Dr Saeid Safari Anesthesiologist Pre CPR CPR (BLS - ALS) Post CPR AHA 2015 Iranian Anesthesiology Network

1. Saeid Safari, MD
Anesthesiologist,
Pain Research Center, Iran University of Medical Sciences,
Tehran, Iran
CPR
BLS and ALS

2. OBJECTIVES
• At the end of this course:
participants should be able to demonstrate:
• How to assess the collapsed victim
• How to perform chest compression and use AED
• How to approach to the pulseless arrest patients

5. This “Guidelines Highlights” publication
summarizes the key issues and changes in
the 2015 American Heart Association (AHA)
Guidelines Update for Cardiopulmonary
Resuscitation (CPR) and Emergency
Cardiovascular Care (EGG).
“Guidelines Highlights”

7. Systems of Care and Continuous Quality
Improvement
• Components of a System of Care
• Universal elements of a system of care have been identified to
provide stakeholders with a common framework with which
to assemble an integrated resuscitation system
• Chains of Survival
• Separate Chains of Survival (Figure 4) have been
recommended that identify the different pathways of care for
patients who experience cardiac arrest in the hospital as
distinct from out-of-hospital settings.

8. Taxonomy of Systems of Care: SPSO

10. CPR Training: Classes
• Routine: Training 1st hand learner or refreshment courses for lay
personnel
• Management: Training CPR managers
• Standardization: Developing local or provinential standards
• Guideline Development: Developing national, regional,
continental, or international guidelines

11. CPR Steps: Definitions
Progressive Vital Organ Detoriation
PreCPR
Cardiac Arrest
CPR
Return Of Spontaneous Circulation (ROSC)
Po st CPR
Vital Organ Function Stability

12. Special Thanks to Dr. Babak Foroutan
for the interesting insightful talk about PreCPR section

13. Recognition &
Activation of
the Emergency
Response
System
Basic &
Advanced
Medical
Services
Rapid
Defibrillation
Immediate
High Quality
CPR
Integrated
post-cardiac
arrest care
Recognition &
Activation of
the Emergency
Response
System
Surveillance
& Prevention
Immediate
High Quality
CPR
Rapid
Defibrillation
Advanced
Life Support
& Post-Arrest
Care

14. PreCPR: Updates
• Early Warning Sign System (Track & Trigger)
2010 Conflicting evidence, expert recommendation
2015 May be considered for adult and children
• Medical Emergency Team (MET) or Rapid Response Team
(RRT)
2010 Questionable
2015 Beneficial in adult & pediatric

15. PreCPR: Rationale
• Preventing cardiac arrest, most effective compared to CPR or
PostCPR, in pts’ survival and post discharge condition.
• Preventing cardiac arrest, least costly compared to CPR or
PostCPR , in pts’ survival and post discharge condition.
• Cardiopulmonary arrest is frequently preceded by PreCPR
mismanagement, therefore is preventable.

16. Pre-CPR Goal:
To Prevent Cardiac
Arrest!

17. PreCPR: Steps
I. “Triage” Pts
I. Detect Pts “A t R i s k ” of cardiac arrest
II. Exclude “ D N R ” Pts
II. Define “Tracking” measures
I. Dz Oriented Monitors
II. Frequency of Evaluation
III. Define “ N o R e s p o n s e ”, “A l e r t ”, a n d “A c t i o n ” criteria for each monitor
III. Define “Triggering” responses
I. Determine “ I n C h a r g e ” Physician(s)
II. Define “ M E T ” activating criteria
III. Document “ P r o o f o f E f f e c t i v e n e s s ( P O E ) ” criteria
IV. Determine “ P e r i o d i c P O E ” interval

18. Vital Organ Failure +
I. Dz: Progressive
II. Pts Mental Status:
I. Frightened
II. Delirious
I. Agitated
II. Disconnected
III. Disorientated
I. Treatment:
I. Poorly or Not
Effective (Wrong
Rx?)
II. Vital
III. Fatal Complications
PreCPR: At Risk Criteria

20. Chain of Survival

21. Simplified BLS
Algorithm

22. Assessment & ERS Activation
1. Establish Unresponsiveness
Sudden Loss of Consciousness + Abn. Respiration
vs
Tap, Shake, Shout
2. Call for Help
2010 Step by step activation of ERS consequentially
2015 Simultaneous assessment of responsiveness, pulse, & breathing
before & while activating ERS

26. Immediated recognition and activation of
emergency response system

27. Chest Compression Depth -updated
2010
> 5 cm
2015
5 – 6 cm
Push Hard !
Class I, LOE C-LD

28. Chest Compression Rate -updated
2010
> 100
2015
100 – 120
Push Fast !
Class IIa, LOE C-LD

29. Fully Recoil !
do not leaning on chest
Class IIa, LOE C-LD

30. Minimizing Interruptions ! -updated
• Achieve chest compression fraction (CCF)
unprotected airway ≥60%
0 9030 60 120
CCF =
105
120
= 87.5

31. Audiovisual
Feedback
Devices
during CPR

32. Delayed ventilation
witnessed OHCA with a shockable rhythm
+ EMS

3 cycles of 200 continuous compressions
+ passive oxygen insufflation & airway adjuncts
Class IIb, LOE C-LD

33. Respiratory Rate (No advanced airway)
Avoid Hyperventilation !
30 : 2
Class IIa, LOE C-LD

34. Respiratory Rate (advanced airway) - updated
2010
> 8-10
2015
10
Avoid Hyperventilation !
Class IIb, LOE C-LD

35. Team-Based Resuscitation

36. CPR (BLS): CPR vs CCCR
Essential Actions:
• Chest Wall Compression

40. CPR (BLS): CPR & AED
Essential Actions:
• Chest Wall Compression
• Early Defibrillation

41. CPR (BLS)
Essential Actions:
• Chest Wall Compression
• Early Defibrillation
• Cause Based Tailoring
2010 Chest compression + Rescue breaths for cardiac arrest
2015 Chest compression + Rescue breaths for cardiac arrest of
cardiac or non-cardiac cause. HCP can tailor CC,RB, & AED
sequence to cause

42. BLS Dos and Don’ts of
Adult High-Quality CPR

43. High Quality CPR Components for BLS

44. High Quality CPR Components for BLS

45. BLS Healthcare Provider Adult Cardiac Arrest
Algorithm—2O15 Update

46. BLS Healthcare Provider Adult Cardiac Arrest
Algorithm—2O15 Update

50. CPR (BLS): 5min VF

53. CPR (BLS): Airway & Breathing
• AMBU + Mask + ECM
• O2 + Mask + CCCR
• AMBU + LMA + ECM
• AMBU + AMD + ECM
B. Forootan M.D.

54. The cause of cardiac arrest is
important
BUT
do not delay CPR to obtain
history

55. CPR – 1 Rescuer
• Look, listen, and fe
for breathing

56. CPR – 1 Rescuer
• Check for a pulse
(≤ 10 seconds)

57. CPR – 1 Rescuer
• If there is no pulse,
find your
landmarks, lower
half of the
sternum, between
the nipples

58. Begin chest
compression
s

59. ‫سینه‬ ‫قفسه‬ ‫بر‬ ‫عمود‬ ‫دستها‬
‫ها‬ ‫آرنج‬ ‫خمیدگی‬ ‫بدون‬
5cm - 6cm
•

60. CPR – 2 Rescuer
1 2
3 4

61. 61
Airway Obstruction
Most common cause: tongue and/or epiglottis

62. Opening the Airway
• Jaw thrust
62
Head tilt–chin lift

63. Nasopharyngeal Airway
• Insertion technique
63

64. Malposition of
Oropharyngeal Airway
64
Too short

65. RESCUE BREATHS
• Pinch the nose
• Take a normal breath
• Place lips over mouth
• Blow until the chest rises
• Avoid excessive ventilation
• Take about 1 second
• Allow chest to fall
• Repeat

66. JAW THRUST (IN TRAUMATIC PATIENT)

67. CONTINUE CPR
• 30 2

68. IF YOU HAVE NOT TENDENCY TO BREATHE
Chest compression only

69. Hands Only CPR
• Needs less training
• Maximize cardiac output
• Encourage bystander CPR
• Not recommended for HCP in case of asphyxic
arrest (children, drowning, toxicity)

70. Standard CPR (CC+RB)
Berg et al, 2001
Aopressure
Time
= chest compression

71. Chest Compression alone
Berg et al, 2001
Bloodpressure
Time
= chest compression

72. Simplified
Adult BLS

73. • One rescuer: 30 compressions 2 breaths
• Two rescuer: 15 compressions 2 breaths
PEDIATRIC BLS

74. METHODS
Child 1-8 Years Infant < 1 Year

75. BREATHING

76. DEFIBRILLATION

77. AED
Approach safely
Check response
Shout for help
Call 115
Attach AED
Follow voice prompts
Start CPR after shock

78. SWITCH ON AED
• Some AEDs will
automatically switch
themselves on when
the lid is opened

79. ATTACH PADS TO CASUALTY’S BARE CHEST

80. ANALYSING RHYTHM
DO NOT TOUCH VICTIM

81. • Stand clear
• Deliver shock
SHOCK INDICATED

82. SHOCK DELIVERED
FOLLOW AED INSTRUCTIONS
30 2

83. IF VICTIM STARTS TO BREATHE NORMALLY PLACE
IN RECOVERY POSITION

87. Recongnition of arrythmia
Lethal or non lethal
Symptomatic or asymptomatic
Stable or unstable
Shockable or unshockable

88. Shockable
VT
Monomorphic or
polymorphic
VF
Fine or Coarse
VF

89. Unshockable
Asystole
PEA- pulseless electrical
activity or EMD-
electromechanical
dissociation

92. Electrode Placement
4 pad positions
• Anterolateral,
• Anteroposterior,
• Anterior-left Infrascapular, And
• Anterior-rightinfrascapular
• For adults, an electrode size of 8 to 12 cm is reasonable
(Class IIa, LOE B).
• Any of the 4 pad positions is reasonable for defibrillation
(Class IIa, LOE B).

94. Defibrillation
• Biphasic wave form: 120- 200 J
• Monophasic wave form: 360 J
• AED- device specific
• Failure of a single adequate shock to restore a pulse should be followed by
continued CPR and second shock delivered after five cycles of CPR
• If cardiac arrest still persist- patient is intubated and IV/IO access achieved

95. Defibrillation Sequence
• Turn the AED on.
• Follow the AED prompts.
• Resume chest compressions immediately after the
shock(minimize interruptions).

96. 1-Shock Protocol Versus 3-Shock Sequence
• Evidence from 2 well-conducted pre/post design studies
suggested significant survival benefit with the single shock
defibrillation protocol compared with 3-stacked-shock protocols
• 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 shock

97. Asystole/PEA
Continue CPR (Intubate and
establish IV access)
Identify and
RX reversible
causes
Continue CPR
if
asystole/PEA

98. • Toxins
• Tamponade (cardiac)
• Tension pneumothorax
• Thrombosis, pulmonary
• Thrombosis, coronary
• Hypoxia
• Hypovolemia
• Hydrogen ion(acidosis)
• Hypo-/hyperkalemia
• Hypothermia
Treatable Causes of Cardiac Arrest:
The H’s and T’s
H’s T’s

99. Airway and Ventilations
• Opening airway – Head tilt, chin lift or jaw thrust, in addition
explore the airway for foreign bodies, dentures and remove them.
Consider oropharyngeal tube placement.
• The Health care provider should open the airway and give rescue
breaths with chest compressions

100. Rescue breaths
• By mouth-to-mouth or bag-mask
• Deliver each rescue breath over 1 second
• Give a sufficient tidal volume to produce visible chest rise
• Use a compression to ventilation ratio of 30 chest compressions
to 2 ventilations
• After advanced airway is placed, rescue breaths given
asynchronus with ventilation
• 1 breath every 6 to 8 seconds (about 8 to 10 breaths per minute)

102. Breathing devices
• Plastic oropharyngeal airways
• Esophageal obturators
• Ambu bag- usual method for continuing breathing in hospital
before ET tube can be inserted.
• Endotracheal tube

104. Routes of Administration
• Peripheral IV – easiest to insert during CPR, must followed by 20
ml NS push
• Central IV – fast onset of action, but do not wait or waste time for
CV line
• Intraosseous – alternative IV route in peds, also in Adult
• Intratracheally (down an ET tube)- not recommended now a days
•

106. Monitoring During CPR
Physiologic parameters
• Monitoring of PETCO2 (35 to 40 mmHg)
• Coronary perfusion pressure (CPP) (15mmHg)
• Central venous oxygen saturation (ScvO2)
• Abrupt increase in any of these parameters is a sensitive
indicator of ROSC that can be monitored without interrupting
chest compressions

107. Quantitative waveform capnography
• If Petco2 <10 mm Hg, attempt to improve CPR quality
Intra-arterial pressure
• If diastolic pressure <20 mm Hg, attempt to improve CPR
quality
• If ScvO2 is < 30%, consider trying to improve the quality of
CPR

113. I. Automated Chest
Compression Devices
II. AED vs Classic
Defibrillator
III. Airway Management
Devices
I. LMA, EO, Combi Tube
II. Video Laryngoscope
IV. Ventilators
V. Drugs
I. Vasopressors of
Choice
II. Infusion vs Bolus
Drugs
VI. Monitors
I. ECG
II. ETCO2
CPR (ALS): Instruments & Drugs

114.  Preventing Dis-organization
 Reducing Group Stress
 Crowd Controls
 Using Experienced
Providers
 Conducting ORDERS:
 Pls, YOU: 200 J Shock
Repeat by provider:
 Shock 200 J
Ready
Clear
Delivered
CPR (ALS): Leadership
B. Forootan M.D.

115. CPR (ALS): Goals
1. Primary: Maintain Tissue Perfusion (Oxygenation)
• Chest Compression
• Defibrillation (AED, Defibrillator)
2. Secondary: Maintain/Improve Cardiac Output
• Intubation (Efficient oxygenation/ventilation)
• Drugs: Vasopressor/Antiarrhythmic (Coronary perfusion)
3. Optional: Problem Oriented Cardiac Support
• Revascularization
• Volume Resuscitation
• Electrolyte Optimization
• Acid-Base Optimization
B. Forootan M.D.

116.  Fibrinolytic Rx
 Alkaline Rx
 Fluid Rx
 Mg, Ca
 Supplemental O2
 Vasopressor
 Antiarrhythmic
CPR (ALS): DRUG Rx
Primary: Effective Contraction (Antiarrhythmia)
Optional: Problem oriented Cardiac Support

117. CPR (ALS): DRUG Rx
Vasopressin
2010 40U IV/IO replaces 1st or 2nd doses of Epinephrine
2015 No advantage in replacing Epinephrine
Epinephrine
2015 ASAP in initial non-shockable rhythms

118. • ECG:
• Arrhythmia/Ischemia
detection & Rx
• ETCO2:
• OTT Confirmation
• <10mmHg Dx: No ROSC
• ScvO2:
• >30% to maintain CPP
• VBG:
• Normal Values
• SpO2
CPR (ALS): Monitoring for ROSC
(High Quality CPR)
No Value In Cardiac Arrest!

119. AMERICAN HEART ASSOCIATION
CAPNOGRAPHY

121. PostCPR: Components
The 4 key components of post cardiac arrest syndrome are:
I. Post cardiac arrest brain injury
II. Post cardiac arrest myocardial dysfunction
III. Systemic ischemia/reperfusion response
IV. Persistent precipitating pathology
B. Forootan M.D.

122. PostCPR: Phases
ROSC
Immediate: Reperfusion, Oxidants & Endotoxin
20 min
Early: Tissue Oxidation, ATP Production Blockage, Oxidant Production
6-12hrs
Intermediate: MSOF Manifestation
72hrs
Recovery: MSOF Resolution
Disposition
Rehabilitation: Post ICU, Post discharge

124.  Dx & Rx of Arrest Cause
 Inotrope & Ventilator
Weaning
 MSOF Rx & Prevention
 Acid Base & Electrolyte
Correction
 Fluid Management
 Tissue
Oxygenation/Perfusion
Stability
 Temperature Management
 Glycemic Control
 Convulsion Rx &
Prevention
 Coronary Reperfusion
PostCPR: Goals
Primary:
Stop Damage Process (1st Hr)
Targeted:
Rx of Underlying Cause (After Primary)

125. PostCPR: Updates
• Angiography
2010 Primary PCI & Fibrinolytic Rx even in coma
2015 ASAP angiography regardless of LOC
• Prognostication
2010 No specific time for prognostication
2015 At least 72hrs for cases of TTM or non-TTM
• TTM
2010 TTM 32-34 in OH arrests for 12-24h, or IH arrests with initial rhythms
2015 TTM 32-36⁰C in all comatose for 24h
B. Forootan M.D.

126. Coronary angiography
• Should be performed emergently for OHCA pt c suspected cardiac
etiology of arrest & ST elevation on ECG
• Emergency coronary angiography is reasonable for select adult pt
who comatose after OHCA of suspected cardiac origin but without
ST elevation on ECG

127. Targeted temperature management
• All comatose adult pt with ROSC after cardiac arrest should have
TTM, with a target temperature between 32-36 ◦C selected and
achieved, then maintained constantly for at least 24 hr

129. Continuing temperature management beyond 24 hr
• Actively preventing fever in comatose pt after TTM
Out-of-hospital cooling
• not recommend

130. Hemodynamics goals after resuscitation
• Avoid and immediately correct hypotension
• (SBP <90 mm HG, MAP <65 mm Hg)

132. Organ donation
• All Patient who are resuscitated from cardiac arrest but who
subsequently progress to death or brain death should be
evaluated as potential organ donors.

133. Thank
s…