Cardiac First Response (CFR)

Practitioner Course
 Format of the Training
 Introduction – Participants / Instructors
 Ground Rules
 CFR, its Objectives
 Pre-test Scenarios
 Presentations & Practical Demonstration
 Hands-on Practice
 Written Examination & Skill Test (>80%)
 Remediation (if required)
 Participant’s Feedback
 Summery & Conclusion
2
 Course Contents of CFR Training
 Safety – Self, Casualty & Bystanders
 Anatomy & Physiology of the Heart
 Airway Management
 Chain of Survival – Adult, Child & Infant
 Circulatory Emergencies
 Use of an AED
 Foreign Body Airway Obstruction (FBAO)
3
 Course Contents of CFR Training
 Recovery Position
 Recognition of Death
 Legal Implications
 Handover to EMS
 Stress Debriefing
 Written & Skill Tests
 Summery & Conclusion

4
 Standard Precautions
Personal Safety / Barrier
Devices
• Gloves (latex free)
• Face Shield
• CPR Mouth Piece
• Pocket Mask
• Safety Goggles/Glasses
• Aprons & Gowns
• Safety Shoes
5
 Airway Equipment
 Airway:
 Various sizes
 BVMs:
 Adult
 Child
 Infant
Cylinder:
 D size
 AF, E, F, G, J
 F size
6
Oro-pharyngeal Airways

7
 Health Hazards – Safety First
 Diseases spread through blood and other
bodily fluids
 HIV / AIDS

 Hepatitis B & C

 Use gloves
 CPR mouth piece / face shield
 Never regard any patients as ‘Safe’, NOT
even children!

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 Safety
• Self
• Scene
• Survivor
Scene Assessment
 Fire, Wires
 Chemical
 Traffic
 Farm
 School, Home
 At Work, Sports 9
 New Guidelines - 2010
Circulation
Airway
Breathing
Defibrillation
 Previous guidelines
 Airway
 Breathing
 Circulation
 Defibrillation 10
 Vital Signs Applicable to First Aid
 Pulse:
 Adult 60 - 100 beats per minute
 Child 80 - 110 beats per minute
 Infant 110 - 140 beats per minute
 Newborn 120 - 150 beats per minute
 Respiration: Normal breathing tempo
 Adult 12 - 20 breaths per minute
 Child 15 - 25 breaths per minute
 Infant 20 - 30 breaths per minute
 Newborn 40 - 50 breaths per minute
• Observe Speed, Depth & Breathing Sound
• ‘Agonal Gasps are not Effective Breaths 11
 The Heart
 Fist size

 Muscular Organ

 Centre of Chest

 Four Chambers

 Pumping Action
12
 Blood Supply to the Heart
Coronary arteries
• Two main Arteries
• Supply blood to the Heart muscle
• Heart Disease due to narrowing or blockage

13
 Heart Attack or Myocardial Infarction

 Commonly caused by a sudden

obstruction of blood supply to part of
the heart’s muscle

 Clot in a Coronary artery

14
 Heart Attack
Symptoms & Signs
 Severe chest pain
 Spreading to jaw or one / both arms
 Pain not eased with rest
 Discomfort high in the abdomen, may feel
like severe indigestion
 Collapse without warning

15
 Heart Attack
 Shortness of Breath
 Feeling of Impending Doom
 Ashen skin (Pallor+Hypoxia)
 Blue lips (Cyanosis)
 Profuse Sweating
 Air Hunger
 Silent Infarction may be seen in Diabetics,
Women and Elderly men
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 Heart Attack
Treatment
 Place patient in Half Sitting Position
 Make casualty Comfortable
 Call an Ambulance/Doctor/ACLS
 Medication
 Patients may take themselves
 Assist patient to take medicine/s
 Administer medicine to the patient
 Rest & constantly Monitor
 MONA (Morphine, Oxygen, Nitrates, Aspirin) 17
 Aspirin
Presentation
 300 mg Soluble Tablet
Administration
 Chewed Slowly

 Dispersed in 100 ml of water

 Coated Tabs not recommended

 Note time when Aspirin is taken

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 Aspirin
Side Effects
 Epigastric pain and discomfort
 Bronchospasm (Asthma)
 Gastrointestinal Hemorrhage

Contra-Indications
 Allergy
 Bleeding disorder
 Active Gastro-intestinal Ulcer
 Age < 16 years
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 Stroke
Occurs when blood flow to the brain is disrupted by
a clot or bleeding from a damaged blood vessel.
Warning Signs of Stroke
 Sudden numbness & Weakness of face, limbs, on
one side of the body
 Headache or Dizziness
 Sudden Confusion, trouble speaking and / or
understanding
 Sudden trouble seeing in one or both eyes
 Gradual or Sudden loss of consciousness
 Paralysis down one side of the body
 Drooping of one side of the face
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 F.A.S.T. Assessment
 F – Facial Weakness
• Can patient smile or show teeth
• Have Eyes or face drooped?
 A – Arms Weakness
• Can patient raise both arms equally and hold
position for 5 seconds
 S – Speech Problems
• Can patient speak clearly and understand what
you say
 T – Time to
• Note onset of Symptoms, Call for help, Treat 21
 Stroke
Treatment
 Keep casualty comfortable
 Call for an ambulance
 Lie casualty down
 Raise head and shoulders slightly
 Tilt casualty's head towards weaker side to
allow fluid to drain out
 Wipe face with damp cloth if they dribble

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Adult Chain of Survival

23
 Pediatric Chain of Survival

Early Prevention Early CPR Early Access Early ALS Early Post
Resuscitation Care

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 Chain of Survival
Adult Child / Infant
• Early Access • Early prevention
• Early CPR • Early CPR
• Early Defibrillation • Early Access
• Early advanced care • Early Advanced care
• Early Post Resuscitation • Early Post Resuscitation
Care care
Mostly Cardiac Arrest Mostly Respiratory
Exceptions: Arrest
Drowning, Suffocation, Poisoning &
Choking 25
 In Europe, You Can dial 112 or 999
from a Mobile
 without entering a Code
 without taking the Lock off

 even if the SIM Card is missing

 if you have no Credit

Important:
• You cannot make a call if the mobile’s
battery is dead
 In Pakistan – Edhi 115 / Rescue 1122 26
 Emergency Services 115 /1122
Try to give the Following Information:
• Name & telephone number
• Exact location with accurate directions
• Type of incident
• Seriousness of incident
• Number of patients
• Age, sex and condition of patient/s
• Number of dead people (if any)
• Any hazards – e.g. risk of fire, collapse of building
• Don’t hang-up until you are told to do so
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• Don’t keep your phone engaged
 Cardiac Arrest
Causes
• Heart Attack
• Drowning
• Poisoning
• Suffocation
• Electrocution
• Major Injuries
• Severe Allergic Reactions
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 Reversible Causes of Cardiac Arrest

Hs Ts
 Hypovolemia  Thrombosis (M.I)
 Hypoxia  Temponade, Cardiac
 Hydrogen Ion (Acidosis)  Tension Pneumo-thorax
 Hypo-Hyperkalemia  Thrombo-embolism (lung)
 Hypothermia  Toxins / Tablets
 Hypo-Hyperglycemia  Trauma

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 Cardiac Arrest
 Heart Attack is the most common cause
 Abnormal rhythm
• Ventricular Fibrillation (70%)
• Chaotic electrical activity
• Uncoordinated muscular contraction
• No effective pumping action
• Death within minutes if not treated
• Other causes are Asystole & Pulseless
Electrical Activity (PEA)
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 CPR TIME LINE
 0-4 mins. brain damage unlikely
 4-6 mins. brain damage possible
 6-10 mins. brain damage probable
 Over 10 mins. probable brain death

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 Cardiac Arrest
Casualty
 Unresponsive
 Not Breathing
 No pulse
Management
 CPR

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 Cardiac Arrest (Adult)
 Safety (Self, Survivor and Scene)
 Standard Precautions
 Check for Response, if No Response, get help and an AED
 Open Airway and scan Chest for signs of Breathing
 In No Breathing or NOT Breathing normally, Call for Help, ask
for an Ambulance and an AED
 Check Carotid Pulse for at least 5 seconds and NOT more
than 10 seconds
 Start Chest Compressions - Hand position in Center of the
Chest between imaginary nipple line
 Deliver 30 Compressions @ 100 per minute in 18
seconds (at least 23 effective out of 30)
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 Cardiac Arrest (Adult)
 Insert right size OPA and give Two Breaths (One
second each) either direct Mouth-to-Mouth, with
Face Shield / pocket Mask or Bag Valve Mask
(BVM)
 Look for the Chest rise
 Continue cycles of 30 Compressions and Two
Breaths until AED arrives
 May check for pulse after two minute of CPR
 Continuing CPR @ 30:2 and follow AED prompts (if
available)
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 Key Concepts- High Quality CPR
 Pushing Hard & Fast
• Rate at least 100 per minute

• Compression depth at least 2 inches (5cm)

 Allow complete Chest Recoil after each compression

 Minimize Interruptions in Chest Compressions to less

than 10 Seconds

 Avoid Hyperventilation
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Cricoid pressure

36
 AED
 Automated

 External

 Defibrillator
37
 AED
Components
• Case
• On /Off switch
• Voice prompts
• Screen (optional)
• Pads
• Leads and connector
• Analyze button (optional)
• Shock button 38
 Important
Only place the AED on a Casualty
who is:

 Unresponsive

 Not breathing

 No Signs of
Circulation or
Pulse
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 AED & Ventricular Fibrillation
 VF -most frequent initial rhythm in Sudden Cardiac
Arrest (SCA)
 Useless quivering of the heart that results in no
blood flow
 Defibrillation is passage of electric current through
the Heart
 Its the only effective treatment for VF
 Chances of survival increase with early CPR & Early
Defibrillation
 Chances of survival decrease by 7-10% with every
passing minute
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 AED Protocol
 Turn on the AED – follow steps 1-2-3.
 Clear the patient’s Chest.
 Put left and right pads on patient’s bare
chest at correct position.
 If shock advised, Shout to warn the people to
stay ‘Clear’.
 Deliver Shock by pressing the Orange button.
 Immediately restart CFR with 30 chest
compressions and follow AED prompts.
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 AED
 To be used cautiously in Wet Weather
 Not used under One year of Age in pre
hospital settings
 Poor maintenance can cause AED
failure

42
 AED Special Situations,
Check for “P’s”
 Pacemaker  Perspiration

 Pendants  Patches

 Piercing  Playtex

 Pregnancy  Pani (H2O) 43

 Cardiac Arrest (Child)
 Safety (Self, Survivor and Scene).
 Standard precautions.
 Check for Response, if no response, Shout for help if you are
alone.
 Otherwise ask someone to call for an Ambulance and an AED.
 Insert right size OPA (if available).
 Look, Listen and Feel for Breathing, if Not breathing.
 Provide Two Effective Breaths in Max Five Attempts.
 Check for Carotid Pulse for at least for at least Five seconds
and NOT more than 10 seconds.
 Start Chest Compressions - Hand position in Center of the
Chest below the nipple line.
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 Cardiac Arrest (Child)
 Deliver 30 Compressions @ 100 per minute in 18
seconds
 Ensure accuracy of Chest Compressions - Depth
about Two inches (5 cm), allow full Chest Recoil
 Continue cycles of 30 Compressions and Two
breaths until AED arrives
 May check for pulse after two minute of CPR

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 Cardiac Arrest (Infant)
 Safety (Self, Survivor and Scene)
 Standard precautions
 Check for Response
 Shout for help if alone
 Otherwise ask someone to call for help
 Open Airway
• Sniffing position
 Insert right size OPA
46
 Cardiac Arrest (Infant)
 Provide Two Effective Breaths in Maximum 5
attempts
 Check Brachial Pulse, if its Absent or < 60,
start 30 Chest Compressions just below the
nipple line
 This is followed by Two effective Breaths
 Change to 15-2 if 2nd Rescuer is arrives
 After 5 cycles (2 Min. CPR), Call for help if not
already done, continue until help arrives or
infant becomes responsive 47
 Infant CPR
 Make good seal over infant’s nose & mouth
with your own mouth
 If your mouth is too small to go over mouth
and nose of the baby, you can blow through
nose while keeping the mouth closed
Remember: If Pulse rate is < 60 with poor
perfusion, Continue CPR

48
 Child / Infant
 One or two Hands technique in Child

 For Infant, use Two Thumbs technique with Two

rescuers CPR.

 For Child & Infant with Two persons CPR, the Rate
changes to 15:2

 For a Child in Cardiac Arrest, you can shock after

initial Two Minutes (5 cycles of CPR)
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 Similarities & Differences
in Adult, Child & Infant CPR
CPR Protocols Adult Child > 1 yr Infant
8 year or older And < 8 yrs Up to 1 Year
Check for By Tapping of By Tapping of By Tapping of
Responsiveness Shoulders Shoulders Feet
Early Access Call for help Shout for Help Shout for Help
Opening the Airway Head Tilt, Head Tilt, Sniffing
Chin Lift Chin Lift Position
Inserting the OPA Invert & Rotate Direct / Straight Direct / Straight

Giving Two Effective Mouth to Mouth Mouth to Mouth Seal Mouth over Nose
Breaths Nose Pinch in two Nose Pinch, in Max. & Mouth, in Max. five
attempts five attempts attempts
Volume of Air Give normal breath Give normal breath Puff of Air
Look for chest rise Look for chest rise Look for chest rise
Ventilation Duration 1 second 1 second 1 second

50
Pulse Check Carotid Carotid Brachial
 Similarities & Differences
in Adult, Child & Infant CPR
CPR Protocols Adult 8 year or Child - > 1 year Less Infant
older than 8 years Up to 1 Year
Compression Both Hands One or Both Hands Two Fingers
Two Thumbs with
Two Rescuers
Compressions At least 2 Inches / About 2 Inches 1/3 AP Diameter
Depth 5-6cm 5 cm 4 cm
Compression:
Ventilations Single 30:2 30:2 30:2
Rescuer
Compression: 30:2 15:2 after initial 5 15:2 after initial 5
Ventilations Cycles of CPR @ of Cycles of CPR @ of
Two Rescuers 30:2 30:2
Compression Rate 100 per minute 100 per minute 100 per minute
(Speed)
AED protocol Shock when Shock when advised Use Used in Hospital
advised Child protocol settings 51
 Key Components - 2010 Guidelines
Component Adults Children Infants
Recognition No breathing or No breathing or only gasping
(Unresponsive ) for all gasping
ages
No Pulse palpated within 10 seconds for all ages
CPR CAB ABC ABC
Compression Rate At least 2 inches (5-6 About 2 inches About 1 ½ inches (4
cm) (5 cm) 1/3 cm) 1/3 AP
AP diameter diameter
Chest Wall Recoil Allow complete recoil between compression
Attempt to limit interruptions to < 10 seconds
Compression – 30:2 30:2 Single Rescuer
Ventilation Ratio 1-2 rescuers 15:2 when two rescuers
Ventilations with One breath every 6-8 seconds (8-10 breaths/min)
Advanced Airway Asynchronous with chest compressions
One breath after 5-6 sec. (10-12 breaths / min) in Adults and One
breath after every 3-5 seconds (12-20 breaths / min) in Children for
Respiratory Arrest situations
Un-trained Rescuer Compression-only OR Hands-only CPR 52
 FBAO
 Foreign

 Body

 Airway

 Obstruction
53
 FBAO (Adult)
Mild or Partial Obstruction
Patient is Responsive
 Ask are you choking?

Patient can
• Speak
• Make sounds
• Cough loudly
• Encourage casualty to Cough
• Advise to go to hospital if needed 54
 FBAO (Adult)
Severe or Full Obstruction
Patient is Responsive
 Ask are you Choking?

 Reassure

 Give up to Five Back Blows

 Perform Five Abdominal Thrusts until

object comes out or Casualty goes
Unresponsive
55
 FBAO (Adult)
Patient Unresponsive
1. Call for Help
2. Start CPR with 30 Chest Compressions
3. Open mouth wide and Remove Object if
you can see it
4. Continue CPR
5. Each time open mouth to see for any
obstructing Object, Try to remove it and
provide two ventilations
56
 FBAO (Adult)
Pregnant or Obese
• Perform Chest Thrusts
Bed Ridden Patient
• Straddle the patient
• Perform Abdominal Thrusts
Wheelchair bound Patient
• Remove sides from chair (if possible)
• Kneel behind the patient
• Perform Abdominal or Chest Thrusts 57
 FBAO (Child)
Mild or Partial Obstruction
Patient is Responsive
• Ask are you choking?
The Child Can
• Speak
• Make Sounds
• Cough loudly
• Encourage casualty to Cough
• Advise to go to hospital if needed 58
 FBAO (Child)
Severe or Full Obstruction
Patient is Responsive
 Ask are you Choking?

 Perform five Back Slaps

 Followed by five Abdominal Thrusts
 Continue until object comes out or casualty
goes Unresponsive
59
 FBAO (Child)
Unresponsive Child
1. Call for Help
2. Place on flat surface
3. Open Airway, look for obstructing
object and try to remove if possible
4. Try to ventilate (up to 5 Times)
5. Continue CPR

60
 FBAO (Infant)
Mild or Partial Obstruction
The Infant Can
 Make Sounds

 Cough loudly

 Let Infant Cough

 Advise to go to Hospital if needed

61
 FBAO (Infant)
Severe or Full Obstruction
Infant is Responsive
1. Cannot Breathe
2. Cannot make a Sound or Cry

3. Has high pitched noisy Breathing

4. Begin Five back Blows and Five chest thrusts until

Object comes out or infant goes Unresponsive

62
 FBAO (Infant)
Unresponsive Infant
1. Call for Help
2. Place on flat surface
3. Open Airway, Look into the mouth for obstructing
object and try to remove it if you fine one
4. Try to ventilate (5 Times)
5. Stray chest compression
Continue steps 3-5 until help arrives or object comes out

63
Recovery Position

64
 Handover to EMS
 Incident Report Form
 Provide Age and Sex of patient
 Describe incident and chief complaints
 Report vital signs & examination results
 Report interventions provided
 Good Samaritan Bill
 DNR – Do Not Resuscitate?
 AND – Allow Natural Death
65
 PTSD & Stress Debriefing
• Denial “Not me!”
• Anger “Why me?”
• Bargaining “Okay, but”
• Depression
• Acceptance
 Stress Management
• Prevent
• Recognize
• Reduce Critical Incident Stress
66
 O.P.Q.R.S.T.A
 O – Onset – Sudden, gradual

 P – Provocation – Aggravated / relieved by

 Q – Quality – Stabbing, colicky, burning

 R – Region / Referral / Recurrence / Relief

 S – Severity – On a scale of 1-10

 T – Time of Onset of symptoms

 A – Associated Symptoms: Nausea, Vomiting

67
 S-A-M-P-L-E
 S – Signs & Symptoms

 A – Allergies (Food, Medicines)

 M – Medications

 P – Past / Pertinent Medical History

 L – Last Oral Intake

 E – Events leading to present condition

68
 S-T-A-B-L-E
 S – Sugar (Hypo/hyperglycemia)

 T – Temperature

 A – Airway

 B – Blood Gases

 L – Lab Works

 E – Empathy
69
 Recognition of Death
 It is inappropriate to commence
resuscitation when following indicators of
Death are present.
• Decomposition
• Rigor mortis
• Incineration
• Decapitation
• Pooling of blood
 Other injuries incompatible with Life 70
 CPR Protocols
 Child less than 18 Years
 When Advanced Medical Care is within 15
minutes away
 Pregnancy
 Hypothermia: "You're not Dead until you're
Warm and Dead"
 In case of Near Drowning
 If one Rescuer decides to continue
 Single handed up to 15-20 minutes?
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 When to STOP(s) CPR
 S – Patient Starts Breathing and has a pulse

 T - The patient is Transferred to another person trained

in BLS, ALS

 O - You are Out of Strength or too tired to continue

 P – Physician gives direction to discontinue CPR

 S - The Scene becomes unsafe

72