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At the end of this course participants should be able to demonstrate: How to assess the collapsed victim. How to perform chest compression and rescue breathing. How to place an unconscious breathing victim in the recovery position. 4

Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world. Cardiac arrest occurs both in and out of the hospital. approximately people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation. 5

Survival to hospital discharge presently approximately 5-10% Early resuscitation prompt defibrillation Early resuscitation & prompt defibrillation (within 1-2 minutes) can result in >60% survival 6

GUIDELINE 2010

Immediate recognition and activation Early CPR Defibrillation,

Advanced life support Integrated post- cardiac arrest care.

10 ارزیابی سطح هوشیاری ارزیابی وضعیت تنفس

11 ارزیابی سطح هوشیاری ارزیابی وضعیت تنفس

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13 BLS 2010 ارزیابی همزمان سطح هوشیاری و تنفس

Unresponsiveness Abnormal Breathing Start CPR

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Arrest Resuscitation Rescue Breathes Chest Compression O2 Content Time

O2 Content Time Arrest Resuscitation Chest Compression

O2 Content Time CAB ABC

* Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths 21

22 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

23 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

24 Shake shoulders gently Ask “Are you all right?” If he responds Leave as you find him. Find out what is wrong. Reassess regularly.

Occurs shortly after the heart stops in up to 40% of cardiac arrests Described as barely, heavy, noisy or gasping breathing Recognise as a sign of cardiac arrest 25

26 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

27 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

How? How many? When? Where? 28

 Once a cardiac arrest is identified, dispatchers can then give CPR instructions to a bystander over the phone until further help arrives.  Telephone instructions have been shown to increase the rates of bystander CPR and enhance outcomes.  Studies have also shown that the time to initiation of chest compressions is more rapid if the caller is given hands-only instructions (ie, no rescue breaths) rather than standard CPR instructions. (2012) 29

Feel within 1 q 5-6 s 1. definite pulse  give 1 breath / q 5-6 s q 2 min. 2. recheck pulse q 2 min. 3. no pulse or suspicious pulse  next step 30

Number of Compressions Delivered The total number of compressions delivered during resuscitation is an important determinant of survival from cardiac arrest. rate and the compression fraction. ( the portion of total CPR time during which compressions are performed). 32

Cardiac Output Time 2 min

Cardiac Output Time 2 min

Cardiac Output Time 2 min With Interruptions Without Interruptions

36 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

 Proper positioning of the patient and rescuer is fundamental to proper compression delivery.  The recommended position in out-of-hospital scenarios is to kneel perpendicular beside the patient’s torso.  For in-hospital cardiac arrest response, the rescuer should stand beside the bed at the level of the patient’s torso. (2012) 37

38 supine victim on a hard surface supine victim on a hard surface Place the heel of one hand in the centre of the chest ( lower half ) Place the heel of one hand in the centre of the chest ( lower half ) Place other hand on top Place other hand on top Interlock fingers Interlock fingers

40 Push hard and fast the chest: Push hard and fast the chest: – Rate at least 100 /min – Depth 5 cm – Equal compression / relaxation – Minimize interruptions in chest compressions. When possible change CPR operator every 2 min When possible change CPR operator every 2 min

 Providers delivering chest compressions should rotate every 2 minutes to minimize the effects of rescuer fatigue, and the switch should take less than 5 seconds.  One technique to minimize the interruption is to position a rescuer on either side of the patient for more seamless transitions. (2012) 41

 Interposed abdominal compression (IAC) is another strategy that has been proposed to increase cardio cerebral perfusion.  The first provider performs conventional chest compressions, while the second compresses the abdomen with similar hand position and depth midway between the xiphoid process and umbilicus during chest wall recoil. The third provider delivers intermittent ventilation, typically via an advanced airway management device. (2012)  This technique could be considered for victims of in-hospital cardiac arrest if a sufficient number of trained providers are present. (2012) 42

43 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

44 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths

● Deliver each breath over 1 second produce visible chest rise. Give a sufficient tidal volume produce visible chest rise. Avoid ● Avoid rapid or forceful breaths. 45

46 Pinch the nose Take a normal breath Place lips over mouth Blow until the chest rises Take about second Allow chest to fall Repeat

 However, an advanced airway device should be inserted and used to provide ventilations only after the patient has received 2 to 3 minutes of chest compressions and attempted defibrillation, if appropriate. (2012) 47

Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths 49

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 CCR aims to improve outcomes through refocusing certain interventions in CPR to maximize myocardial and cerebral perfusion.  In CCR, chest compressions are started immediately and continued for 200 continuous compressions. During this time, oxygen is given via a noninvasive airway (ie, no endotracheal intubation), and defibrillator pads are placed on the patient. The rhythm is analyzed, and, when appropriate, a shock is given followed immediately by another interval of 200 compressions without pulse check. (2012) 51

 Epinephrine is given early, and endotracheal intubation is delayed until after 3 rounds of chest compressions are completed.  the first 3 years of this data was presented in percentages, CCR showed a survival to hospital discharge increase of 5.4% versus 1.8%. (2012) 52

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In settings with 1-lay rescuer AED programs (AED on-site and available) 2-in-hospital environments witnesses the collapse 3-EMS rescuer witnesses the collapse, use the defibrillator The rescuer should use the defibrillator as soon as ( within first 3-5 min) ( within first 3-5 min) it is available for children and adults.

56 cardiac arrest not witnessed by EMS personnel EMS may initiate CPR while checking the rhythm with the AED or on the electrocardiogram (ECG) and preparing for defibrillation. In such instances, 1½ to 3 minutes of CPR may be considered before attempted defibrillation.

 CPR Before Defibrillation The rate of survival-to-hospital discharge is higher among patients who experienced an unwitnessed SCA and received 1.5 to 3 minutes of CPR followed by defibrillation.  In witnessed SCA, early defibrillation is imperative; CPR should be performed while the defibrillator is being prepared. (2012) 57

58 AED Use in Children Now Includes Infants 2010 (New) For infants (<1 year of age), defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used.

59 The precordial thump 2010 (New) should not be used for unwitnessed out-of-hospital cardiac arrest. 1-for patients with witnessed monitored, 2-unstable VT (including pulse less VT) 3-if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery.

 Percussion pacing, an extension of the precordial thump, is essentially rhythmic percussion of the chest wall with a fist to pace the myocardium.  Several case reports and small case series have documented successful resuscitation with this technique, but there is insufficient evidence to support its routine use. (2012) 60

*Approach safely Check response Check breathing Shout for help and call 115, get AED Attach AED Follow voice prompts 61

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63 Some AEDs will automatically switch them-selves on when the lid is opened

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66 Stand clear Deliver shock

 studies have affirmed that it is extremely safe to continue compressions during defibrillation when a biphasic defibrillator is used with self-adhesive electrodes and the rescuer wears standard examination gloves.  The simulated rescuers in these studies perceived no electrical charge, despite voltage delivery during the compressions.  Therefore, uninterrupted manual chest compressions are feasible during shock delivery, without risk of harm to the rescuer.  The AHA did not adopt this practice until now (2012) 68

69 Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths Approach safely Check response Check breathing Shout for help & Call chest compressions 2 rescue breaths Approach safely Check response Check breathing Shout for help and call 115, get AED Attach AED Follow voice prompts Approach safely Check response Check breathing Shout for help and call 115, get AED Attach AED Follow voice prompts

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