apr-2017
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1. bls & als for adults

Health & Medicine