DR SUJATA
PROFESSOR
DEPT.OF ANAESTHESIOLOGY
&CRITICAL CARE
UCMS & GTB HOSPITAL
CPBR/ CPCR
 CPR
 Cardiopulmonary
brain resuscitation -
CPBR
 Cardiopulmonary cerebral resuscitationCPCR
Goal
Support
& restore effective oxygenation,
ventilation and circulation with return of intact
neurological function.
Intermediate Goal:
Return of spontaneous circulation (ROSC)
Approach
 BLS
( Basic Life Support) Primary survey.
 ACLS
(Advanced Cardiovascular Life
Support) Secondary survey
Cardiopulmonary
Resuscitation
A - Airway
B - Breathing
C - Circulation
D- Defibrillation
Does BLS work?
BLS- maximum attention of public
.MMajority(70-80%) of cardiac arrests
Out-of-Hospital
.Pre-hospital care –key factor
ajority(70-80%) of cardiac arrests
Out-of-Hospital
.Pre-hospital care –key factor
Adult Chain of Survival
Early access
Early CPR
Early
Defibrillation
Early ACLS
1.Recognition of Early warning signs
2.Activation of Emergency Medical Services
3.Basic CPR
4.Defibrillation
Before BLS Primary Survey
Scene safety
 Check responsiveness
 Activate EMS and get AED

Assess & Perform appropriate action.
Performance of the action improves chances of
survival and better neurological outcome
Before BLS Primary Survey
Assess
Action
Scene safety
For you and victim
Check responsiveness
Tap/ shake and shout
“Are you all right?”
Activate emergency
response system and get
AED
Alone- shout for help.
Activate emergency 102/ 1099
Get AED…if available
Return to victim ……start CPR
BLS Primary survey
 Support/
restore effective oxygenation,
ventilation and circulation until ROSC or
ACLS team takes over.
 No
advanced interventions- airway tech./
drugs (use universal precautions)
 Early
CPR and early defibrillation
BLS Primary Survey….components
Assess
Action
Airway
Open?
Head tilt- chin lift or jaw thrust
Breathing
Yes/ adequate?..... Look, Listen
and Feel
2 Breaths using a barrier device,
Each over 1 sec, visible chest rise.
Circulation
CPR until AED arrives.
Pulse present?...Carotid 5- 10 sec. C:V -30:2 5 cycles over 2 min.
Defibrillation
AED/ Shockable rhythm
Shock as indicated.
Resume CPR with compressions.
Basic airway skills
 Head
tilt- chin lift
 Jaw thrust without head extension (? Cx
spine trauma)
 Mouth- to- mouth ventilation
 Mouth- to- nose ventilation
 Mouth- to- barrier device (pocket mask)
 Bag-mask ventilation
Airway
Head tilt, Chin lift, Jaw thrust
AVOID HEAD TILT IF TRAUMA
Keeping airway open- LOOK, LISTEN, FEEL
LOOK
LISTEN
CHEST MOVEMENTS
BREATH SOUNDS
RESP. RATE
VOICE QUALITY
CYANOSIS
ABNORMAL SOUNDS
TRAUMA
FLUID/BLOOD /VOMITING
FEEL
AIR FLOW
CHEST MOVEMENTS
TRACHEAL POSITION
NOT MORE THAN 10 SECONDS
BREATHING PRESENT
BREATHING ABSENT
2 EFFECTIVE RESCUE BREATHS
RECOVERY POSITION
AND TRANSPORT
•SLOW BREATHS
•TIDAL VOL. 8-10 ml/kg
•Deliver in one sec.
•Rate- 10-12/min.
•Chest rise/ expand
Assessing the victim
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1-- Make sure the victim, any bystanders,
and you are safe.
2-- Check the victim for a response.
Shake shoulders gently
Ask “Are you all right
If he responds
Leave as you find him.
Find out what is wrong.
Reassess regularly
If he does not respond:
Activate Code Blue and get AED
4 --Keeping the airway open, look, listen,
and feel for normal breathing.
OPEN AIRWAY
Look, listen and feel for NORMAL
breathing
Do not confuse agonal breathing with
NORMAL breathing
Keeping the airway open, look, listen, and feel for
normal breathing. ……OPEN AIRWAY
Look, listen and feel for NORMAL breathing
If he is breathing normally
• Turn him into the recovery position
• Send or go for help, or call for an ambulance.
• Check for continued breathing.
If he is not breathing normally

Give 2 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
Chest Compressions

Patient positioning:
Firm and hard surface (ground, table/ hard bed) deflate
air/ water mattresses.
 Rescuer's position:
Level with patient, elbows vertically straight and locked,
shoulders directly above the hands, heel of one palm
over the other.
 Site : sternum in inter-mammary line.
 Depth: 11/2- 2 inches.
 Rate:100 per minute (5 cycles of 30:2-C:V over 2 min.).
 Allow complete chest recoil.
CHEST COMPRESSIONS
30 CHEST COMPRESSIONS
Hands off- time


Less than 10 sec.
Specific interventions: defibrillation, advanced airway,
moving the patient.
Avoid :
 Prolonged rhythm analysis
 Frequent pulse checks
 Too long breaths
 Unnecessary moving the pt.
CHECK FOR SIGNS OF CIRCULATION
PULSE PRESENT
CONTINUE VENTILATION
TILL SPONTANEOUS
RESPIRATION
PULSE ABSENT / NOT DETECTED
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PULSE CHECK
NOT RECOMMENDED FOR LAY RESCUERS
POOR SENSITIVITY-55%
POOR SPECIFICITY-90%
ACCURACY RATE -65%
CHEST COMPRESSIONS
• Rate: 100/MIN., SITE- Sternal depression -1.5 in.-2 in.
•Universal compression-ventilation ratio (30:2) - Recommended for all
single rescuers of infant, child and adult victims (excluding newborns)
• Two Rescuers = 30:2- ALL ADULTS,
15:2 – Infants and child
PURPOSE : PUSH HARD,PUSH FAST
Defibrillation
 AED:
Follow the prompts.
 Manual defibrillator: Analyse rhythm,
shockable- decide shock (Monophasic
360 J, Biphasic 120-200 J ), apply gel,
charge, clear the patient, no inflammables
(incl. oxygen), deliver shock….. Resume
CPR immediately.
AED
Positioning of electrodes for automated external defibrillator
DEFIBRILLATION
ATTACH PADS TO VICTIM’S BARE
CHEST
Ventricular Fibrillation
Continuous electrocardiogram showing successful
treatment of ventricular fibrillation by a countershock (given
at the arrow)
ANALYSING RHYTHM
DO NOT TOUCH VICTIM
SHOCK INDICATED
Stand clear
Speak Aloud- “I Clear......You Clear.......All Clear!”
Deliver shock
IF VICTIM STARTS TO BREATHE NORMALLY PLACE IN
RECOVERY POSITION
ACLS Secondary survey
Advanced, invasive assessment and management
techniques required.
Basic airway adjuncts:
OPA, NPA
Advanced Airway interventions:
Combitube, LMA, Endotracheal intubation.
Advanced circulatory interventions:
Drugs to control heart rhythm and blood pressure.
ACLS Secondary Survey…… components
Assess
Action
Airway
Patent? Advanced needed?
Head tilt-chin lift, OPA, NPA.
Advanced airway if needed
(combitube, LMA, ETT)
Breathing
Oxygenation, ventilation
adequate?
Advanced airway needed?
Placement, securement
confirmed?
EtCO2,SpO2 monitored?
Give supple O2,
Clinical- chest rise,
O2 saturation,
Capnometry / capnography
Integrate Compressions & vent (1
breath 6-8 sec i.e. 8-10 bpm)
TECHNIQUES- Mouth-Mouth, Mouth-Nose
VENTILATORY DEVICES
ADJUNCT of CHOICE: TRACHEAL TUBE
Masks, Bag-Valve Devices
Airway Adjuncts
1.Oropharygeal Airway
2.Nasopharyngeal Airway
3.Esophageal –Tracheal Combitube
4.Laryngeal Mask Airway
5.Transtracheal catheter ventilation
6.Cuffed oropharyngeal airway
PURPOSE
MAINTAIN AIRWAYAND OXYGENATE
ACLS Secondary Survey…….components
Assess
Action
Circulation
Initial/ current cardiac rhythm?
Access for drugs/ fluids?
Needs volume/ drugs
Obtain IV/ IO access
Attach ECG leads, monitor for
rhythms (Cardiac arrest: VF,
Pulseless VT, Asystole, PEA).
Give IV/ IO fluids
Appropriate drugs (Rhythm:
Amiodarone, Lidocaine, Atropine,
Magnesium; BP: Adrenaline,
Vasopressin, Dopamine)
Differential Diagnosis
Reversible cause of arrest?
Search for, find and treat the
cause (H`s and T`s)
Common Reversible Causes
H`s
T`s
Hypovolemia
Toxins
Hypoxia
Tamponade (cardiac)
Hydrogen ion (Acidosis)
Tension pneumothorax
Hyper-/ Hypokalemia
Thrombosis (coronary/
pulmonary)
Trauma
Hypoglycemia
Hypothermia
PROBLEMS AND COMPLICATIONS OF CHEST
COMPRESSIONS
1. RIB FRACTURES
2. FRACTURE STERNUM
3. RIB SEPARATION
4. PNEUMOTHORAX
5. HEMOTHORAX
6. LUNG CONTUSIONS
7. LIVER LACERATIONS
8. FAT EMBOLI
9. HIV, HEPATITIS
10.INFECTIONS
MANAGE ACCORDINGLY BUT CONTINUE CPR
EFFECTIVE CHEST COMPRESSION WITH
MINIMAL HANDS OFF
IS
KEY
FOR
EFFECTIVE CPR
When to stop BLS
 ROSC,
Conscious pt.
 ACLS team takes over
 Rescuer tired
SUMMARY
Infant
(1-12 mo.)
Child
(>12 mo.)
Adult
Resp. rate
12-20/min.
20/min.
10-12/min.
Pulse Check
Brachial/femoral
Carotid
Carotid
Comp. Rate
100/min.
100/min.
100/min.
Comp. Method
2-3 fingers
1/3-1/2 depth of
chest
Heel of hand
1/3-1/2 depth of
chest
Hands interfaced
1.5-2 inches
Comp:Ventil.
30:2
(single rescuer)
HCP-15:2
(2 rescuers)
30:2
(single rescuer)
HCP-15:2
(2 rescuers)
30:2
(1 or 2 rescuers)
Foreign body
Obstructions
Back blows
Chest thrusts
Abdominal
Thrusts
Abdominal
Thrusts
DRUGS
EPINEPHRINE
1. Peripheral vasoconstriction -adrenergic
2. Increase in Central aortic perfusion
pressure
3. Decrease Threshold for
Defibrillation
4. Fine VF to Coarse VF
DRUGS
For Rhythm
• Amiodarone
• Lidocaine
• Atropine
• Magnesium
For Blood Pressure
• Epinephrine
• Vasopressin
•
DOPAMINE-2-4 micro/kg/min.-DA rec
4-10 micro/kg/min- Beta-rec.
10-20 micro/kg/min- Alpha rec.
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WHITE-RIGHT SIDE
RED- RIBS-LEFT MID-AXILLARY
LEFT-OVER-LEFT SHOULDER
LA
The dying heart
1.VENTRICULAR FIBRILLATION
2. RAPID VENTRICULAR TACHYCARDIA
3. PULSELESS ELECRICAL ACTIVITY
4. ASYSTOLE
2
OR