Cardiopulmonary

Resuscitation (CPR)

Simeneh mola ( MSc, Ass. professor of

Anesthesia)
 Outline
• Objectives
• Introduction
• Recognation of crtically ill patient
• Adult BLS/ACLS
• Pediatrics BLS/ACLS
 Goal
• To provide students with the knowledge, skill
and attitude of effective basic life support BLS
& ACLS
• To provide current resuscitation guideline and
practical experience in running cardiac arrest
scenarios
 objectives
• Identify and manage critically ill patients
• Provide high quality BLS/ACLS
• Differentiate shockable and non shockable
rythm
• Identify reversable cuases of cardiac arrest
• Uderstand ethical issue related with CPR
• Appreciate the importance of teamwork in the
managment of critically ill patients
• Plan appropriate post resuscitation plan
 Introduction
• Definition:
Cardiopulmonary Resuscitation (CPR) is an
emergency lifesaving procedure performed
when the heart stops beating.
• Purpose:
To manually preserve intact brain function until
further measures restore spontaneous blood
circulation and breathing in a person who is in
cardiac arrest.
 Background
• In Europe, survival to hospital discharge is 10.7% for all rhythm cardiac
arrest ie. most people who have a cardiorespiratory arrest die

• Those who survive usually have witnessed and monitored VF arrests

and receive immediate defibrillation

• Most in hospital cardiorespiratory arrests are predictable with 80% of

cases showing deterioration in the hours preceding arrest

• The usual arrest rhythm in this group is usually non-shockable for which
the survival rate to hospital discharge is very low

• Therefore, early recognition and treatment of deteriorating patients is the

key to preventing deaths and also in identifying patients in whom CPR is
not appropriate
Components
 Recognition of the critically ill
adult patient and prevention of

cardio-respiratory arrest
 Recognising the critically ill patient
• Regular assessment of simple vital signs are essential in recognising
critical illness and helping to predict cardiorespiratory arrest

• Many hospitals use early warning systems which help to identify

deteriorating patients and trigger a response (either from the medical team
looking after the patient or from a designated medical emergency team)

• Critically ill patients should placed in an area with the highest supervision
(this may be near the nursing station or on a different ward or in recovery)

• Nights and weekends are a high risk time

 Approach to critically ill patients - ABCDE
(A) Airway
(B) Breathing
(C) Circulation
(D) Disability
(E) Exposure

Treat life-threatening problems before moving to the next step

Re-assess regularly

Recognise the need for additional help early and use a team effectively
Multiple tasks need to occur simultaneously requiring multiple people
(A) Airway - assessment
• Talk to the patient – is he responding?
• Is there evidence of airway obstruction?
If partial
- patient may complain of difficulty in breathing (if conscious)
- patient is distressed (if conscious)
- choking (if conscious)
- stridor or snoring may be present if upper airway obstruction
- wheeze may be present if lower airway obstruction
If complete (patient likely to be unconscious)
- respiration silent
- no air movement at patient’s mouth
- respiratory movement are strenuous
“see saw” pattern of chest & abdominal movement
indrawing at sternal notch
(A) Airway - management
• If evidence of airway obstruction – act immediately & get help
 remove anything from mouth ie. suction secretions /
vomit
 airway manoeuvres head tilt, chin lift or jaw thrust
 use oropharyngeal airway or nasopharyngeal airway
 consider need for ETT or tracheostomy (very rarely
required for immediate airway patency)
• Treat any patient with depressed LOC (GCS < 8) as at risk of airway
obstruction / unprotected airway

• If at risk of airway obstruction but currently airway is patent -

remove anything from mouth ie. suction secretions / vomit
turn the patient into lateral position (recovery position)

• Give oxygen (if necessary move the patient)

Recovery Position
(A) Airway

Causes of airway obstruction

• CNS depression leading to loss of airway control

• Face or throat trauma
• Foreign body eg. tooth / food / vomit
• Pharyngeal swelling
• Epiglottitis
• Laryngospasm
• Bronchospasm
• Bronchial secretions
 (B) Breathing - assessment
• inspection - evidence respiratory distress?
- central cyanosis?
- noisy breathing?
- respiratory rate?
- JVP?
- adequacy and equality of chest expansion?
• palpation - trachea, chest wall
• percussion

• auscultation

• pulse oximetry and inspired oxygen concentration (FiO 2)

- only measures oxygenation not ventilation
• if available arterial blood gas analysis
(B) Breathing

Causes of respiratory compromise

• CNS depression - drugs, head injury, hypercapnia, metabolic

• Poor respiratory effort

resp. muscle weakness - spinal cord injury, high spinal block
gen. muscle weakness - chronic malnourishment, critical illness
myasthenia gravis, GB
•syndrome
Lung pathology
infection PE
COPD lung contusion
asthma ARDS
pulmonary oedema (pneumothorax)
(B) Breathing - management
• Give oxygen (if necessary move the
patient)
• Treat reversible causes promptly eg.
- antibiotics for pneumonia
- bronchodilators for asthma
- naloxone if opiate overdose
- ventilate CO2 down if hypercapnic (can do with mask)
- needle decompression for pneumothorax

• Reassess patients after intervention

• If patients do not respond to intervention they may require

increased level of support – this may not be available in this set-up
and will require discussion with seniors as to how to proceed
(C) Circulation - assessment

• assess patients colour / temperature / CRT – peripherally and centrally

• pulse rate and character

• blood pressure

• assess the JVP

• auscultate the heart

• look for sources of haemorrhage including intra-abdominal / intra-

thoracic

• assess the urine output

(C) Circulation - management
• give oxygen

• insert 1 or more large bore IV cannula (14G or 16G)

• treat the cause

- if hypovolaemia; rapid fluid challenge 500 mL - 1L over 5 - 10 min
- if cardiac failure and hypotensive; more cautious fluid challenge
with careful monitoring

• reassess (every 5 mins)

• if no improvement – repeat fluid challenge

• if signs of pulmonary oedema – slow or stop fluids and consider inotrope

• if evidence of acute cardiac syndrome – 12 lead ECG, O2, aspirin,

GTN, morphine, etc.
(C) Circulation – causes of cardiac arrest
Primary cardiac cause
Ischaemic heart disease → VF, severe LVF, valve rupture
Valvular disease
Myocarditis
Cardiomyopathy
Congential cardiac disease eg accessory pathways / long QT
Secondary cardiac cause
Distributive shock – sepsis / anaphylaxis / neurogenic
Hypovolaemic shock
Obstructive shock – tamponade / tension pneumothorax / PE
Metabolic – electrolytes / hypoglycaemia / acidosis
Hypoxia (secondary to airway or breathing problems)
Toxins
Electrocution
Hypothermia
(D) Disability – assessment (1)
• measure conscious level
GCS OR use AVPU
M = 6 obeys commands A – alert
M = 5 localises pain V - responds to voice
M = 4 withdraws to pain P - responds to pain
M = 3 flexes to pain U - unresponsive
M = 2 extends to pain
M = 1 no motor response
V = 5 orientated
V = 4 confused
V = 3 inappropriate words
V = 2 inarticulate sounds
V = 1 no verbal response
E = 4 eyes spontaneously open
E = 3 eye opening to speech
E = 2 eye opening to pain
E = 1 no eye opening
(D) Disability – assessment (2)

• examine for signs of head injury

• examine pupils – size, equality, light reaction

• check drug chart / collateral history - ? drug induced depressed LOC

• check blood glucose

(D) Disability – management

• treat the cause (where possible)

hypoxia
hypercapnia
hypotension
hypoglycaemia – glucose 50mls 10% dextrose
head injury – inform surgeons
drug induced – give antagonist where appropriate e.g. naloxone

• supportive treatment may be the only option, the aim being to

maintain the airway, breathing and circulation (as discussed) giving
the patient time to recover from the insult and to prevent secondary
brain injury
(D) Disability

Causes of reduced consciousness

• hypoxia
• hypercapnia
• hypotension
• hypoglycaemia
• raised ICP – haematoma / SOL
• drug induced
• large CVA
• severe electrolyte disturbances (e.g. Na+)
• epilepsy
(E) Exposure

• examine and expose the patient fully whilst trying to minimise heat loss

• treat any relevant finding appropriately

 Other considerations
• take a history from patient / relatives / staff

• review the patient’s notes / chart paying particular attention to

- absolute and trend values of vital signs
- whether important routine medications have been prescribed and
administered
- relevant laboratory and radiological investigations

• in a critically ill patient many of these tasks should be done

simultaneously  essential to have a team approach

• having initiated treatment regular, frequent reassessment is essential

• consider a plan for definitive treatment

• consider where best the patient should be cared for

 In-hospital
Adult Basic Life Support
(BLS)
 In-hospital basic life support
Safety – ensure your personal safety

Stimulate the patient for a response

• If response; assess using ABCDE approach already described

• If no response

Shout for help

Turn patient on back

shake and shout

 Open airway – head tilt, chin lift, jaw thrust
A Check mouth for foreign bodies
Consider C-spine precautions (no head tilt)

head tilt and chin lift

 Keeping airway open
B look, listen and feel for breathing (max 10 secs)
can be done
simultaneously
Feel for carotid pulse and observe for signs of
C life

simultaneous
checking for
breathing and carotid
pulse
 • If the patient has pulse or signs of life and is breathing
C - use ABCDE approach already described

• If the patient is not breathing but has a pulse (respiratory arrest)

ventilate the patient and check for a pulse every minute
(all patients in respiratory arrest will develop cardiac arrest if
untreated)

mouth-to-mask ventilation two-person bag-mask ventilation

C
• If the patient has no pulse or signs of life

Start CPR & get a colleague to call for help & get resuscitation equipment
Alternatively, if alone leave the patient to get help then return & start CPR

30 chest compressions : 2 breaths

What is the role of CPR?

It maintains blood flow and oxygenation to critical organs e.g. heart

and brain whilst the cause of cardiac arrest is treated.
i.e. it buys time
it is not generally itself, a treatment for cardiac arrest
 Compressions
• Hand position – middle of the lower half of the sternum

• Compress 4-5 cm at rate 100 compressions per minute, allow

chest to fully recoil after compression

• Do not rely on a palpable carotid or femoral pulse to assess

effectiveness of CPR

hand position for chest hands placed in the middle of

compressions the lower half of the sternum
 Ventilations
• Use whatever equipment is readily available;
ideally a facemask with a self-inflating bag +/- oropharyngeal
airway connected to an oxygen source
• Other options to maintain an airway include
nasopharyngeal airway
LMA
ETT
• If no airway equipment is available  mouth to mouth ventilation or
continuous chest compressions until airway equipment arrives
• Priority is oxygenation not insertion of an ETT (which may take time
and delay mask ventilation)
• Inspiratory time of about 1s and give enough volume for chest to rise
• Compression : ventilation ratio 30 : 2
(unless patient intubated, in which case continuous compressions and
ventilate approximately 10 breaths per minute)
 Ventilations

mouth-to-mask ventilation two-person technique for bag-

mask ventilation
 Collapsed / sick adult patient

Call for help and assess patient

No Signs of life Yes

Call resuscitation team Assess ABCDE

Call for additional help Recognise and treat
O2, monitoring & IV access

Start CPR 30:2

ALS algorithm Call for senior / expert help
Adult Advanced Life Support
(ALS) Algorithm

Simeneh Mola
What is the aim of advanced life support ?

• To restore spontaneous breathing and circulation with

minimal irreversible organ damage in patients with a cardiac
arrest

• In addition, to recognise peri-arrest patients and intervene

accordingly to prevent deterioration and cardiac arrest
Adult ALS Algorithm
Unresponsive?
During CPR
• Ensure IV access
• Check electrode position Assess ABC
• When airway secure continuous
compressions
• Correct reversible causes No signs of life Call for help
If VF/PVT persists
•1mg adrenaline before 3rd shock
•300mg amiodarone before 4th shock
CPR 30:2
•Subsequent adrenaline 1mg before Attach cardiac monitor if available
alternate shocks

Assess rhythm

Shockable (VF/PVT) Non-shockable (PEA/asystole)

1mg adrenaline
alternate cycles
1 shock 150-200J biphasic
360J monophasic
Asystole/PEA < 60
 atropine 3mg

CPR 30:2 for 2 mins CPR 30:2 for 2 mins

 Adult ALS Algorithm
“Reversible causes” – 4 H’s, 4 T’s

Hypoxia
Hypovolaemia
Hypo/hyperkalaemia (metabolic)
Hypothermia

Thrombosis
Toxic
Tension pneumothorax
Tamponade
Adult ALS Algorithm Unresponsive?

Assess ABC

No signs of life Call for help

CPR 30:2
Attach cardiac monitor if available

Skills / knowledge required

1. Airway management
2. Cardiac monitoring
 Airway management (1)
Basic techniques for maintaining the airway

jaw thrust

head tilt and chin lift

If suspected cervical spine injury avoid head tilt and use jaw-thrust with
manual in-line stabilisation, but establishing a patent airway takes priority
 Airway management (2)
Adjuncts to basic airway techniques

oropharyngeal airway and nasopharyngeal airways

 Airway management (3)

Sizing of an oropharyngeal airway

sizing of an oropharyngeal airway

 Airway management (4)
Insertion of an oropharyngeal airway

• Open patient’s mouth & ensure no foreign material which could be

pushed into larynx
• Insert ‘upside down’ as far as junction between hard & soft palate, then
rotate 180°
• Advance the airway until it lies in the pharynx
• Remove if the patient gags or strains
 Airway management (5)

Nasopharyngeal Airway

Made from soft and malleable plastic, bevelled at one end, flange at the other

In patients who are semi-conscious, it is better tolerated than a Guedel airway

Ideally avoid if suspicion of basal skull fracture

Size 6-7 mm is usually suitable for adults

 Airway management (6)
Technique for insertion of a nasopharyngeal airway

• Check for patency of nostril

• Lubricate the airway with water-soluble jelly

• Insert along the floor of the airway with a slight twisting action

• If there is resistance, try the other nostril

 Airway management (7)
Confirmation of successful airway
• Look for chest movement

• Look for misting of the facemask

• Listen and feel for airflow at the mouth (if patient breathing
spontaneously)

Other considerations
• Always give oxygen when it is available

• Suction - Use a wide bore rigid sucker (Yankauer) to remove

blood, saliva and gastric contents from the upper airway only
 Airway management (8)
Ventilation

A self-inflating bag should be used which can be connected to

your airway device (facemask / LMA / ETT / tracheostomy)

A one-way valve prevents re-breathing of expired gas

Without supplemental O2 it delivers 21% oxygen

Attached to 5 L/min O2 it delivers approximately 45% oxygen

With a reservoir system it can delivers up to 85% oxygen

 Airway management (9)
Ventilation

Use a 2 person technique unless very

experienced in mask ventilation

This helps reduce the peak airway

pressure and gas being forced into the
stomach resulting in reduced ventilation
and increased risk of aspiration

two-person technique for bag-

mask ventilation
 Airway management (10)
LMA (laryngeal mask airway)

Effective facemask ventilation

requires considerable skill

In inexperienced hands it may

result in insufficient tidal
volumes and gastric inflation

A LMA is easy to insert and may

improve quality of ventilation

insertion of a laryngeal mask

airway (LMA)
 Airway management (11)
Tracheal Intubation

Advantages of tracheal intubation over bag mask ventilation

• it protects the airway from blood or gastric contents
• adequate volumes can be delivered with continuous chest compressions
• it allows suctioning of the lungs
• it provides a route for drug delivery

Disadvantages of tracheal intubation over bag mask ventilation

• unless skilled staff; significant risk of tube misplacement
• in some cases laryngoscopy can cause life-threatening deteriorations
• chest compressions will be interrupted during laryngoscopy
• more equipment is required
• in summary, complications of tracheal intubation in unskilled staff is
unacceptably high
 Airway management (12)
Optimal airway?

There is insufficient evidence to support or refute any specific

technique used for airway maintenance

Only 1 RCT has compared tracheal vs. facemask ventilation in

children requiring emergency airway intervention
There was no difference in survival to discharge
 Cardiac monitoring (1)
Cardiac monitors display the ECG on screen in real time

Most include a display of heart rate

Attach ECG electrodes as shown below, making sure skin is dry

Most leads are colour-coded

Red – Right arm
yeLow – Left arm
Green – leG lead

Cardiac monitors should predominantly be used for rhythm

recognition (not ST segment interpretation)
 Cardiac monitoring (2)

position of
adhesive
electrodes for
monitoring
ECG
Adult ALS Algorithm Unresponsive?

Assess ABC

No signs of life Call for help

CPR 30:2
Attach cardiac monitor if available

Assess rhythm

Shockable (VF/PVT) Non-shockable (PEA/asystole)

Skills / knowledge required

1. Interpretation of ECG rhythm strips
 Interpretation of ECG rhythm strips (1)

Normal sinus rhythm

 Interpretation of ECG rhythm strips (2)

Asystole – non-shockable
 Interpretation of ECG rhythm strips (3)

In a patient with no pulse and no sign of life

Pulseless electrical activity – non-shockable

 Interpretation of ECG rhythm strips (4)

Coarse ventricular fibrillation

Fine ventricular fibrillation

Ventricular fibrillation is “shockable”

 Interpretation of ECG rhythm strips (5)

Ventricular tachycardia

Ventricular Tachycardia is ”shockable” (remember to check

for a pulse, it may be compatible with a cardiac output)
Adult ALS Algorithm
Unresponsive?
During CPR
• Ensure IV access
• Check electrode position Assess ABC
• When airway secure continuous
compressions
• Correct reversible causes No signs of life Call for help
If VF/PVT persists
•1mg adrenaline before 3rd shock
•300mg amiodarone before 4th shock
CPR 30:2
•Subsequent adrenaline 1mg before Attach cardiac monitor if available
alternate shocks

Assess rhythm

Shockable (VF/PVT)

Skills / knowledge required

1 shock 150-200J biphasic 1. Defibrillation
360J monophasic
2. Shockable algorithm

CPR 30:2 for 2 mins

 Defibrillation (1)
Following onset VF/PVT, CO ceases & cerebral hypoxic injury starts
within 3 mins

To achieve complete neurological recovery, early successful

defibrillation with return of spontaneous circulation (ROSC) is needed

Defibrillation is the passage of current of sufficient magnitude across

the myocardium to depolarise a critical mass of cardiac muscle
simultaneously (allowing natural pacemaker tissue to resume control)

Defibrillators have
- power source able to provide direct current
- a capacitor that can be charged to pre-determined energy level
- 2 electrodes placed on patient’s chest
 Defibrillation (2)
Factors affecting defibrillation success
• time before first shock
• transthoracic impedence
• electrode position
• pads vs. paddles
• shock energy & waveforms

standard electrode positions for if self-adhesive pads are used,

defibrillation maintain chest compressions
 BLS: Defibrillate
• Early defibrillation is recommended:
– Survival drops by up to 10% with each minute
delay
– Repeat every 2 min when shockable
• Automated External Defibrillator (AED)
– Are safe for cardiac arrest victims/ or for victims
not in cardiac arrest, bystanders and first responders

– Power →Attachment → analyze (shockable Vs.

non-shockable rhythm)

Firmly place appropriate pads

(adult/pediatric) to patient’s
skin to the indicated locations
(pad image).
Yell: “Clear, I’m Clear,
you’re Clear!” prior to
delivering a shock
 Defibrillation (3)
Safety during defibrillation

defibrillation must NOT risk safety of resuscitation team

do NOT defibrillate in wet surroundings or clothing

NO part of any person should make direct or indirect contact with the patient

the operator must NOT touch any part of the electrode surface

REMOVE any oxygen source from the patient before defibrillation - there is
a risk sparking from defibrillator paddles causing fire

paddles should NEVER be charged anywhere other than on the patient’s

chest

it is the OPERATOR’s responsibility to ensure everyone is clear of the patient

before a shock is delivered
 Defibrillation (4)
Sequence for defibrillation

1. Confirm cardiac arrest

2. Confirm VF / PVT with cardiac monitor

3. Place defibrillator gel pads on patient’s chest

4. Place defibrillator paddles firmly on patient’s chest

5. Select 360J

6. Remove oxygen from defibrillation zone

7. Warn everyone to ‘stand clear’ and verbalise ‘charging’

8. Charge paddles
 Defibrillation (5)
Sequence for defibrillation
9. Reconfirm and check everyone is clear

10. Deliver the shock (time between stopping CPR and shock delivery
should be < 10 secs)

11. Replace paddles immediately

12. Resume CPR for 2 mins

13. Re-check rhythm

14. If patient remains in VF / PVT give 2nd shock (repeating steps 3 -13)

15. If patient remains in VF / PVT give 1mg adrenaline IV then give 3 rd

shock (repeating steps 3 -13)
 Defibrillation (6)
Sequence for defibrillation

16. If patient remains in VF / PVT consider amiodarone 300 mg IV or if

unavailable lidocaine 100mg then give 4th shock (repeat steps 3 -13)

17. If patient remains in VF / PVT repeat shock cycles (steps 3 -13) and
administer 1mg IV adrenaline on alternate cycles

18. If organised electrical activity is seen with the rhythm check - feel for
a pulse
If no pulse ie PEA – continue CPR → non-shockable side of algorithm
If pulse – start post-resuscitation care

19. If asystole is seen – continue CPR → non-shockable side of algorithm

 Defibrillation (3)
Safety during defibrillation

defibrillation must NOT risk safety of resuscitation team

do NOT defibrillate in wet surroundings or clothing

NO part of any person should make direct or indirect contact with the patient

the operator must NOT touch any part of the electrode surface

REMOVE any oxygen source from the patient before defibrillation - there is
a risk sparking from defibrillator paddles causing fire

paddles should NEVER be charged anywhere other than on the patient’s

chest

it is the OPERATOR’s responsibility to ensure everyone is clear of the patient

before a shock is delivered
 Defibrillation (7)
Precordial thump
Can be used after witnessed VF/VT arrest if a defibrillator is not to hand

Tightly clenched fist

Deliver sharp impact to lower half
of sternum
Most likely to be successful for
pulseless VT
If delivered < 10 secs of VF may
be successful

precordial thump
Adult ALS Algorithm
Unresponsive?
During CPR
• Ensure IV access
• Check electrode position Assess ABC
• When airway secure continuous
compressions
• Correct reversible causes No signs of life Call for help

CPR 30:2
Attach cardiac monitor if available

Assess rhythm

Shockable (VF/PVT) Non-shockable (PEA/asystole)

1mg adrenaline
alternate cycles
1 shock 150-200J biphasic
Skills / knowledge required
360J monophasic
Non-shockable algorithm Asystole/PEA <60
atropine 3mg

CPR 30:2 for 2 mins CPR 30:2 for 2 mins

 Non-shockable algorithm (1)

1. Start CPR 30:2 (until airway secured – then continuous compressions)

2. Give 1 mg adrenaline as soon as IV access achieved

(or 3 mg via ETT if in situ)

3. Re-check rhythm after 2 mins

 Non-shockable algorithm (2)
• If organised electrical activity – check for pulse &/or signs of life
• If no pulse continue CPR for 2 mins
(PEA) re-check rhythm
continue 2 min cycles accordingly
give 1mg IV adrenaline alternate cycles
if rate < 60 give 3 mg atropine (once only)
• If pulse start post resuscitation care
• If asystole or agonal rhythm
continue CPR for 2 mins
re-check rhythm
continue 2 min cycles accordingly
give 1 mg IV adrenaline alternate cycles
give 3 mg atropine (once only)

• If VF/PVT change to shockable algorithm

Adult ALS Algorithm Unresponsive?
During CPR
• Ensure IV access Assess ABC
• Check electrode position
• When airway secure continuous
compressions No signs of life Call for help
• Correct reversible causes

CPR 30:2
Attach cardiac monitor if available
Skills / knowledge required
Correction of reversible causes
Assessdelivery
Securing IV access/drug rhythm route

Shockable (VF/PVT) Non-shockable (PEA/asystole)

1mg adrenaline
alternate cycles
1 shock 150-200J biphasic
360J monophasic
Asystole/PEA <60
atropine 3mg

CPR 30:2 for 2 mins CPR 30:2 for 2 mins

 Drug delivery routes (1)
Via peripheral veins

Advantages
Patients may already have IV access
represents the fastest
IV cannula can be very rapidly sited route for drug delivery

Complications are minimal

Disadvantages
With a collapsed circulation, insertion may be difficult

If a distal site ie, foot is used, it may take longer for the drug to
reach the heart

This is the preferred route of drug administration in a cardiac arrest

 Drug delivery routes (2)
Via central veins
(This refers to central venous catheters in relation to cardiac arrest only,
it is not applicable to other clinical scenarios)

Advantages
May be possible where peripheral cannulation has failed
Allows administered drugs to reach the heart more rapidly

Disadvantages
Takes time
Almost impossible whilst CPR is ongoing
Requires a very experienced operator
Significant complications

Central venous catheterisation is not generally appropriate during

cardiac arrest, its role relates more to post-resuscitation care
 Drug delivery routes (3)
Intra-osseous route

Whilst this is usually considered in children, it can also be an effective

route in adults

IO injection of drugs achieves adequate plasma concentrations in a time

comparable to injection through a central venous cannula

Sites for injection in adults include

proximal tibia 2cm below tibial tuberosity on antero-medial side
distal tibia 2cm proximal to the medial malleolus

It may, however, be difficult to give adequate volumes of fluid required for

volume resuscitation
 Drug delivery routes (4)

Via endotracheal tube

This can be used for patients in whom no other access is possible

The following drugs can all be given via the endotracheal route
adrenaline (use 3 x IV dose – 3mg in at least 10 mL)
atropine
lidocaine
naloxone

Absorption is not as predictable via this route compared to those

described previously
 ( Drug delivery routes (5) )
( Intra-cardiac )

Intra-cardiac administration of drugs is NOT described in any current

European or US guidelines

Intra-cardiac administration has a significant risk of catastrophic

injury to the LAD artery

Patients who are going to respond to adrenaline, should respond to it

given by any of the other routes already described if you are
performing effective CPR (if your CPR is ineffective you will be
resuscitating a patient with hypoxic brain injury)

Intra-cardiac drug administration should not be used

Cardiac arrest in special
circumstances

Simeneh Mola
 Cardiac arrest in special circumstances (1)
Drowning
Protect the patient’s airway early during CPR preferably with an ETT

Asthma
Intubate the trachea early

If gas trapping; chest wall compression may help

Hyperinflation of the lungs may ↑ thoracic impedance, so if in VF,

consider increasing shock energy if initial defibrillation fails

Consider the possibility of bilateral pneumothoraces

Anaphylaxis
Ensure trigger is removed and consider use of steroids,
antihistamines and large volumes of fluid may be required
 Cardiac arrest in special circumstances (2)
Pregnancy
Left lateral tilt of at least 15° to relieve IVC compression

Hand position for chest compressions may need to be adjusted

Consider early tracheal intubation because of increased risk of

aspiration

Electrocution
Ensure personal safety before approaching patient

If there are burns around the head and neck, consider the need for early
tracheal intubation as soft tissue oedema may subsequently cause
airway obstruction
Pediatrics BLS/ALS
 Age appropriate Compressions
Infant
• One provider: 2 finger technique
• Two providers: 2 thumb-encircling hand
technique.
Child
• Use 1 or 2 hand-depending on size of child

• Compression : breath-
15:2
• Advanced airway?
• Switch roles b/n
compressor and breather
q2min
Post-resuscitation care

Simeneh Mola
 Post-resuscitation care (1)

Achievement of ROSC is an important step in the continuum of

resuscitation

However, the next step is to achieve a patient with normal cerebral

function, stable cardiac rhythm and normal haemodynamic function

The quality of post-resuscitation care significantly influences the ultimate

outcome

Once ROSC has been achieved, revert to the ABCDE approach used for
the critically ill patient
 Post-resuscitation care (2)

Further assessment

History

Monitoring Aim: to enable continuous assessment of

vital organ function and to identify trends

Investigations FBC
Biochemistry
12 lead ECG
CXR
Echo
(ABG)
 Post-resuscitation care (3)

Patient transfer Aim to transfer the patient safely between the site
of resuscitation and a place of definitive care

The overall aim of post-resuscitation care is to optimise vital organ

function and limit secondary organ damage
This is the role of intensive care medicine
It is not within the scope of this course to cover intensive care
management of patients
 Post-
resuscitation
Care: ROSC

TTM
Ethical aspects of resuscitation

Simeneh Mola
 Ethical aspects of resuscitation (1)

This is an area which is differs between different countries

depending on both cultural and legal aspects

Guidelines on the ethics of resuscitation (including who to

resuscitate) should be drawn up locally
DNR: Do not rescistitate
 Ethical aspects of resuscitation (2)
When to abandon a resuscitation attempt ?

Remember the majority of resuscitation attempts are

unsuccessful and therefore have to be abandoned

Several factors should influence this decision -

Medical history and anticipated prognosis

Period between cardiac arrest and CPR starting
Time to defibrillation
Period of ALS with continued asystole and no reversible cause
Irreverssible Death
 Ethical aspects of resuscitation (3)
When to abandon a resuscitation attempt ?

Generally,
• resuscitation should continue if VF persists
• asystole for > 20mins with no reversible cause is accepted as
grounds for abandoning a resuscitation attempt
• there are exceptions to this such as drowning, hypothermia

The decision to abandon a resuscitation attempt should be made

by the resuscitation team leader after consultation with other team
members
The decision is based on clinical judgement and needs to be made
on a case by case basis
The Resuscitation Team

Simeneh Mola
 The resuscitation team
The team leader’s role
• Directs and co-ordinates resuscitation
• Makes decisions confidently & quickly & gives clear instructions
• Maintains an overview and allocates tasks to team members
• Takes responsibility for team members safety
• Takes responsibility for ending resuscitation attempt
• Takes responsibility for ensuring staff and relatives are supported
at the end of the resuscitation attempt

The team members’ roles

• Follow team leaders instruction
• Contribute ideas and suggestions
• Be clear and precise when passing on information
• Ask for assistance if unsure
Thank You!