Course of First Aid for 1st year
Medical Students
(2 lecture)
Cardiopulmonary resuscitation (CPR). Basic life support
(BLS). Drowning. Electrocution. Hypothermia. Hypertermia.
Shock.
Aleksander Sipria / Kadri Tamme
Cardiopulmonary Resuscitation
(CPR)
Basic Life Support (BLS)
Immediate Life Support (ILS)
Advanced Life Support (ACLS)
ERC guidelines for resuscitation 2010
Clinic of Anaesthesiology and Intensive Care
Tartu University (http://www.kliinikum.ee/aikliinik)
Sudden death
• Death that occurs unexpectedly and from 1 to 24 hours
after onset of symptoms, with or without known
preexisting conditions. Mosby`s Medical Dictionary, 8 th edition,
2009, Elsevier
• Sudden cardiac arrest is the sudden, unexpected loss of
heart function, breathing and consciousness.
• Sudden cardiac arrest is a leading cause of death in
Europe, affecting about 700 000 individuals a year
• Sudden cardiac arrest is reversible in most patients if it is
treated within minutes
Sudden death
Stop of breathing
Cardiac arrest
• Closure of airway
* Rhythm disturbances
- Unconscious patient
- Ventricular fibrillation
- Foreign body
- Pulseless electrical activity
- Trauma
- Asystole
- Inflammatory diseases of throat
• Drowning
* Myocardial infarction
• Electrical trauma
* Hypothermia
• Musculature weakness
* Electrical trauma
- Nervous system diseases
* Blood (fluid) loss
- Drug overdoses
Gasping (agonal breathing) can be
Initially, during few minutes, pulse (heart
continued for 5 minutes after cardiac arrest
beating) is preserved
Cardiac arrest can be prevented by quick
Defibrillation (electric shock) is
and effective first aid (open the airway,
the treatment of ventricular fibrillation.
artificial ventilation).
AED- automatic external defibrillator
Clinical and biological death
• After cardiac arrest the brain cells are the first to begin to
die. Cells have a residual oxygen supply and can survive
for a short time (reversible damage or clinical deathduration 4-6 minutes). Effective CPR may reverse
clinical death and possibly restore the patient to an
undamaged state.
• After 4-6 minutes brain damage become irreversible
(biological death)
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Signs of clinical death
• Unconsciousness
• Absence of breathing or agonal gasps
(may occur in the first few minutes after SCA)
• Absence of movement
• Absence of pulse on the large arteries
(carotid pulse in the neck, femoral pulse at
the upper thigh)
• Skin color that is pale or cyanosed (blue)
Determinators of survival
• When was clinical death diagnosed? (bystander
witnessed vs unwitnessed)?
• Was BLS given?
• When did the emergency team arrive at the
scene?
• What was the form of primary cardiac arrest? If
VF, when defibrillated?
• When ALS started?
How to decrease the mortality of sudden
cardiac arrest?
Survival from Out-of-Hospital Cardiac Arrest
(all resuscitation attempts)
• Seattle and King County, Washington
14-18% (1984)
• Helsinki 17% (1996)
• Göteborg 13% (1994)
• Sweden 5% (1998)
• Norway 6-13% (1999)
• Estonia 9%, Tartu 15% (1999-2008)
Additional determinators of survival
First aid skills of the population
Quality of work of 112
Skills and equipment of the emergency
team
Quality of hospital treatment
Quality of rehabilitation
Out-of-hospital CPR attempts in Estonia 1999-2009.
4322 attempts (suspected cardiac arrest).
Place of CPR.
ERC 2010
AHA 2010
ALS
Post-cardiac arrest care
apartment
public place
at work
ambulance
medical facility
other
First aid skills of the family members?
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Out-of-hospital CPR attempts in Estonia 1999-2009.
2492 attempts (bystander-witnessed suspected cardiac arrest).
History of resuscitation
Use of BLS
(52 cases unknown)
N=645 (26%)
Alive 89
(13,8%)
No CPR
P<0.01
bypasser
co-worker
medical professional
relative
• 100 years ago effective measures of
resuscitation
• 1956 first defibrillation (Zoll)
• 1958 methods of upper airway
management and mouth to mouth
ventilation (Safar, Elam)
• 1960 reinvention of chest compressions
(Kowenhoven, Jude, Knickerbocker)
no CPR
(P.Safar 1981)
1992
1992
1992
Mistakes
• Mistakes of assessing the condition of the victim:
incorrect primary assessment, incorrect
interpretation of agonal breaths, mistakes of
pulse assessment, inadequate information to the
emergency call centre
• Mistakes of the emergency call centre:
inadequate assessment of the situation,
inadequate counselling
• Mistakes of chest compression: soft surface, late
start, unnecessary interruptions, inadequate
technique
ERC guidelines for resuscitation 2010
Universal algorithm:
Minimal interruption of chest
compressions!
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ABC or CAB?
• Witnessed suspected cardiac arrest
(agonal breaths present) - CAB
• Unwitnessed cardiac arrest (breathing
absent) or primary respiratory arrest ABC
If unconscious:
- Call for help without leaving the patient, or
consider leaving the patient to call for help?
- Open the upper airway, leaving the patient in the
same position, if possible (important in case of
trauma)
check if the victim is breathing
- If not successful, lie the victim on his/her back
and open the airway
- Tilting the head back is dangerous when
cervical trauma is possible
BLS - adult cardiac arrest
You are alone and the victim is adult
•ENSURE SAFETY
•CHECK CONSCIOUSNESS
If conscious:
- Leave in the same position
-Assess general condition
-Assess repeatedly
-Call for help
If breathing is absent or abnormal
• Turn the victim on his/her back, assess consciousness,
movements or coughing
• Open the airway and assess breathing. Check skin color.
• Check pulse on femoral or carotid arteries if you are a
trained helper.
• Do not spend more than
10 seconds to assess the
condition of the victim.
In case of unconsciousness and abnormal
breathing
(bystander witnessed suspected cardiac arrest)
Call112
Immediately start with chest compressions
(30 compressions 100 – 120 x/min), then
open the upper airway again
The depth of chest compressions must be
5 – 6 cm
Time of compression and decompression
must be equal
(P.Safar 1981)
With chest compressions systolic pressure of 60-80 mmHg is
maintained, mean arterial pressure rarely exceeds 40 mmHg
Chest compressions are of extreme importance when
defibrillation is delayed > 5 min
The person performing chest compressions should be
changed every 2 minutes.
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Continue with mouth-to-mouth breaths (B) and
chest compressions (C) 2:30
• Remove visible foreign bodies (also loose dentures)
from the victim’s mouth (?)
• After opening the upper airway and closing the nose,
perform 2 effective breaths of volume of 6-7mL/kg
(500-600mL) and duration of about 1 sek per one
breath (duration of 2 breaths not more than 5 sec)
• Hands-Only (Compression-Only)
Cardiopulmonary Resuscitation
Circulation 2008; 117:2162-2167
American Heart Association
• If agonal breaths continue (∼ 40% of cases), rescue
breaths are not obligatory during the first 4-6 min
(AHA)
Chest compression-only CPR
Recommendations for trained vs untrained rescuers
On 31.03.2008, the American Heart Association (AHA) issued a statement
recommending that bystanders who witness the sudden collapse of an adult
should give chest compressions without ventilations, so-called ‘hands-only’
CPR.
The European Resuscitation Council (ERC) has reviewed the studies published
since its guidelines were introduced in 2005, and has concluded that there is
insufficient evidence to make any changes at this time. The Council has, therefore,
issued a statement confirming its advice that CPR should consist of alternating 30
chest compressions, of adequate force and depth, at a rate of 100/minute, with 2
mouth-to-mouth ventilations. The rescuer (s) should ensure that ventilations cause
minimal interruption of chest compressions. For those rescuers who are unwilling or
unable to give mouth-to-mouth ventilations, chest compression-only is much more
acceptable than performing no CPR at all.
Both statements can be found at:
The AHA statement: http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.189380
The ERC statement: http://www.erc.edu/index.php/docLibrary/en/viewDoc/775/3/
2010 American Heart Association
Cardiac arrest and early defibrillation (aim <5 min
out of hospital and <3 min in hospital)
?
ERC Resuscitation
Guidelines 2010
``Look listen and feel
for breathing`` (AHA 2010)
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Early defibrillation and survival
An AED at a railway station in Japan.
The AED box has information on how
to use it in Japanese, English,
Chinese and Korean, and station staff
are trained to use it.
View of defibrillator
position and
placement, using the
standard hands free
electrodes.
ERC 2010
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2
3
4
ERC 2010
AHA 2010
Chest compressions until the defibrillator is ready, while defibrillating, pauses
in chest compressions ≤ 5 sek !!
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Action if sudden death
is unwitnessed or primary
breathing problem is suspected
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series1989
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series1989
Action if sudden death is of suspected cardiac cause and bystander
witnessed. Before chest compression call for 112.
CPR with Entry of Second Person
•
•
•
•
•
•
The second person shall identify himself or herself as being trained in
CPR and that they are willing to help (``I know CPR. Can I help?``)
The second person should call the local emergency number or
medical personnel for assistance if it not already been done
The person doing CPR will indicate when he or she is tired; and
should stop CPR after the next 2 full breath. Take over CPR every 2
min to prevent fatigue.
The second person should kneel next to the casualty opposite the
first person, tilt the casualty` s head back, and check for a carotid
pulse for 5 seconds (?)
If there is no pulse, the second rescuer should give 2 full breath and
continue CPR
The first person will monitor the effectiveness of CPR by looking for
the chest to rise during rescue breathing and feeling for a carotid
pulse (artificial pulse) during chest compressions (?)
Continue resuscitation until
• Qualified help arrives and takes over
• The victim starts breathing normally
• You become exhausted
European Resuscitation Council
Guidelines 2010 for Pediatric BLS
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Pediatric BLS
• Rescuers should perform 5 initial breath
followed by approximately 1 min of CPR before
they go for help
• Blow steadily into the mouth over about 1-1.5 s,
watching for chest rise
• Lay rescuers, who usually learn only single
rescuer techniques, should be taught to use a
ratio of 30 compressions to 2 ventilations
• Two or more rescuers with a duty to respond
should learn a different ratio (15:2)
Prehospital Emergency Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series
1989
An infant is a child
under 1 year of age;
a child is between 1 year
and puberty
Pediatric basic life support algorithm (ERC 2010)
Drowning
• Drowning accounts for approximately
450 000 death each year
• Death from drowning is more common in
young males (leading cause of accidental
death in Europe in this group)
• Alcohol consumption is a contributory
factor in up to 70% of drowning
• The incidence of cervical spine injury is
about 0,5%
Definitions
• Drowning itself is defined as a process resulting
in primary respiratory impairment from
submersion/immersion in a liquid medium
• Submersion implies that the entire body,
including airway, is under the water or other fluid
• Old terms: dry and wet drowning, active and
passive drowning, silent drowning, secondary
drowning and drowned versus near-drowned
should no longer be used
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The first aid for the drowning victim
• Remove all the drowning victims from the water
by the fastest and safest means available,
without danger to rescuer and resuscitate as
quickly as possible
• Despite potential spinal injury, victims who are
pulseless and apnoeic should be quickly
removed from water (even if a back support is
not available), while attempting to limit neck
flexion and extension
• Do nothing if person is talking or breathing
BLS for the drowning victim
Prehospital Emergency
Care
and Crisis Intervention
Third Edition
by Brent Q. Hafen,
Keith J.Karren
Brady Morton Series
1989
• If there is no spontaneous breathing after
opening the airway, give up to 5 rescue
breath for approximately 1 min
• There is no need to clear the airway of
aspirated water
BLS for the drowning victim
Electrocution
• Pulse may be difficult to find in a drowning
victim, particularly if cold
• If the there is no spontaneous breathing or
victim does not breathe normally, start with
chest compression (30:2)
• If vomiting occurs, turn the victim` s mouth
to the side and remove the gastric content
manually or use suction
• Give first aid for hypothermia if needed
• Most electrical injuries in adults occur in the
workplace (associated generally with the high
voltage), whereas children are at risk primarily at
home
• Direct effect of current on cell membranes and
vascular smooth muscle
• Alternating current more dangerous (tetanic
contraction of skeletal muscle, respiratory and
cardiac arrest)
• Hand to hand pathway is more likely to be fatal
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Rescue and resuscitation victims of
electrocution
• Ensure that any power source is switched
off and do not approach the casualty until
it is safe
• Start standard basic life support without
delay
• Most electrical injury patients – even those
in full arrest – can be successfully
resuscitated with vigorous CPR
Hypothermia
First aid for hypothermia
• Remove the casualty from the cold environment
and insulate him against further heat loss
• Handle the casualty very gently
• Replace wet clothing with dry clothing
• Application of direct heat, such as hot-water
bottles or hot baths is not recommended
• If the person is conscious, give warm, sweet
drinks to help maintain the blood sugar level to
provide energy
Resuscitation of hypothermia
victims
• If there are no signs of breathing, start
artificial respiration
• Any sign of a pulse, no matter how week,
indicates that the heart is beating – do not
start CPR
• Remember that CPR , once started, must
be continued without interruption until
hand over to medical aid
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Heatstroke
Signs and symptoms of heatstroke
• Classic heatstroke occurs when the
body`s temperature control mechanism
fails; sweating ceases and body
temperature rises rapidly
• Exertional heatstroke occurs as a result of
heavy physical exertion in high
temperatures; sweating continues, but
body temperature rises rapidly
• Temperature markedly elevated, reaching 42°C
to 44°C.
• Pulse rapid and becomes weaker
• Respiration noisy
• Consciousness – headache, dizziness,
restlessness, convulsions, progressing to
unconsciousness and coma
• Appearance – skin flushed, hot and either dry or
wet
• Muscular reaction – convulsions, nausea and
vomiting
A1
First aid for heatstroke
First aid for heatstroke
• Lowering body temperature is the most urgent
first aid for heatstroke. The casualty`s life
depends on how quickly this can be done
• Remove the person to a cool, shaded place
• Remove any excess clothing
• Use sponge with lukewarm water, wet sheets
and fan
• Medical aid is needed urgently
Shock
Signs and symptoms of shock
• Shock is a condition of inadequate circulation to the body
tissues. It can deprive the brain and other vital organs of
oxygen and can lead to unconsciousness and death if
untreated
• Causes of shock:
- severe external or internal bleeding
- burns
- crush injuries
- cardiac emergencies
- respiratory emergencies
- spinal cord or nerve injuries
- severe allergic reaction
- infection
• Pallor or blue-grey color of the skin, especially
the lips, fingernail beds and earlobes, indicating
lack of oxygen
• Cold and clammy skin
• Weak and rapid pulse
• Shallow and rapid breathing and, in later stages,
gasping for air
• Thirst
• Nausea and vomiting
• Changes in the level of consciousness
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Slaid 64
A1
Aleksander; 10.03.2008
First aid for shock
• Treat the obvious causes of shock such as
severe bleeding, fractures and burns
• Reassure the casualty
• Handle the casualty gently to avoid causing pain
• Position lying on back with legs raised and
head tilted backward
• Prevent loss of body heat (cover with a blanket),
but do not overheat a person in shock
• Give nothing by mouth if shock is severe
• Place an unconscious person in the recovery
position and obtain medical aid as quickly as
possible
Shock position
(conscious)
Unconscious
casualties or those
who show signs of
vomiting should be
placed in the
recovery position
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