Cardio-pulmonary

Resuscitation
American Heart Assocation
Guidelines CPR ECC 2010
Definition of cardiac
arrest
 A cardiac arrest, also known as cardio
respiratory arrest, cardiopulmonary
arrest or circulatory arrest, can be
defined as the abrupt cessation of
spontaneous and effective ventilation
and systemic perfusion. (Sudden
cessation of breathing & circulation).
Definition of cardio-
pulmonary resuscitation

CPR is a basic life support for the purpose of

oxygenating the brain, heart and other vital
organs until the appropriate definite medical
treatment can restore the normal heart and
ventilator function.
Signs & symptoms of Cardiac Arrest
EARLY
 Unresponsiveness
 Absence of normal respiration( the victim is not breathing or only
gasping)
 Incase of adults absence of carotid pulse and incase of infants
Brachial pulse

LATE
 Cyanosis
 Cold clammy skin
 Dilated pupils
 ECG –Asystole / pulse less VT/ VF
Differential diagnoses of cardiac
arrest- 5“H”s and 5“T”s

5“H”s
 Hypovolemia
 Hypoxia
 Hydrogen ions (sever acidosis)
 Hypo/ hyperkalemia
 Hypothermia
5“T”s
 Tamponade cardiac (fluid outside the heart,& air in
plural cavity)
 Tension pneumothorax
 Toxin
 Thrombosis(Pulmonary and cardiac)
 Trauma
Phases of CPR

1. Basic Life Support:

 C -- Circulation support.
 A -- Establishment of an Airway.
 B -- Breathing support.
Basic Life Support
Immediate recognition & activation of the
Code Blue( Emergency response system ,
*7201/7200*)

 Rescuer finds unresponsive (may witnessed or

unwitnessed) or no normal breathing ( only
gasping).
 Safe scene
 Shake and shout by tapping the victim on the
shoulder
 Activate code blue if in hospital situation.
Pulse check:

 Check Pulse within 10 seconds

 Check for carotid pulse. In the
groove between trachea and
sternocleido-mastoid muscle by
counting 1-2-3-4-5 (not more than 10
secs)
C – CIRCULATION

No pulse – Commence external cardiac

compression (ECC)
Position self correctly (i.e. close to and
adequately above patient, kneel on the bed
close to patient),
Locate correct hand position. (4 finger above
the xyphoid sternum)
 Keep elbow straight at 90 degree angle to the
body of patient.
 Perform cardiac compression – compress
sternum at least 2 inches (5cm) for adult & 1.5
inches for infants
 Compression at appropriate rate (100 /
minute) 30 compressions within 18 seconds.
 Ratio of compression and ventilation is 30:2
for both Single and Two Rescuer for adult

 Incase of infant compression & ventilation

ratio is 15:2 for Two Rescuer.
A- AIRWAY

 Clean the airway by finger sweep in case of

visible foreign body, or oral suction
 Open & clear the airway (using head –
tilt/chin – lift), Double maneuver
 Suspected head and neck trauma -use Jaw
thrust Maneuver only
B- BREATHING

 If patient is not breathing or only

gasping, GIVE 2 RESCUE BREATHS.
Observe for visible chest rise.
 Deliver 1 rescue breath over one second
The mouth-to-mouth technique is
performed as follows --
The nostrils of the patient are pinched closed to
assist with an airtight seal
The provider puts his mouth completely over the
patient’s mouth

The provider gives a breath

for approximately 1 second
with enough force to make
the patient’s chest rise
HIGH QUALITY OF CPR:
 Push hard & push fast
Rate: 100/ min
Depth: at least 2’’
 Allow complete chest recoil
 Minimize interruption during chest
compression(< 10secs)
 Avoid hyperventilation.
 Rotate compressor every 2 mins
2.Advanced Cardiovascular Life
Support
 C – Circulation (IV/IO access, Monitor for ECG, give
fluids if indicated
 A – Airway Head tilt-chin lift (for easy access to Oro-
pharyngeal airway, Nasopharyngeal airway)
(ET tube, Combi tube, Laryngeal mask airway)
 B – Breathing (Give bag-mask ventilations every 5
to 6 seconds about 10 to 12 breaths per min)
ACLS
 In the in-hospital setting or when a paramedic or other
advanced provider is present, ACLS guidelines call for a
more robust approach to treatment of cardiac arrest,
including the following:

 Defibrillation
 Drug interventions
 ECG monitoring
 Invasive airway procedures

Cardiopulmonary Resuscitation (CPR)

Author: Catharine A Bon, MD; Chief Editor: Rick Kulkarni, MD more...
Updated: Jul 29, 2013
 DEFIBRILLATION / AED (automated external
defibrillator)

 Attach monitor / defibrillator when available ( in

institution availability of defibrillator within 1 min)
 Assess for cardiac rhythm
 If Asystole / PEA (Pulse less Electrical Activity) – do not
defibrillate continue CPR.( Follow CAB sequence)
 If pulseless VT/ VF then give one shock using 200 joules
for Biphasic Defibrillator ( if monophasic defibrillator
use 360 joules) ( For better skin attachment use jelly
generously and apply adequate pressure -25lb)
 Resume CPR immediately after Shock,
continue five cycle of CPR.( follow CAB
sequence)
 Charge defibrillator for another shock with
same joules if required.
 If patient is conscious, breathing and pulse
present then put patient into recovery
position- side lying position.
 Drug interventions
DRUG INDICATION DOSE ACTION
•Adrenaline(1 •Cardiac •1mg (1ml) IV bolus •Inotropic: Increase
mg/ml) arrest in case of cardiac contractility
•Class: Adreno arrest for adult •Chronotropic: Increase heart
receptor agonist patient rate
(no dilution is •Dose can be •Domotropic: Increase
required)(paed- repeated at each 3- conductivity
1ml+9ml NS in 5 min •Bathmotropic: Increase
10 cc syringe •Max dose upto 18 ventricular irritability threshold
take 1ml from it mg
+9ml NS take
1ml makes
1ml=0.01 mg)
•Vasopressin •Cardiac •40 U (2ml) for •Antidiuresis
(1amp contains arrest replacement of 1st •Increase peripheral vascular
20 U) or 2nd dose of resistance
•Class: Adrenaline •Vasoconstriction
Antidiuretic •Can be given only
Hormone once in the CPR
•Vasoconstrictor
DRUG INDICATION DOSE ACTION

Calcium Cardiac •1gm (1amp = 10ml) IV bolus •Stimulates

Gluconate arrest slowly over 10 mins secretion and
Class: Electrolyte •It should not given in the enzyme activity
and water balance same line with sodium •Stimulate action
agent bicarbonate simultaneously potential, cell
one after another division and
•After giving sodium metabolic activities
bicarbonate flush with 10ml •Maintains renal
then give calcium function

Sodium Metabolic & 1 mmol /kg bolus in During cardiac

Bicarbonate(893 respiratory emergency arrest, mixed
mmol/lit) acidosis According to level of acidosis metabolic and
Class: Alkalizer dose can be calculated respiratory acidosis
(take in 50cc occur. Hypoxia
syringe for adult) generates lactic
(for paediatric acid, resulting in
children 50:50NS metabolic acidosis.
dilution is used Concurrently
take in 50cc ventilator failure
syringe) results in CO2
retention, resulting
respiratory acidosis
DRUG INDICATION DOSE ACTION

Cordarone(50mg/ •Ventricular •After 2nd cycle of Supresses

ml) (1ampcontains Tachycardia CPR arrhythmogenic
3ml) •Ventricular •1st dose 300 mg activity of heart
Class: ClassIII Fibrillation bolus dose in slow muscle
antiarrhythmic •Cardiac arrest IV
(diluted in 50ml •2nd Dose 150mg over
5%D infused over 1 hr
10min or 1hr for first
dose)
( for second dose
50ml over 1hr) ( for
VT/VF 23hr
600/900mg in 5% D)

Atropine Bradycardia with 0.5mg IV bolus Increase heart rate

(0.6mg/ml) pulse (Heart rate Dose can be
Class: more than equal to repeated at each 3-5
Anticholinergic, 50 beats/min) min
parasympatholytics, Max dose upto 3 mg
mydriatic(2cc)
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILATION
VENTRICULAR ASYSTOLE
The BMV or invasive airway technique
is performed as follows:

 The provider ensures a tight seal

between the mask and the patient’s face.

 The bag is squeezed with one hand for

approximately 1 second, forcing at least
500 mL of air into the patient’s lungs.
 If no advanced airway, 30:2 ratio

 Quatitative waveform capnography

If PETCO2<10 mm Hg, improve CPR quality

 If in relaxation phase pressure the intra

arterial pressure <20mm Hg, attempt to
improve CPR
COMBITUBE - Invasive airway
Immediate Early CPR , Rapid Effective life Integrated
recognition that defibrillation support post cardiac
of cardiac Emphasizes if indicated. arrest care
arrest and chest
activation of compression
the
emergency
response
system.
1 Rescuer CPR for Infants
1 – Check for scene safety.
2 – Check for responsiveness.
3 – If no response SHOUT for help, send someone to
ACTIVATE EMS and get an AED.

 C - Start CPR 30 compressions and 2 breaths at a

rate of 100 compressions per min.
 A – Open the Airway (head-tilt-chin-lift or jaw
thrust) Look, Listen, Feel for breath (5 – 10 secs).
 B – Give 2 breaths (give enough breath to make the
chest rise).
 After 5 cycles of 30:2 if alone ACTIVATE the EMS
and get the AED
Complications
 rib fractures,
 sternal fractures,
 bleeding in the anterior mediastinum,
 heart contusion,
 hemopericardium,
 damage to the abdominal viscus - lacerations of
the liver and spleen, fat emboli,
 pulmonary complications - pneumothorax,
hemothorax, lung contusions.
2 minute
Check
If VF/ VT Post
Rhythm
shock Cardiac
Arrest Care

Drug Therapy
IV/IO Access
Epinephrine each 3-5 min
Amiderone for refractory VT/VF
Consider advanced airway
Quantitative waveform capnography
Treat Reversible causes
Thank You
Cardio-pulmonary
Resuscitation
American Heart Assocation
Guidelines CPR ECC 2010
Definition of cardiac
arrest
 A cardiac arrest, also known as cardio
respiratory arrest, cardiopulmonary
arrest or circulatory arrest, can be
defined as the abrupt cessation of
spontaneous and effective ventilation
and systemic perfusion. (Sudden
cessation of breathing & circulation).
Definition of cardio-
pulmonary resuscitation

CPR is a basic life support for the purpose of

oxygenating the brain, heart and other vital
organs until the appropriate definite medical
treatment can restore the normal heart and
ventilator function.
Signs & symptoms of Cardiac Arrest
EARLY
 Unresponsiveness
 Absence of normal respiration( the victim is not breathing or only
gasping)
 Incase of adults absence of carotid pulse and incase of infants
Brachial pulse

LATE
 Cyanosis
 Cold clammy skin
 Dilated pupils
 ECG –Asystole / pulse less VT/ VF
Differential diagnoses of cardiac
arrest- 5“H”s and 5“T”s

5“H”s
 Hypovolemia
 Hypoxia
 Hydrogen ions (sever acidosis)
 Hypo/ hyperkalemia
 Hypothermia
5“T”s
 Tamponade cardiac (fluid outside the heart,& air in
plural cavity)
 Tension pneumothorax
 Toxin
 Thrombosis(Pulmonary and cardiac)
 Trauma
Phases of CPR

1. Basic Life Support:

 C -- Circulation support.
 A -- Establishment of an Airway.
 B -- Breathing support.
Basic Life Support
Immediate recognition & activation of the
Code Blue( Emergency response system ,
*7201/7200*)

 Rescuer finds unresponsive (may witnessed or

unwitnessed) or no normal breathing ( only
gasping).
 Safe scene
 Shake and shout by tapping the victim on the
shoulder
 Activate code blue if in hospital situation.
Pulse check:

 Check Pulse within 10 seconds

 Check for carotid pulse. In the
groove between trachea and
sternocleido-mastoid muscle by
counting 1-2-3-4-5 (not more than 10
secs)
C – CIRCULATION

No pulse – Commence external cardiac

compression (ECC)
Position self correctly (i.e. close to and
adequately above patient, kneel on the bed
close to patient),
Locate correct hand position. (4 finger above
the xyphoid sternum)
 Keep elbow straight at 90 degree angle to the
body of patient.
 Perform cardiac compression – compress
sternum at least 2 inches (5cm) for adult & 1.5
inches for infants
 Compression at appropriate rate (100 /
minute) 30 compressions within 18 seconds.
 Ratio of compression and ventilation is 30:2
for both Single and Two Rescuer for adult

 Incase of infant compression & ventilation

ratio is 15:2 for Two Rescuer.
A- AIRWAY

 Clean the airway by finger sweep in case of

visible foreign body, or oral suction
 Open & clear the airway (using head –
tilt/chin – lift), Double maneuver
 Suspected head and neck trauma -use Jaw
thrust Maneuver only
B- BREATHING

 If patient is not breathing or only

gasping, GIVE 2 RESCUE BREATHS.
Observe for visible chest rise.
 Deliver 1 rescue breath over one second
The mouth-to-mouth technique is
performed as follows --
The nostrils of the patient are pinched closed to
assist with an airtight seal
The provider puts his mouth completely over the
patient’s mouth

The provider gives a breath

for approximately 1 second
with enough force to make
the patient’s chest rise
HIGH QUALITY OF CPR:
 Push hard & push fast
Rate: 100/ min
Depth: at least 2’’
 Allow complete chest recoil
 Minimize interruption during chest
compression(< 10secs)
 Avoid hyperventilation.
 Rotate compressor every 2 mins
2.Advanced Cardiovascular Life
Support
 C – Circulation (IV/IO access, Monitor for ECG, give
fluids if indicated
 A – Airway Head tilt-chin lift (for easy access to Oro-
pharyngeal airway, Nasopharyngeal airway)
(ET tube, Combi tube, Laryngeal mask airway)
 B – Breathing (Give bag-mask ventilations every 5
to 6 seconds about 10 to 12 breaths per min)
ACLS
 In the in-hospital setting or when a paramedic or other
advanced provider is present, ACLS guidelines call for a
more robust approach to treatment of cardiac arrest,
including the following:

 Defibrillation
 Drug interventions
 ECG monitoring
 Invasive airway procedures

Cardiopulmonary Resuscitation (CPR)

Author: Catharine A Bon, MD; Chief Editor: Rick Kulkarni, MD more...
Updated: Jul 29, 2013
 DEFIBRILLATION / AED (automated external
defibrillator)

 Attach monitor / defibrillator when available ( in

institution availability of defibrillator within 1 min)
 Assess for cardiac rhythm
 If Asystole / PEA (Pulse less Electrical Activity) – do not
defibrillate continue CPR.( Follow CAB sequence)
 If pulseless VT/ VF then give one shock using 200 joules
for Biphasic Defibrillator ( if monophasic defibrillator
use 360 joules) ( For better skin attachment use jelly
generously and apply adequate pressure -25lb)
 Resume CPR immediately after Shock,
continue five cycle of CPR.( follow CAB
sequence)
 Charge defibrillator for another shock with
same joules if required.
 If patient is conscious, breathing and pulse
present then put patient into recovery
position- side lying position.
 Drug interventions
DRUG INDICATION DOSE ACTION
•Adrenaline(1 •Cardiac •1mg (1ml) IV bolus •Inotropic: Increase
mg/ml) arrest in case of cardiac contractility
•Class: Adreno arrest for adult •Chronotropic: Increase heart
receptor agonist patient rate
(no dilution is •Dose can be •Domotropic: Increase
required)(paed- repeated at each 3- conductivity
1ml+9ml NS in 5 min •Bathmotropic: Increase
10 cc syringe •Max dose upto 18 ventricular irritability threshold
take 1ml from it mg
+9ml NS take
1ml makes
1ml=0.01 mg)
•Vasopressin •Cardiac •40 U (2ml) for •Antidiuresis
(1amp contains arrest replacement of 1st •Increase peripheral vascular
20 U) or 2nd dose of resistance
•Class: Adrenaline •Vasoconstriction
Antidiuretic •Can be given only
Hormone once in the CPR
•Vasoconstrictor
DRUG INDICATION DOSE ACTION

Calcium Cardiac •1gm (1amp = 10ml) IV bolus •Stimulates

Gluconate arrest slowly over 10 mins secretion and
Class: Electrolyte •It should not given in the enzyme activity
and water balance same line with sodium •Stimulate action
agent bicarbonate simultaneously potential, cell
one after another division and
•After giving sodium metabolic activities
bicarbonate flush with 10ml •Maintains renal
then give calcium function

Sodium Metabolic & 1 mmol /kg bolus in During cardiac

Bicarbonate(893 respiratory emergency arrest, mixed
mmol/lit) acidosis According to level of acidosis metabolic and
Class: Alkalizer dose can be calculated respiratory acidosis
(take in 50cc occur. Hypoxia
syringe for adult) generates lactic
(for paediatric acid, resulting in
children 50:50NS metabolic acidosis.
dilution is used Concurrently
take in 50cc ventilator failure
syringe) results in CO2
retention, resulting
respiratory acidosis
DRUG INDICATION DOSE ACTION

Cordarone(50mg/ •Ventricular •After 2nd cycle of Supresses

ml) (1ampcontains Tachycardia CPR arrhythmogenic
3ml) •Ventricular •1st dose 300 mg activity of heart
Class: ClassIII Fibrillation bolus dose in slow muscle
antiarrhythmic •Cardiac arrest IV
(diluted in 50ml •2nd Dose 150mg over
5%D infused over 1 hr
10min or 1hr for first
dose)
( for second dose
50ml over 1hr) ( for
VT/VF 23hr
600/900mg in 5% D)

Atropine Bradycardia with 0.5mg IV bolus Increase heart rate

(0.6mg/ml) pulse (Heart rate Dose can be
Class: more than equal to repeated at each 3-5
Anticholinergic, 50 beats/min) min
parasympatholytics, Max dose upto 3 mg
mydriatic(2cc)
VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILATION
VENTRICULAR ASYSTOLE
The BMV or invasive airway technique
is performed as follows:

 The provider ensures a tight seal

between the mask and the patient’s face.

 The bag is squeezed with one hand for

approximately 1 second, forcing at least
500 mL of air into the patient’s lungs.
 If no advanced airway, 30:2 ratio

 Quatitative waveform capnography

If PETCO2<10 mm Hg, improve CPR quality

 If in relaxation phase pressure the intra

arterial pressure <20mm Hg, attempt to
improve CPR
COMBITUBE - Invasive airway
Immediate Early CPR , Rapid Effective life Integrated
recognition that defibrillation support post cardiac
of cardiac Emphasizes if indicated. arrest care
arrest and chest
activation of compression
the
emergency
response
system.
1 Rescuer CPR for Infants
1 – Check for scene safety.
2 – Check for responsiveness.
3 – If no response SHOUT for help, send someone to
ACTIVATE EMS and get an AED.

 C - Start CPR 30 compressions and 2 breaths at a

rate of 100 compressions per min.
 A – Open the Airway (head-tilt-chin-lift or jaw
thrust) Look, Listen, Feel for breath (5 – 10 secs).
 B – Give 2 breaths (give enough breath to make the
chest rise).
 After 5 cycles of 30:2 if alone ACTIVATE the EMS
and get the AED