1. CPR

2. CARDIOPULMONARY RESUSCITATION CPR is a life-saving technique that done when a person has a cardiac arrest. The primary aim of resuscitation is to restore a beating heart and a functioning circulation, which can help prevent brain and organ damage. CPR consists of 2 stages: basic life support (BLS) and advanced life support (ALS).

3. PATHOPHYSIOLOGY Failure of adequate delivery of oxygen to the tissue rapidly results in the following changes: 1- Hypoxia : After a brief period of cardiac arrest, PaO2 falls dramatically as oxygen continues to be consumed. In the brain, the PaO2 falls critically within 15 seconds and consciousness is lost. After a minute, the PaO2 will have fallen to zero. 2-Acidosis :The brain and heart have a relatively high rate of oxygen consumption and O2 delivery to them will fall below critical levels during cardiac arrest. Acidosis then arises as the result of increased anaerobic metabolism and the accumulation of carbon dioxide in the tissues. The degree of acidosis developing in the brain, even with basic life support, will threaten tissue survival within 5 – 6 minutes. Also, in the heart, acidosis depresses contractility and there is a higher risk of further arrhythmias. Cardiovascular collapse prompts a massive stress response. The possible detrimental effects of these changes include hyperglycaemia, hypokalaemia, increased lactate levels and a tendency towards further arrhythmias.

5. Basic Life Support (BLS) BLS is cardio-pulmonary resuscitation (CPR) using no equipment other than a protective oral device. (old)BLS establishes a clear airway followed by assisted ventilation and support of the circulation. Refinements have been made to recommendations for immediate recognition and activation of the emergency response system based on signs of unresponsiveness, as well as initiation of CPR if the victim is unresponsive with no breathing or no normal breathing (ie, victim is only gasping). When approaching a patient who appears to have suffered a cardiac arrest the rescuer should check that there are no hazards to himself before proceeding to treat the patient, as electric shocks or toxic substances.

6. Check Responsiveness Shake and Shout Unresponsive Shout for help Open Airway Head Tilt, Chin Lift (Jaw Thrust) Check Breathing Look, Listen, Feel (Up to 10 secs) No Circulation Commence chest compressions No Breathing 2 effective breaths Circulation Present Continue rescue breathing Check circulation every minute Breathing Present Place in recovery position Assess Circulation Movement / Pulse (No more than 10 secs) Old recommended sequence for BLS

9. unresponsive with no breathing or no normal breathing (ie, victim is only gasping) Cardiac arrest victims may present with seizure-like activity or agonal gasps that may confuse rescuers. The rescuer should be begin CPR if the victim has “no breathing or no normal breathing (ie, only gasping).” Therefore, breathing is briefly checked as part of a check for cardiac arrest before activating the emergency response system and retrieves the AED (or sends someone to do so). Then (quickly -10 seconds) checks for a pulse and begins CPR and uses the AED.

10. Activation of Emergency Response System The healthcare provider should not delay activation of the emergency response system but check the victim for response and check for no breathing or no normal breathing. If the victim is unresponsive and is not breathing at all or has no normal breathing (ie, only agonal gasps), the provider should activate the emergency response system and retrieve the AED if available (or send someone to do so). If the healthcare provider does not feel a pulse within 10 seconds, the provider should begin CPR and use the AED when it is available.

11. Emphasis on Chest Compressions 1- 2010 (New): Chest compressions are emphasized for all rescuers. If a bystander is not trained in CPR, the bystander should provide Hands-Only (compression-only) CPR for the adult who suddenly collapses, with an emphasis to “push hard and fast” on the center of the chest. The rescuer should continue Hands-Only CPR until an AED arrives and is ready for use or EMS providers take over care of the victim. Optimally all healthcare providers should be trained in BLS. In this trained population, it is reasonable for both EMS and in-hospital professional rescuers to provide chest compressions and rescue breaths for cardiac arrest victims.

12. 2- Change in CPR Sequence: C-A-B Rather Than A-B-C A change in the 2010 AHA Guidelines for CPR and ECC is to recommend the initiation of chest compressions before ventilations. The old sequence of adult CPR began with opening of the airway, checking for normal breathing, and then delivering 2 rescue breaths followed by cycles of 30 chest compressions and 2 breaths. “Look, listen, and feel for breathing” was removed from the sequence for assessment of breathing after opening the airway. The healthcare provider briefly checks for breathing when checking responsiveness to detect signs of cardiac arrest. After delivery of 30 compressions, the lone rescuer opens the victim’s airway and delivers 2 breaths, Each breath should last about 1 second and be of sufficient pressure to allow normal chest excursion. Expired air ventilation only supplies 16-19% oxygen. The delay in initiation of compressions can be reduced if 2 rescuers are present: the first rescuer begins chest compressions, and the second rescuer opens the airway and is prepared to deliver breaths as soon as the first rescuer has completed the first set of 30 chest compressions. Whether 1 or more rescuers are present, initiation of CPR with chest compressions ensures that the victim receives this critical intervention early.

13. 3-Chest Compression Rate: At Least 100 per Minute 2010 (New): It is reasonable for lay rescuers and healthcare providers to perform chest compressions at a rate of at least 100/min. 2005 (Old): Compress at a rate of about 100/min. The number of chest compressions delivered per minute during CPR is an important determinant of ROSC and survival with good neurologic function. The actual number of chest compressions delivered per minute is determined by the rate of chest compressions and the number and duration of interruptions in compressions (eg, to open the airway, deliver rescue breaths, or allow AED analysis). In most studies, delivery of more compressions during resuscitation is associated with better survival, and delivery of fewer compressions is associated with lower survival.

14. 4-Chest Compression Depth 2010 (New): The adult sternum should be depressed at least 2 inches (5 cm). 2005 (Old): The adult sternum should be depressed 1. to 2 inches (approximately 4 to 5 cm). Compressions create blood flow primarily by increasing intrathoracic pressure and directly compressing the heart. Compressions generate critical blood flow and oxygen and energy delivery to the heart and brain. Rescuers often do not adequately compress the chest despite recommendations to “push hard.” In addition, the available science suggests that compressions of at least 2 inches are more effective than compressions of 1. inches.

15. 5-perfect compressions Allow complete recoil between compressions. Compression-to-ventilation ratio (until advanced airway placed) 30:2 for 1 or 2 rescuers. The compressors should be on the center of the chest. Keep your elbows straight, and ensure that all the pressure is directed through the sternum and not through the ribs. To perform chest compressions adequately, it is necessary to be above the patient. HCPs should rotate compressors every 2 minutes.

16. 6-Team Resuscitation The steps in the BLS algorithm have traditionally been presented as a sequence to help a single rescuer prioritize actions. There is increased focus on providing CPR as a team because resuscitations in most EMS and healthcare systems involve teams of rescuers, with rescuers performing several actions simultaneously. For example, one rescuer activates the emergency response system while a second begins chest compressions, a third is either providing ventilations or retrieving the bag-mask for rescue breathing, and a fourth is retrieving and setting up a defibrillator.

17. Automated External Defibrillators In-Hospital Use of AEDs AED is a semi and fully automatic defibrillators,When connected to the patient these are able to interpret cardiac rhythms and deliver shocks when appropriate. Some are also able to measure the transthoracic impedance of the patient and attempt to match the energy delivery to the required current flow. 2010 (Reaffirmed 2005 Recommendation): Despite limited evidence, AEDs may be considered for the hospital setting as a way to facilitate early defibrillation (a goal of shock delivery ≤3 minutes from collapse), especially in areas where staff have no rhythm recognition skills or defibrillators are used infrequently.

18. Community Lay Rescuer AED Programs 2010 (Slightly Modified): Cardiopulmonary resuscitation and the use of AEDs by public safety first responders are recommended to increase survival rates for out-of-hospital sudden cardiac arrest. The 2010 AHA Guidelines for CPR and ECC again recommend the establishment of AED programs in public locations where there is a relatively high likelihood of witnessed cardiac arrest. To maximize the effectiveness of these programs, the AHA continues to emphasize the importance of organizing, planning, training, linking with the EMS system, and establishing a process of continuous quality improvement.

19. Shock First vs. CPR First When any rescuer witnesses an out-of-hospital arrest and an AED is immediately available on-site, or healthcare providers who treat cardiac arrest in hospitals and other facilities with on- site AEDs or defibrillators, the rescuer should start CPR with chest compressions for 2 minutes (approximately 5 cycles of 30:2) before defibrillation and then use the AED as soon as possible. With in-hospital sudden cardiac arrest, there is insufficient evidence to support or refute CPR before defibrillation. However, in monitored patients, the time from VF to shock delivery should be under 3 minutes, and CPR should be performed while the defibrillator is readied. Because when VF is present for more than a few minutes, the myocardium is depleted of oxygen and energy. A brief period of chest compressions can deliver oxygen and energy to the heart, increasing the likelihood that a shock will both eliminate VF (defibrillation) and be followed by ROSC.

20. CPR Techniques (The precordial thump ) This is delivered with a heel of a clenched fist from a height of around 8 inches from the chest. This generates a few joules of electrical current within the heart which, in the early phase of a cardiac arrest, may be enough to return sinus rhythm. The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest. The precordial thump may be considered for patients with witnessed, monitored, unstable VT (including pulseless VT) if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery.

21. ADVANCED LIFE SUPPORT (AcLS) Advanced cardiac Life Support refers to the use of specialised techniques. The aim is to rapidly restore an effective rhythm to the heart. The most important components of the advanced life support techniques are : 1- High-quality CPR 2-Defibrillation 3-Advanced Airway Management 4- Drug Therapy 2010 (New) : Quantitative waveform capnography is recommended for confirmation and monitoring of endotracheal tube placement and CPR quality. The conventional ACLS Cardiac Arrest Algorithm has been simplified and streamlined to emphasize the importance of high-quality CPR.

22. Capnography Recommendation Continuous quantitative waveform capnography is now recommended for intubated patients throughout the periarrest period. Capnography applications now include recommendations for confirming tracheal tube placement and for monitoring CPR quality and detecting ROSC based on end-tidal carbon dioxide (PETCO2) values Ineffective chest compressions (due to either patient characteristics or rescuer performance) are associated with a low PETCO2. Falling cardiac output or rearrest in the patient with ROSC also causes a decrease in PETCO2. In contrast, ROSC may cause an abrupt increase in PETCO2.

24. 2010 ACLS Algorithm 2010 ACLS Algorithm ACLS algorithms use simple formats that focus on delivery of high-quality CPR and early defibrillation for VF/pulseless VT ( The treatment pathway is divided into shockable rhythm (VF/VT) treated by defibrillation, and non-shockable rhythms (asystole and PEA )). If there is difficulty differentiating between a rhythm of fine VF and asystole, the treatment should be as for asystole and no shock given. Defibrillation in these cases causes myocardial injury and chest compression is the preferred treatment. Although adjunctive drug therapy and advanced airway management are still part of ACLS, there is increased emphasis on high-quality CPR (providing compressions of adequate rate and depth, allowing complete chest recoil after each compression, minimizing interruptions in chest compressions, and avoiding excessive ventilation). The 2010 Guidelines for CPR note that CPR is ideally guided by physiologic monitoring and includes adequate oxygenation and early defibrillation while the ACLS provider assesses and treats possible underlying causes of the arrest. Vascular access, drug delivery, and advanced airway placement, while still recommended, should not cause significant interruptions in chest compressions and should not delay shocks. There is no definitive clinical evidence that early intubation or drug therapy improves neurologically intact survival to hospital discharge.

25. CPR Quality Push hard (≥2 inches [5 cm]) and fast (≥100/min) and allow complete chest recoil Minimize interruptions in compressions Avoid excessive ventilation Rotate compressor every 2 minutes If no advanced airway, 30:2 compression-ventilation ratio Quantitative waveform capnography – If Petco2 <10 mm Hg, attempt to improve CPR quality Intra-arterial pressure – If relaxation phase (diastolic) pressure <20 mm Hg, attempt to improve CPR quality

26. Defibrillation Defibrillation Treat VF or pulseless VT with a single shock followed by resumption of CPR. The likelihood of successful defibrillation decreases with the duration of cardiac arrest (an estimated 2 - 7% for every minute of the arrest). Defibrillation delivers an electrical current through the heart simultaneously depolarising a critical mass of the myocardium and introducing a coordinated absolute refractory period. This results in a period during which another action potential cannot be triggered by a stimulus of any magnitude and, if successful will stop the chaotic electrical activity of ventricular fibrillation momentarily. Only a relatively small proportion of the energy is delivered to the heart and variations in transthoracic impedance (resistance to current flow caused by chest tissues) will occur. The energy requirement for defibrillation (defibrillation threshold) will tend to increase with the duration of the arrest. The sternal paddle is placed high on the right side of the anterior chest wall, lateral to the upper part of the sternum and below the clavicle; the apex paddle is placed just lateral to the position of the normal apex beat, avoiding breast tissue in females.

28. Defibrillation Waveforms and Energy Levels The data studies indicate that biphasic waveform shocks at energy settings comparable to or lower than 200-J monophasic shocks have equivalent or higher success for termination of VF. The initial and subsequent shocks for monophasic defibrillators are now 360J. Fixed and Escalating Energy The optimal biphasic energy level for first or subsequent shocks has not been determined. Therefore, it is not possible to make a definitive recommendation for the selected energy for subsequent biphasic defibrillation attempts. If the initial biphasic shock is unsuccessful in terminating VF, subsequent energy levels should be at least equivalent, and higher energy levels may be considered, if available.

29. 1-Shock Protocol vs. 3-Shock Sequence Evidence from 2 studies suggests significant survival benefit with a single-shock defibrillation protocol compared with a 3-stacked shock protocol. If 1 shock fails to eliminate VF, the incremental benefit of another shock is low, and resumption of CPR is likely to confer a greater value than another immediate shock. This fact, combined with the data from studies documenting harmful effects from interruptions to chest compressions and studies suggesting a survival benefit from a CPR, approach that includes a 1-shock compared with a 3-shock protocol, supports the recommendation of single shocks followed by immediate CPR rather than stacked shocks for attempted defibrillation. Even if the output is restored post-shock, a period of CPR is believed to encourage myocardial perfusion.

30. DEFIBRILLATION SEQUENCE ActionAnnouncements 1. Switch on. 2. Place coupling pads/gelDC shocks should be delivered with the correct paddle position and good contact using conductive pads or a coupling medium 3. Apply paddles 4. Check ECG rhythm and confirm no pulse ECG monitoring via the paddles or via leads attached to the machine. 5. Select non-synchronised (VF) setting 6. “Charging”For monophasic defibrillators empirical energy levels of 200 Joules (J) for the first two shocks and 360J subsequently have been used. Now the initial and subsequent shocks used are 360J.

31. ActionAnnouncements 7. “Stand clear”Remove any oxygen source away from the patient by more than 1m during defibrillation, or if the patient is intubated, leave the tracheal tube connected to the oxygen source and stand away. Ensure no-one is in contact with anything touching the patient 8. “Shocking now” Press paddle buttons simultaneously 9. Resumption of CPRIf 1 shock fails to eliminate VF, then resume CPR. Even if the output is restored post-shock, a period of CPR is believed to encourage myocardial perfusion. 10. Check ECG rhythm Check pulse Following 2 minutes of CPR the electrical rhythm is assessed. if still VF or pulseless VT give another shock. If organised complexes are seen but there is no pulse palpable the PEA algorithm is followed (resume CPR). If organised complexes are seen during CPR, chest compressions are continued unless signs of life (suggesting a return of spontaneous circulation) are seen. 11. Return to ALS algorithm for further steps

32. Advanced Airway Management and ventilation Advanced Airway Management and ventilation Where available, supply oxygen-enriched air. The tracheal tube is the most efficient way to ventilate the lungs and protect against aspiration of gastric contents. However, intubation must be carried out swiftly, without the need to stop chest compressions. Confirmation of correct position of an endotracheal tube is imperative. Alternative airway devices include the Laryngeal Mask Airway (LMA), the proseal LMA, the combitube. Oral and nasopharyngeal airways also can be used for maintenance of the airway patency. If it is impossible to ventilate an apnoeic patient with a bag-mask, or to pass a tracheal tube or alternative airway device, delivery of oxygen through a cannula or surgical cricothyroidotomy may be life-saving Provide artificial ventilation as soon as possible in any patient in whom spontaneous ventilation is inadequate or absent. Deliver each breath over approximately 1 s and give a volume that corresponds to normal chest movement. During CPR with an unprotected airway, give two ventilations after each sequence of 30 chest compressions. Once a tracheal tube or SAD has been inserted, ventilate the lungs at a rate of about 10 breaths min-1 and continue chest compression without pausing during ventilation.

33. Drug Therapy Drug Therapy Adrenaline (Epinephrine) When commencing ACLS for VF/VT, give adrenaline after the third shock once chest compressions have resumed, and then repeat every 3-5 min during cardiac arrest (alternate cycles). For PEA and asystole, give 1mg adrenaline as soon as venous access is established and every 3-5 minutes thereafter (approximately every 2-3 CPR loops). Giving adrenaline in doses of 1mg causes massive peripheral vasoconstriction, thereby increasing cerebral and myocardial perfusion. Do not interrupt CPR to give drugs. Vasopressin Vasopressin is a nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction No difference in outcomes (ROSC, survival to discharge, or neurologic outcome) with vasopressin (40 units IV) versus epinephrine (1 mg) as a first- line vasopressor in cardiac arrest Because the effects of vasopressin have not been shown to differ from those of epinephrine in cardiac arrest, 1 dose of vasopressin 40 units IV/IO may replace either the first or second dose of epinephrine in the treatment of cardiac arrest.

34. Atropine It is not more recommended for routine use in the management of PEA/asystole and has been removed from the ACLS Cardiac Arrest Algorithm. For symptomatic or unstable bradycardia, intravenous (IV) infusion of chronotropic agents is now recommended as an equally effective alternative to external transcutaneous pacing when atropine is ineffective. Sodium bicarbonate Giving sodium bicarbonate routinely during cardiac arrest and CPR (especially in out-ofhospital cardiac arrest), or after ROSC, is not recommended. Give sodium bicarbonate (50 mmol) if cardiac arrest is associated with hyperkalaemia or tricyclic antidepressant overdose.

35. Amiodarone Amiodarone is the first-line antiarrhythmic agent given during cardiac arrest because it has been clinically demonstrated to improve the rate of ROSC and hospital admission in adults with refractory VF/pulseless VT. Amiodarone may be considered when VF/VT is unresponsive to CPR, defibrillation, and vasopressor therapy if VF/VT persists. give amiodarone 300 mg by bolus injection (flushed with 20 ml of 0.9% sodium chloride or 5% dextrose) after the third shock. A further dose of 150 mg may be given for recurrent or refractory VF/VT, followed by an infusion of 900 mg over 24 h. Lidocaine 1 mg kg-1 may be used as an alternative if amiodarone is not available, but do not give lidocaine if amiodarone has been given already.

36. Magnesium the benefit of giving magnesium routinely during cardiac arrest is unproven. Give an initial intravenous dose of 2 g (= 8 mmol, 4 ml of 50% magnesium sulphate) for refractory VF if there is any suspicion of hypomagnesaemia (e.g. patients on potassium-losing diuretics); it may be repeated after 10-15 min. Other indications are : torsade de pointes VT; and digoxin toxicity. Calcium There are no data supporting any beneficial action for calcium after most cases of cardiac arrest. Give calcium during resuscitation only when indicated specifically, i.e., in cardiac arrest caused by hyperkalaemia, hypocalcaemia, or overdose of calcium channel-blocking drugs. The initial dose of 10 ml 10% calcium chloride (6.8 mmol Ca2+) may be repeated if necessary. Do not give calcium solutions and sodium bicarbonate simultaneously by the same route.

37. Post–Cardiac Arrest Care Post–Cardiac Arrest Care To improve survival for victims of cardiac arrest who are admitted to a hospital after ROSC, a comprehensive, structured, integrated, multidisciplinary system of post– cardiac arrest care should be implemented in a consistent manner. Treatment should include cardiopulmonary and neurologic support. Therapeutic hypothermia and percutaneous coronary interventions (PCIs) should be provided when indicated Because seizures are common after cardiac arrest, an electroencephalogram for the diagnosis of seizures should be performed with prompt interpretation as soon as possible and should be monitored frequently or continuously in comatose patients after ROSC.