Welcome to the Basic Life Support course.

The following text describes the steps that are to be followed

as the immediate step in the case of a cardiac arrest scenario. Candidates are requested to familiarize
themselves with the information provided so that understanding instructions in the class would be
easier. You are required to score more than 80% in the written test to be eligible to appear for the
practical test (skill demonstration). Passing both theory and practical skill test is necessary for
certification.

Objective of this manual:

To help candidates perform CPR (cardio pulmonary resuscitation) in a variety of settings. The manual
gives details of the skills you will be learning in the class, such as:

 Immediate recognition of cardiac arrest and starting chest compression.

 Performing prompt and high-quality chest compressions for adult, child and infant victims.

 Initiating early use of the defibrillator.

 Providing appropriate rescue breaths.

 Practicing 2-rescuer team CPR.

 Relieving choking.

Step 1:
Assess scene safety: The first rescuer who arrives at the side of the victim must quickly be sure that the
scene is safe.

Check for response:

 Tap the victim’s shoulder and shout, “Are you all right?”

 Check to see if the victim is breathing. If the victim is not breathing or not breathing normally
(ie, only gasping), you must activate the emergency response system (code blue).

 Gasping is not normal breathing. It is a sign of cardiac arrest in someone who does not respond.

Step 2:
Activate the emergency response system (code blue) and get a defibrillator.
  If you are alone and find an unresponsive victim not breathing, shout for help. If no one
responds, activate code blue, get a defibrillator (if available), and then return to the victim to
check a pulse and begin CPR.

Step 3:
Pulse check.

 To perform pulse check in an adult, palpate the carotid pulse.

 Locate the trachea using 2 or 3 fingers. Slide these fingers into the groove between the trachea
and the muscles at the side of the neck, where you can feel the carotid pulse.

 Feel for a pulse for at least 5 but no more than 10 seconds. If you do not definitely feel a pulse,
begin CPR, starting with chest compressions.

Step 4:
Begin cycles of 30 compressions and 2 breaths (CPR):

The lone rescuer should use the compression-ventilation ratio of 30 compressions to 2 breaths
when giving CPR to victims of any age.

Chest compression technique:

1) Position yourself at the victim’s side.

2) Make sure the victim is lying faceup on a firm, flat surface. If the victim is lying facedown,
carefully roll him faceup. If a head or neck injury is suspected, try to keep the head, neck, and
torso in a line when rolling the victim to a faceup position.

3) Put the heel of one hand on the centre of the victim’s chest on the lower half of the breast
bone. Put the heel of the other hand on top of the first hand.

4) Straighten your arms and position your shoulders directly above your hands.

5) Push hard and push fast. Press down at least 5 cms (2 inches) with each compression. Deliver
compressions at a rate of at least 100/min.
Do not move the victim while CPR is in progress unless the victim is in a dangerous environment.
CPR is better and has fewer interruptions when rescuers perform the resuscitation where they
find the victim.

Opening the airway for breaths (Head tilt-chin lift):

1. Place one hand on the victim’s forehead and push with your palm to tilt the head back.

2. Place the fingers of the other hand under the bony part of the lower jaw near the chin.

3. Lift the jaw to bring the chin forward.

This manouevre relieves obstruction by the tongue.

Some don’ts:

 Do not press deeply into the soft tissue under the chin because this might block the
airway.

 Do not use the thumb to lift the chin.

 Do not close the victim’s mouth completely.

The bag-mask device:

Bag-mask devices consist of a bag attached to a face mask. They may include a 1-way
valve. Steps for using the bag-mask device are:

1. Position yourself directly above the victim’s head.

2. Place the mask on the victim’s face, using the bridge of the nose as a rough
guide for correct position.

3. Use the E-C clamp technique to hold the mask in place while you lift the jaw to
hold the airway open.

 Perform a head tilt.

  Place the mask on the face with the narrow portion at the bridge of the
nose.

 Use the thumb and index finger of one hand to make a “C” on the side
of the mask, pressing the edges of the mask to the face.

 Use the remaining fingers to lift the angles of the jaw (3 fingers form an
“E”), open the airway, and press the face to the mask.

4. Squeeze the bag to give breaths (1 second each) while watching for chest rise.
Deliver all breaths over 1 second whether or not you use supplementary
oxygen.

Duties for each rescuer in a 2-rescuer CPR

Rescuer 1: Location at the victim’s side.

Performs chest compressions.

Rescuer 2: Location at the victim’s head.

Maintains an open airway.

Gives breaths, watching for chest rise.

Switches duties with first rescuer.

It is important for the rescuer giving chest compressions to count out aloud so that the person
giving breaths can anticipate when breaths will be given and prepare to give them effectively to
minimize interruptions in compressions.

Jaw thrust:

If the victim has a head or neck injury and a spine injury is suspected, a jaw thrust can be used to
open the airway. If the jaw thrust does not open the airway then use a head tilt-chin lift.

How to perform a jaw thrust:

  Place one hand on each side of the victim’s head, resting your elbows on the surface on
which the victim is lying.

 Place your fingers under the angles of the victim’s lower jaw and lift with both hands,
displacing the jaw forward.

 If the lips close, push the lower lip with your thumb to open the lips.

Defibrillation: if no pulse, check for a shockable rhythm with an AED/defibrillator as soon as it

arrives. Deliver shock if indicated. Follow each shock immediately with CPR, beginning with
chest compressions.

Defibrillation does not restart the heart. It stuns the heart and briefly terminates all electrical
activity, including VF and VT. If the heart is still viable, its normal pacemaker may eventually
resume electrical activity that results in a perfusing rhythm (ROSC).

CPR in a child (1 year of age to puberty):

(Sign of puberty include chest or underarm hair on males and any breast development in
females).

 Compression to ventilation ratio is 30:2 for lone rescuer and 15:2 for 2 rescuer CPR.

 Compress the chest at least one-third the depth of the chest (approximately 5 cm).

 Compression technique: may use 1- or 2-handed chest compressions for very small
children.

 When to activate the emergency response system: 1) if the arrest is not witnessed and
you are alone, then provide 2 minutes of CPR before leaving the child to activate the
emergency response system. 2) if the arrest is sudden and witnessed, leave the child to
activate the emergency response system and get a defibrillator, and then return to the
child.

 To perform pulse check palpate the carotid or femoral artery. To locate the femoral
artery pulse place 2 fingers in the inner thigh, midway between the hipbone and the
pubic bone and just below the crease where the leg meets the abdomen.
BLS/CPR for infants:

The term infant means upto 1 year (12 months) of age, excluding the newly born infants in the
delivery room.

 To check pulse palpate the brachial artery (put 3 fingers on the inner side of the arm
between shoulder and elbow).

 Technique for delivering compression: 2 fingers for single rescuer and 2 thumb-
encircling hands technique for 2 rescuers.

 Compression depth is at least one third the chest depth, approximately 4 cm(1 ½
inches).

 Compression ventilation ratio is the same as in child CPR.

If an advanced airway is in place then compression rate remains the same, however breaths are
delivered at a rate of 8-10 breaths / minute (ie 1 breath every 6 to 8 seconds).

When an victim is not breathing effectively but is having a palpable pulse, then only rescue
breaths are to be given at a rate of 10 to 12 breaths per minute (for an adult) OR 12 to 20
breaths per minute (in a child).

Management of respiratory arrest

 Give supplementary oxygen

 Opening the airway

 Providing basic ventilation

 Using basic airway adjuncts (OPA and NPA)

 Suctioning
Giving supplementary oxygen: monitor oxygen saturation and titrate supplementary oxygen to maintain
a saturation ≥94%.

Opening the airway:

The most common cause of upper airway obstruction in the unconscious/unresponsive patient is loss of
tone in the throat muscles. The tongue falls back and occludes the airway at the level of the pharynx.

Basic airway skills used to ventilate a patient are:

 Head tilt-chin lift.

 Jaw thrust without head extension (suspected cervical spine trauma).

 Mouth-to-mouth ventilation.

 Mouth-to-nose ventilation.

 Mouth-to-barrier device (pocket mask) ventilation.

 Bag-mask ventilation.

Basic airway adjuncts: Oropharyngeal airway (OPA):

This is a J shaped device that is used in patients at risk for developing airway obstruction from the
tongue or from relaxed upper airway muscle. It fits over the tongue and holds it along with soft
hypopharynryngeal structures away from the posterior pharyngeal wall. It is used in the following
situations:

 To keep airway open during bag-mask ventilation.

 During suctioning of the mouth and throat.

 In intubated patients to prevent them from biting and occluding the ET tube.

Some don’t’s regarding the OPA:

 Too large OPAs may obstruct the larynx or cause trauma to the laryngeal structures.

 Too small or improperly inserted OPAs may push the base of the tongue posteriorly and
obstruct the airway.

 Do not use the OPA in a conscious patient or patient with intact gag reflex.

How to select a proper size OPA?

Place the OPA against the side of the face. When the tip of the OPA is at the corner of the mouth, the
flange should be at the angle of the mandible.

Insertion: Insert the OPA with curvature facing anteriorly into the oral cavity. As it reaches the posterior
pharynx, rotate it 1800 into proper position. Alternately, the OPA can be inserted straight in while using
the tongue depressor.

Remember:

 Too large OPA may obstruct the larynx or cause trauma to laryngeal wall.

 Too small or improperly inserted OPA may push the base of the tongue posteriorly and obstruct
the airway.

Nasopharyngeal Airway (NPA): its use is indicated in:

 Insertion of OPA is technically difficult or dangerous (intact gag reflex, trismus, massive trauma
around mouth, wiring of jaws).

 Neurologically impaired with poor pharyngeal tone leading to upper airway obstruction.

Proper size: length should the same as distance from tip of the patient’s nose to earlobe.

Insertion: through the nostril in a posterior direction perpendicular to the plane of the face. In case of
resistance, slightly rotate the tube to facilitate insertion at the angle of the nasal passage and
nasopharynx, or attempt placement through other nostril because patients have different-sized nasal
passages.

Use with caution in patients with facial trauma because of the risk of misplacement into the cranial
cavity through a fractured cribriform plate.

Cardiac arrest algorithm: VF and Pulseless VT

The algorithm assumes that healthcare providers have completed the BLS survey, including activation of
emergency system, performing CPR, attaching the manual defibrillator, and delivering the first shock.

The ACLS resuscitation team now intervenes and conducts the ACLS survey. The team assesses the
patient and takes action as needed. The team leader coordinates the efforts of the resuscitation team as
they perform the steps of the algorithm.

It is not recommended to continue use of the AED when a manual defibrillator is available and the
provider’s skills are adequate for rhythm interpretation.

Chest compression should ideally be interrupted only for: 1) ventilation (unless an advanced airway is in
place); 2) rhythm checks; 3)shock delivery.
Perform a pulse check only if an organized rhythm is observed.

Shortening the interval between the last compression and the shock by even a few seconds ca improve
shock success. Hence it is reasonable for healthcare providers to practice efficient coordination between
CPR and defibrillation to minimize hands-off intervals between stopping compressions and
administering a shock.

While the charging sequence of a defibrillator has been initiated, it is important that another rescuer
continues the compressions while the device is being fully charged.

Immediately after the shock, resume CPR, beginning with chest compressions. Give 2 minutes (about 5
cycles) of CPR. A cycle consists of 30 compressions followed by 2 ventilations in a patient without an
advanced airway.

Shock and vasopressors:

When IV/IO access is available, give a vasopressor during CPR (either before or after the shock) as
follows:

Adrenaline: 1 mg IV/IO – repeat every 3-5 minutes.

If additional team members are available, they should anticipate the need for drugs and prepare them
in advance.

Adrenaline is used during resuscitation primarily for its α-adrenergic effects, ie, vasoconstriction. This
increases cerebral and coronary blood flow during CPR by increasing mean arterial pressure and aortic
diastolic pressure.

Vasopressin is a nonadrenergic peripheral vasoconstrictor. A metaanalysis of 5 randomized trials found

no difference between vasopressin and epinephrine for ROSC, 24-hour survival, or survival to hospital
discharge.

In case of a monophasic defibrillator, give a single 360-J shock. Use the same energy dose for
subsequent shocks. When using biphasic defibrillators, providers should use the manufacturer’s
recommended energy dose (eg, initial dose of 120-200 J). many manufacturers display the effective
energy dose range on the face of the device. If you do not know the effective dose range, deliver the
maximum energy dose for the first and all subsequent shocks.
If the initial shock terminates VF but the arrhythmia recurs later in the resuscitation attempt, deliver
subsequent shocks at the previously successful energy level.

Rhythm check:

Conduct a rhythm check after 2 minutes (5 cycles) of CPR. The pause in chest compressions to check the
rhythm should not exceed 10 seconds.

If a non-shockable rhythm is present and the rhythm is organized (regular and narrow complexes), a
team member should try to palpate a pulse. If there is any doubt about the presence of a pulse,
immediately resume CPR.

Perform a pulse check, preferably during rhythm analysis, only if an organized rhythm is present. If the
rhythm is organized and there is a palpable pulse, proceed to post-cardiac arrest care. If the rhythm
check reveals a non-shockable rhythm and there is no palpable pulse, proceed along the asystole/PEA
pathway.

Rhythm check:

Interruption in CPR to conduct a rhythm analysis should not exceed 10 seconds.

 If a nonshockable rhythm is present and the rhythm is organized (regular and narrow
complexes), a team member should try to palpate a pulse. If there is any doubt about the
presence of a pulse, immediately resume CPR.

 If the rhythm check is organized and there is a palpable pulse, proceed to post-cardiac arrest
care.

 If the rhythm check reveals a non-shockable rhythm and there is no pulse, proceed to
asystole/PEA pathway.

 If the rhythm check reveals a shockable rhythm, resume chest compressions if indicated while
the defibrillator is charging.

Antiarrhythmic drugs:

 Amiodarone: 300 mg IV/IO bolus, then consider an additional 150 mg. if amiodarone is not
available then lidocaine may be administered in its place.

 Lidocaine: 1 to 1.5 mg/kg IV/IO first dose, then 0.5 to 0.75 mg/kg IV/IO at 5- to 10-minute
intervals, to a maximum dose of 3 mg/kg.

 Magnesium sulphate: to be considered only for torsades de pointes associated with long QT
interval. Loading dose 1-2 g IV/IO diluted to 10 ml of D5W given as IV/IO bolus, over 5-20
minutes.
Physiologic monitoring during CPR

Studies (animal and human) indicate that PETCO2, CPP, and ScVO2 monitoring provide valuable
information on patient’s condition and response to therapy: they correlate with cardiac output and
myocardial blood flow during CPR. An abrupt increase in any of these parameters is a sensitive indicator
of ROSC that can be monitored without interrupting chest compressions. These parameters help to
optimize compressions and guide vasopressor therapy during cardiac arrest. It is not yet proved if
monitoring these parameters improves outcome.

End-Tidal CO2: This depends on blood delivery to lungs during CPR. Persistently low PETCO2 values < 10
mmHg during CPR in intubated patients suggests that ROSC is unlikely. If PETCO2 abruptly rises to a
normal value of 35 to 40 mmHg, this can be considered an indicator of ROSC. If the PETCO2 is < 10
mmHg during CPR, then one must try to improve chest compressions and vasopressor therapy.

Coronary Perfusion Pressure (CPP) or Arterial Relaxation Pressure: Increased CPP correlates with both
myocardial blood flow and ROSC. The arterial relaxation pressure (diastolic pressure) can be taken as a
surrogate for CPP during CPR. This can be measured by an intra-arterial catheter.

If the arterial relaxation pressure is < 20 mmHg, if is reasonable to try to improve chest compressions
and vasopressor therapy.

Central Venous Oxygen Saturation: If oxygen consumption, arterial oxygen saturation, and hemoglobin
are constant, changes in ScvO2 reflect changes in oxygen delivery due to changes in cardiac output. If
the ScvO2 is < 30%, it is reasonable to try to improve chest compressions and vasopressor therapy.

Drugs:

A peripheral iv is preferred for drug and fluid administration (unless central line access is already
present). Central line access is not necessary during most resuscitation attempts. Attempts to access a
central line may cause interruptions in CPR and complications during insertions, including vascular
laceration, haematomas, and bleeding.

If a drug is given by peripheral venous route, administer it as follows:

 Give the drug by bolus injection (unless otherwise specified).

 Follow with a 20-ml bolus of iv fluid.

 Elevate the extremity for about 10 to 20 seconds to facilitate delivery of the drug to the central
circulation.
Epinephrine stimulates adrenergic receptors, producing vasoconstriction, increasing blood pressure
and heart rate, and improving perfusion pressure to the brain and heart. Repeat epinephrine (1 mg)
every 3 to 5 minutes during cardiac arrest.

Amiodarone is a complex drug that affects sodium, potassium, and calcium channels. It also has α-
adrenergic and β-adrenergic blocking properties. During cardiac arrest, consider amiodarone 300 mg
iv push for the first dose. If VF/pulseless VT persists, consider giving a second dose of 150 mg iv in 3
to 5 minutes.

Lidocaine: no proven long-term or short-term efficacy in cardiac arrest. It may be considered when
amiodarone is not available. Initial dose is 1 to 1.5 mg/kg iv. Repeat if indicated at 0.5 0.75 mg/kg iv
over 5- to 10- minute intervals to a maximum of 3 mg/kg. Endotracheal dose is 2 to 4 mg/kg.

Magnesium sulphate: May termite or prevent recurrent torsades de pointes in patients who have a
prolonged QT interval during normal sinus rhythm. When VF/pulseless VT cardiac arrest is
associated with torsades de pointes, give magnesium suphate in loading dose of 1 to 2 g diluted in
10 ml D5W given over 5 to 20 minutes. (if a prearrest 12-lead ECG is available for review, check the
QT interval for prolongation.
Respiratory Arrest:
Average respiratory rate is 12 to 16 / min.

Tachypnoea is respiratory rate above 20/min, bradypnoea is respiratory rate below 12/min.

Respiratory rate below 6/min (hypoventilation) requires assisted ventilation with a bag-mask device
or advanced airway with 100% oxygen.

One needs to differentiate between respiratory distress and respiratory arrest.

Respiratory distress is a clinical state characterized by abnormal respiratory rate or effort. Clinical
signs are: tachypnea, increased/inadequate respiratory effort, abnormal breath sounds (stridor,
wheezing, grunting), tachycardia, pale or cool skin, altered sensorium or agitation, use of abdominal
muscles to assist in breathing.

Respiratory failure is a clinical state of inadequate oxygenation, ventilation, or both. It is the end
stage of respiratory distress. Clinical signs are marked tachypnea, bradypnoea or apnoea (late sign),
increased, decreased or no respiratory effort; tachycardia (early); bradycardia (late); cyanosis;
stupor or coma (late).

Respiratory failure can occur with increase in partial pressure of arterial carbon dioxide (PaCO2), or
decrease in partial pressure of arterial oxygen (PaO2), or both.

Respiratory arrest is the absence of breathing. Management of respiratory arrest includes:

 Administering supplementary oxygen:

 Opening the airway

 Provide basic ventilation (bag-mask, or use of advanced airway)

 Using basic airway adjuncts (OPA and NPA)

 Suctioning.
Adult Bradycardia With Pulse Algorithm

Definition: Bradycardia is defined as heart rate less than 60/min. If signs and symptoms arise due to
slow heart rate, then it is called symptomatic bradycardia.

Atropine: 0.6 mg, repeat every 3-5 minutes, till a maximum dose of 3 mg.

(If patient has type II second-degree, or third degree AV block atropine is unlikely to benefit, hence
TCP should be initiated after the second dose of atropine.

Adrenaline : Start infusion @ 2-10 mcg/min, titrate to patient response.

Dopamine: Start infusion @ 2-20 mcg/min, titrate to patient response.

Trans Cutaneous Pacing (TCP): Place electrodes, turn pacer on, set demand rate to 60/min, set
current milliamperes output 2mA above the dose that captures.

Do not use TCP in asystole, and severe hypothermia.

Do not assess carotid pulse to confirm mechanical capture.

Adult Tachycardia With Pulse Algorithm

Definition: Heart rate more than 100 / min.

Synchronized cardioversion: Narrow regular (50-100J); Narrow irregular (120-200 J), Wide regular
(100J), Wide irregular (defibrillation)

Adenosine: First dose 6 mg, rapid iv push followed by saline flush. Second dose 12 mg (if required)

Procainamide IV infusion: 20-50 mg/min (till arrhythmia subsides, hypotension occurs, QRS duration
increases by 50%) followed by 1-4 mg/min maintenance infusion. Avoid in prolonged QT of CHF.

Max dose: 17 mg/kg

Amiodarone: First dose 150 mg over 10 min followed by maintenance infusion 1 mg/min.

Sotalol: 1.5 mg/kg (100 mg) over 5 minutes. Do not use if there is QT prolongation.
Immediate Post-Cardiac Arrest Care Algorithm