CPR(BLS & ACLS)

SPEAKER- DIPRO BHATTACHARYA

MODERATOR- DR. SUMANTA MONDAL

RMO, DEPT OF ANESTHESIOLOGY, PAIN AND CRITICAL CARE MEDICINE, RG KAR
MEDICAL COLLEGE AND HOSPITAL
 HISTORY
• James Elam – First to demonstrate CPR ( Cardio pulmonary
resuscitation) as a sound technique

• Peter Safar – Father of modern CPR

• Asmund Laerdal– “Resusci Anne” – Model of medical simulator

(Laerdal Medical)

• Resusci Anne- Face based on the death mask of an unidentified

young female reportedly drowned in River Seine
 DEFINITION
• Cardiac arrest – Cessation of all cardiac mechanical activities
which is confirmed by unresponsiveness, absence of detectable
pulse, apnea/ agonal gasps

• CPR- Emergency maneuver for reviving a patient with cardiac

arrest / an attempt to restore spontaneous circulation and
respiration through a range of maneuvers and techniques
Goals
Restore spontaneous
Maintain oxygen circulation ( CARDIAC
and blood supply to OUTPUT during CPR with
effective, uninterrupted
vital organs during chest compression is at
cardiac arrest best 25-30% of normal
spontaneous circulation

Improve patients
Minimize post
survival and
resuscitation organ
neurologic
injury
outcome
 BLS DO’s AND DONT’s of adult high quality CPR
RESCUERS SHOULD RESCUERS SHOULD NOT
perform chest compressions @ Compress @ slower than 100 or
100-120 per min faster than 120 per min
Compress to a depth of at least 2 Compress to depth < 2 inches or >
inches (5cm) 2.4 inches
Allow full recoil after each Lean on the chest between
compression compressions
Minimize pauses in compressions Interrupt compressions greater than
10 seconds
Ventilate adequately (2 breaths after Provide excessive ventilation (i.e too
30 compressions, each breath many breaths or breaths with
delivered over 1 second, each excessive force)
causing chest rise)
 WHEN NOT TO START CPR ???

1. Scene unsafe
2. Patient breathing normally
3. Obvious clinical signs of irreversible death (rigor
mortis, decapitation, dependent lividity)
4. Valid signed DNR (DO NOT RESUSCITATE) order
Age and site of pulse check in CPR

Category AGE SITE

NEONATE 1st 30 days after birth Precordial auscultation
/ 3 lead ECG
INFANT 30 days to 1 year BRACHIAL ARTERY

CHILD 1 year to puberty FEMORAL/ CAROTID

ARTERY
ADULT/ADOLESCENT After puberty CAROTID ARTERY
 ADULT vs PAEDIATRIC CPR
POINTS ADULT CHILDREN/INFANT
1. Activation of emergency 1st – Activate ERS and get Witnessed collapse- SAME as
response system AED adult
2nd- Start CPR Unwitnessed collapse-
1st- 2 mins of CPR
2nd – Leave the victim to
active ERS
2. Compression to ventilation Always 30:2 1 rescuer: 30:2
ratio without advanced 2 rescuers: 15:2
airway
3. Compression to ventilation 1 breath every 6 seconds ( 10 1 breath every 2-3 seconds (
ratio with advanced airway breaths per min) 20-30 breaths per min)
4. Depth of compression 2 to 2.4 inches Children: about 2 inches
Infant: About 1.5 inches
5. Hand placement Lower half of sternum INFANTS - 1 rescuer: 1 finger
technique
2 rescuers: THUMB encircling
Key changes of CPR 2020
1. A sixth link recovery added to all 4 chains of survival
2. Emphasis on early epinephrine administration. (within 5 minutes
of cardiac arrest), repeat doses every 4 minutes to coincide with
alternate pulse check
3. Separate algorithm for pregnant women and opiod related arrests
4. EEG, Neurological imaging introduced as part of post resuscitation
care
Cont.
5. Rate of breaths in paediatric age group increased to 1 breath
every 2 to 3 seconds (20-30 breaths per min) 30 in children <1
year and 25 for >1 year
6. Advised to consider a cuffed Endotracheal tube in paediatric age
group
7. New algorithm for paediatric tachycardia with pulse (QRS
duration 0.09 sec)
8. Umbilical vein catheterization to be considered
9. 2 thumb encircling compression in infants is better than 2
fingers compression
Cont.
[Link] (facial drop, arm drift, speech difficulties) changed to
FAST (time to call emergency number) for stroke
[Link] intake advised for all non traumatic chest pain before
arrival of emergency medical services unless contraindicated
[Link] monitoring not advised during maternal resuscitation.
Post ROSC it can be done.
[Link] rate in adults 1 breath every 6 seconds rather than
5-6 seconds.
[Link] of waveform capnography recommended during bag
mask ventilation too.
[Link] of mobile technology reasonable.
Rever.
causes
 POST CARDIAC ARREST CARE
• THERAPEUTIC HYPOTHERMIA

Recommended for comatose individuals with ROSC after a cardiac arrest event
Individuals should be cooled to 89.6 to 93.2 degrees F (32 to 36 degrees C) for at least 24 hrs

• OPTIMIZE HEMODYNAMICS AND VENTILATION

 100 percent oxygen is acceptable for early intervention but not for extended periods of time
Oxygen should be titrated, so that pulse oximetry is greater than 94% to avoid oxygen toxicity
Do not overventilate
Ventilation rate of 10 to 12 breaths per min to achieve ETCO2 at 35 to 40 mm Hg
IV fluids and vasoactive medications to be titrated for hemodynamic stability.
Key changes in ACLS
1. Amiodarone and lidocaine are now considered equivalent as
antiarrythmic in cardiac arrest scenario.
2. For adult symptomatic bradycardia , atropine dose changed
from 0.5mg to 1 mg. Dopamine changed from 2-20 mcg/kg/
min to 5-20 mcg/kg/min
3. Emphasis on prevention of hyperoxia, hypoxemia and
hypotension
4. Initial stabilization split in to manage Airway, respiratory
parameters and hemodynamic parameters.
Cont.
5. UPDATED ACS algorithm , contact to balloon inflation goal less then or
equal to 90 minutes
6. Target Spo2 >94% for stroke and general care , 92-98% for post cardiac
arrest care.
7. During CPR, 15 seconds before pausing compressions, high performance
team should check for pulse, precharge defibrillator , prepare to deliver
shock in 10 seconds or less
8. IV preferred over IO
9. New diagram to guide neuroprognostication
10. Routine use of cricoid pressure is not recommended during
endotracheal intubation.
New concepts
CPR coach to help
team leader . He Double
ensures high quality
BLS, while team leader sequencial IN SITU TRAINING
focuses on other defibrillation
aspects like ACLS

SPACED
BOOSTER
LEARNING
TRAINING
APPROACH
 MAJOR UPDATES AND EXPLANATION
UPDATE REASON

Early initiation of CPR by lay rescuers- New evidence shows that risk of
CPR should be initiated for presumed harm to a victim who receives chest
cardiac arrest because the risk of compressions when not in cardiac
harm to the patient is low if the patient arrest is low. Lay rescuers where not
is not in cardiac arrest. able to determine pulse accurately.
Early administration of ephinephrine – More survivors with favorable
It is reasonable to administer neurological outcome according to
epinephrine as soon as feasible in non systematic review and metaanalysis
shockable rhythm cardiac arrest.
Double sequential defibrillation It is the practice of using 2
simultaneous defibrillators for
Cont.
for refractory shockable rhythm
applying near simultaneous shocks.
not supported
2020 ILCOR systematic review found
no evidence to support it. Recent
pilot RCT found repositioning the
pads and changing direction of
defibrillation current is as effective
as double sequential defibrillation

Cardiac arrest in pregnancy- As Maternal metabolism

pregnant patients are more FRC due to gravid uterus
Risk of fetal brain injury from
prone to hypoxia, oxygenation
hypoxaemia
and airway management should
be prioritized
 UPDATE REASON
Real time audiovisual feedback- Recent RCT reported 25%
It is reasonable to use increase in survival to hospital
audiovisual feedback devices discharge from IHCA with
during CPR for real time audio feedback on
optimization of CPR compression depth and recoil.
performance
Physiologic monitoring of CPR Monitoring depends on
quality- It is reasonable to use presence of ETT or arterial
Arterial BP or ETCO2 when line. Targeting compressions
feasible to monitor and to an ETCO2 level of at least
optimize CPR quality 10 mm Hg and idealy 20mm
Hg or greater, maybe useful as
a marker of CPR quality.
IV > IO access- First attempt establishing 2020 ILCOR systematic review comparing
iv access . IO access may be considered if IV the two routes found that IV route was
access is unsuccessful or not feasible. associated with better clinical outcomes in 5
retrospective studies.

Care and support during recovery- Cardiac The process of recovery from cardiac
arrest survivors should have multimodal arrest extends long after initial
rehabilitation assessment and treatment of hospitalization.
physical, neurologic, cardiopulmonary and
cognitive impairments before discharge

Debriefings for rescuers- Referral for follow ANXIETY, POST TRAUMATIC STRESS,
up for emotional support to lay rescuers, emotional and psychological events of
EMS providers, healthcare workers after caring a patient with cardiac arrest. Team
cardiac arrest event. briefings allow review of team performance
 AIRWAY
• Bag mask ventilation with a head tilt chin lift or head tilt- jaw thrust
manouvre is recommended for initial airway control in most
circumstances

• Triple manouvre : Head tilt- chin lift- mouth open, jaw thrust
 ADVANCED AIRWAY
• Depending on level of expertise
of the CPR provider
• ETT
• LMA

• “UNDER NO CIRCUMSTANCES
SHOULD INSERTION OF
ADVANCED AIRWAY
COMPROMISE THE CHEST
COMPRESSIONS”
 DEFIBRILATION
• Delivery of electrical current through the myocardium to
interrupt disorganized cardiac activity and restore organized
cardiac rhythm
MONOPHASIC BIPHASIC

Single 360 Joule shock is 120 – 200 Joule, is usually

delivered (old- not used sufficient to terminate
anymore) arrythmia ( new and better)
DEFIBIRILATOR
 Electrode placement
ADULT
• Upper right sternal border, just below clavicle.
• Lateral to left nipple

CHILD OR INFANT
• Anterior or posterior
CPR IN COVID
 BLS By LAY
RESCUERS

After CPR, wash

hands thoroughly
Perform with soap or disinfect
Place a cloth/towel
hands-only hand with alcohol-
over the person's Use automated
CPR. mouth and nose based hand-gel.
external defibrillator
before performing (AED), if available.
chest
compressions
 BLS BY HEALTH CARE
PROVIDERS
Defibrillation is not
an aerosol-
Should Use a high- generating
have prior efficiency procedure and can
training in particulate air be undertaken after
(HEPA) filter or wearing a surgical
the use of bacterial/viral filter mask, eye
PPE during bag-mask protection, apron,
ventilation and gloves.

Consider Use two hands to hold the mask

compression-only and the person doing
CPR if bag-mask compressions can squeeze the
bag when they pause after 30
ventilation is
compressions
difficult
 ACLS IN COVID
• In high-risk patients, take appropriate steps to prevent cardiac arrest
and consider proactively moving the patient to a negative pressure
room, if available.
• Consider “Do-not-attempt CPR (DNACPR)” in patients with poor
prognosis.
• Restrict the number of staff in the room.
• Clearly communicate COVID-19 status to any new providers
• If shockable rhythm, consider three attempts of shocks before
wearing PPE and starting chest compression.
• Place an oxygen mask and supplement oxygen, if not done already.
Cont.
• Pause chest compression during intubation and consider video
laryngoscopy, if available.
• If supraglottic airway (SGA) is inserted, the compression ventilation ratio
should be 30:2.
• In already intubated, do not disconnect the ventilator circuit while starting
CPR.
• Consider a mechanical compression device, if there is a need for
prolonged CPR.
• Patient in the prone position: If un-intubated, turn immediately to supine
before attempting CPR. If intubated, start CPR in the prone position itself.
• Ensure the safe removal of PPE
 REFERENCES
1. AHA BLS/ACLS provider manual- 2020
2. Kundra P, Vinayagam S. COVID-19 cardiopulmonary
resuscitation: Guidelines and modifications. J Anesthesiology
and Clinical Pharmacology 2020;36:S39-44
3. ISA cardiopulmonary resuscitation guidelines 2017
THANK YOU