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ALS and BTLS
1. ““And if anyone saved a life, it would be as if he saved allAnd if anyone saved a life, it would be as if he saved all
mankind.” (Quran: 5:32).mankind.” (Quran: 5:32).
2. DateDate 2020thth
JUNE 2006JUNE 2006
Patient Lt Col XYZPatient Lt Col XYZ
Age 45 yearsAge 45 years
PlacePlace SSG CENTRE CHIRATSSG CENTRE CHIRAT
ActivityActivity Routine Morning ExerciseRoutine Morning Exercise
Suddenly collapsed, became unresponsive with irregularSuddenly collapsed, became unresponsive with irregular
gasping breathinggasping breathing
Rescuer Major. ABC surgical specialistRescuer Major. ABC surgical specialist
Diagnosis of Cardiac Arrest was madeDiagnosis of Cardiac Arrest was made
Airway maintained, mouth to mouth breathing and chestAirway maintained, mouth to mouth breathing and chest
compressions were started. A bystander SSG officer wascompressions were started. A bystander SSG officer was
involved in CPRinvolved in CPR
CPR continued and patient shifted to CMH Cherat in a militaryCPR continued and patient shifted to CMH Cherat in a military
vehicle in 4-5 minutesvehicle in 4-5 minutes
CPR continued, patient intubated and 100% O2 givenCPR continued, patient intubated and 100% O2 given
I/V line established and defib. attached, (VF)I/V line established and defib. attached, (VF)
3. 360 J DC shock was immediately given but no effect360 J DC shock was immediately given but no effect
CPR continued and inj. Adrenaline 1 mg repeated every 3 minsCPR continued and inj. Adrenaline 1 mg repeated every 3 mins
(3mg)(3mg)
360 J DC shock repeated and VF converted to sinus tachycardia360 J DC shock repeated and VF converted to sinus tachycardia
Carotid pulse was not palpableCarotid pulse was not palpable
CPR continued, after 5 mins rhythm again changed to VFCPR continued, after 5 mins rhythm again changed to VF
360 J DC shock repeated, VF changed to sinus tachycardia360 J DC shock repeated, VF changed to sinus tachycardia
Carotids became palpable and patient started breathing (irregularCarotids became palpable and patient started breathing (irregular
gasps)gasps)
Chest compression stopped and breathing assistedChest compression stopped and breathing assisted
Heart rate 160/min, radial pulse became palpable, SpO2 72%Heart rate 160/min, radial pulse became palpable, SpO2 72%
80mg lignocaine and 60mmols soda bicarb. administered I/V and80mg lignocaine and 60mmols soda bicarb. administered I/V and
dobutamine infusion starteddobutamine infusion started
Call was sent for a rescue helicopterCall was sent for a rescue helicopter
Patient opened his eyes but was confused and restlessPatient opened his eyes but was confused and restless
Inj. morphine sulphate 7.5 mg I/V was given for sedationInj. morphine sulphate 7.5 mg I/V was given for sedation
4. Patient flown to AFIC in a military helicopter with O2Patient flown to AFIC in a military helicopter with O2
cylinder, emergency drugs, defib., and was accompaniedcylinder, emergency drugs, defib., and was accompanied
by 2 doctorsby 2 doctors
Total flight time 45 mins, uneventfulTotal flight time 45 mins, uneventful
Admitted in CCU with mech. vent. SupportAdmitted in CCU with mech. vent. Support
IABP passed, supportive and symptomatic treatmentIABP passed, supportive and symptomatic treatment
given, weaned off ventilator after 24 hoursgiven, weaned off ventilator after 24 hours
No neurological deficit notedNo neurological deficit noted
Angioplasty done after 39 days of cardiac arrestAngioplasty done after 39 days of cardiac arrest
Back on job, enjoying normal family lifeBack on job, enjoying normal family life
Total BLS ACLS time 94 minsTotal BLS ACLS time 94 mins
5. SEQUENCESEQUENCE
European resuscitation council (ERC) guidelinesEuropean resuscitation council (ERC) guidelines
for resuscitation 2005for resuscitation 2005
BLSBLS
Chest compressionChest compression
Airway managementAirway management
AlgorithmsAlgorithms
6. Basic life support (BLS)Basic life support (BLS)
Maintaining airway patency*Maintaining airway patency*
Supporting breathing *Supporting breathing *
Supporting circulation*Supporting circulation*
**Without the use of equipmentWithout the use of equipment
7. IntroductionIntroduction
700,000 deaths/year in Europe (SCA)700,000 deaths/year in Europe (SCA)
Causes IHD (VF/VT/ Asystole)Causes IHD (VF/VT/ Asystole)
TraumaTrauma
Drug over doseDrug over dose
DrowningDrowning
AsphyxiaAsphyxia
Optimum treatment (Chest Compression,Optimum treatment (Chest Compression,
Rescue Breathing and electrical defib)Rescue Breathing and electrical defib)
8. SurvivalSurvival
Early recognition of SCAEarly recognition of SCA
Early bystander CPR improves survival (2 – 3 times)Early bystander CPR improves survival (2 – 3 times)
Early Defibrillation within 3 – 5 min of SCA (50 –Early Defibrillation within 3 – 5 min of SCA (50 –
75%)75%)
9. ABLS
Personal and patient safety
Check the victim for a response
Gently shake the patient for a response
If he responds,
Leave him in position in which you found
him
Try to find out what is wrong with him
Reassess him regularly
10. If he does not respondIf he does not respond
Shout for helpShout for help
Turn the victim in supine positionTurn the victim in supine position
Open the Air way using head tilt andOpen the Air way using head tilt and
chin liftchin lift
Look, listen and feel for normalLook, listen and feel for normal
breathingbreathing
Look for chest movementLook for chest movement
Listen at the victims mouth for breathListen at the victims mouth for breath
soundssounds
Feel for air on your cheekFeel for air on your cheek
Don’t waste more than 10 secsDon’t waste more than 10 secs
11. If he is breathing normallyIf he is breathing normally
Turn him into the recovery positionTurn him into the recovery position
Call for help/ ambulanceCall for help/ ambulance
Check for continued breathingCheck for continued breathing
If he is not breathing normallyIf he is not breathing normally
Send someone for help/ ambulance serviceSend someone for help/ ambulance service
Kneel by the side of the victim.Kneel by the side of the victim.
Place the heel of one hand in the centre of the victim’s chestPlace the heel of one hand in the centre of the victim’s chest
Place the heel of the other hand on top of the first handPlace the heel of the other hand on top of the first hand
Interlock the fingers of your hands and ensure that pressure is notInterlock the fingers of your hands and ensure that pressure is not
applied over the victim’s ribs or xiphisternumapplied over the victim’s ribs or xiphisternum
Position yourself vertically above the victim’s chest and withPosition yourself vertically above the victim’s chest and with
your arms straight, press down the sternum 4 – 5 cmsyour arms straight, press down the sternum 4 – 5 cms
After each compression, release all the pressure on the chestAfter each compression, release all the pressure on the chest
without losing contact between your hands and the sternum repeat at awithout losing contact between your hands and the sternum repeat at a
rate of about 100/minrate of about 100/min
Compress and release for equal duration of timeCompress and release for equal duration of time
12. Combine chest compression with rescue breaths.
• After 30 compressions open the airway using head tilt and chin lift.
• Pinch the soft part of the nose, using the index finger and
thumb of your hand on the forehead.
• Allow the mouth to open, but maintain chin lift.
• Take a normal breath and place your lips around his mouth, making
sure that you have a good seal..
• Blow steadily into the mouth while watching for the chest to rise,
taking about 1 sec as in normal breathing; this is an effective rescue
breath.
• Maintaining head tilt and chin lift, take your mouth away from the
victim and watch for the chest to fall as air passes out.
* Blow another normal breath into the patients mouth and resume
chest compressions
* Continue with chest compressions and rescue breaths in a ratio of
30 – 2
* Stop to recheck if the victim starts breathing
* If there are two rescuers they should take over CPR every two min
* Not able/ unwilling to give rescue breaths (Continue chest
compressions only)
13.
14.
15.
16. Continue resuscitation until
• Qualified help arrives and takes over
• The victim starts breathing normally
• You become exhausted
17. VentilationVentilation
Reduced blood flow to the lungs during CPR.Reduced blood flow to the lungs during CPR.
Ventilation/ perfusion ratio maintained Vt and RR.Ventilation/ perfusion ratio maintained Vt and RR.
Hyperventilation and large Vt are unnecessary and harmfulHyperventilation and large Vt are unnecessary and harmful
increased intrathoracic pressure leads to reduced CO. andincreased intrathoracic pressure leads to reduced CO. and
large Vt 1 ltr or more may cause gastric distention/large Vt 1 ltr or more may cause gastric distention/
regurgitationregurgitation
Interruptions in chest compression should be minimal.Interruptions in chest compression should be minimal.
18. Chest CompressionChest Compression
Blood flow isBlood flow is
generatedgenerated
1.1. IncreasedIncreased
intrathoracic pressureintrathoracic pressure
2.2. Direct compression ofDirect compression of
the heartthe heart
3.3. Systolic arterialSystolic arterial
pressure peaks – 60 –pressure peaks – 60 –
80 mm Hg80 mm Hg
4.4. Low diastolic pressureLow diastolic pressure
5.5. Mean BP in carotid 40Mean BP in carotid 40
mm Hgmm Hg
19.
20.
21. Airway Management and VentilationAirway Management and Ventilation
Airway obstructionAirway obstruction
1.1. Secondary to loss of consciousnessSecondary to loss of consciousness
2.2. Primary cause of cardio respiratory arrestPrimary cause of cardio respiratory arrest
Prompt assessment control of airway andPrompt assessment control of airway and
ventilation will prevent secondary hypoxicventilation will prevent secondary hypoxic
damage to the brain and other vital organsdamage to the brain and other vital organs
Airway obstruction in unconscious and obtundedAirway obstruction in unconscious and obtunded
patientpatient
1.1. Decreased muscle tone/ posterior displacement of theDecreased muscle tone/ posterior displacement of the
tongue and at the soft palate and epiglottis leveltongue and at the soft palate and epiglottis level
2. Vomitus, blood, foreign body, laryngeal oedema are2. Vomitus, blood, foreign body, laryngeal oedema are
other causes of airway obstructionother causes of airway obstruction
22.
23. RECOGNITION OF AIRWAYRECOGNITION OF AIRWAY
OBSTRUCTIONOBSTRUCTION
A Diagnosis often missed by Healthcare ProfessionalsA Diagnosis often missed by Healthcare Professionals
Look for Chest and Abdominal movementsLook for Chest and Abdominal movements
Listen and feel for Airflow at the Mouth and NoseListen and feel for Airflow at the Mouth and Nose
1) Diminished air entry and noisy breathing indicates partial airway1) Diminished air entry and noisy breathing indicates partial airway
obstructionobstruction
2) Inspiratory stridor is caused by obstruction at the pharyngeal and supra2) Inspiratory stridor is caused by obstruction at the pharyngeal and supra
glottic levelglottic level
3) Biphasic stridor in glottic or cervical tracheal obstruction3) Biphasic stridor in glottic or cervical tracheal obstruction
4) Expiratory wheeze implies obstruction of the lower airways4) Expiratory wheeze implies obstruction of the lower airways
5) Gurgling is caused by liquid or semisolid foreign material in the main5) Gurgling is caused by liquid or semisolid foreign material in the main
airwaysairways
6) Snoring arises when the pharynx is partially occluded by the soft palate or6) Snoring arises when the pharynx is partially occluded by the soft palate or
epiglottisepiglottis
7) Crowing is the sound of laryngeal spasm7) Crowing is the sound of laryngeal spasm
24. AIRWAY OBSTRUCTION cont…AIRWAY OBSTRUCTION cont…
Paradoxical breathingParadoxical breathing
Use of accessory muscles of respiration*Use of accessory muscles of respiration*
**suprasternal, intercostal and subcostal recessionssuprasternal, intercostal and subcostal recessions
Listening for absence of breath soundsListening for absence of breath sounds
Failure to inflate the lungs during IPPVFailure to inflate the lungs during IPPV
26. BASIC AIRWAY MANAGEMENTBASIC AIRWAY MANAGEMENT
cont…cont…
Jaw thrustJaw thrust
Suspected cervical spine injurySuspected cervical spine injury
Finger sweep and manual removal of foreign bodiesFinger sweep and manual removal of foreign bodies
27. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY
TECHNIQUESTECHNIQUES
Oropharyngeal airwayOropharyngeal airway
SizesSizes
Vomiting and laryngospasmVomiting and laryngospasm
28. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY
TECHNIQUES cont…TECHNIQUES cont…
Nasopharyngeal airwayNasopharyngeal airway
IndicationsIndications
1) In patients who are not1) In patients who are not
deeply unconsciousdeeply unconscious
2) Life saving in patients with2) Life saving in patients with
clenched jaws, trismus orclenched jaws, trismus or
maxillofacial injuriesmaxillofacial injuries
ContraindicationsContraindications
1) Fracture or deformity of1) Fracture or deformity of
the nosethe nose
2) Fracture base of skull2) Fracture base of skull
3) Coagulopathies3) Coagulopathies
29. ADJUNCTS TO BASIC AIRWAYADJUNCTS TO BASIC AIRWAY
TECHNIQUES cont…TECHNIQUES cont…
Oxygen inhalationOxygen inhalation
Oxygen masks with reservoir bagOxygen masks with reservoir bag
Oxygen flow / litre per minuteOxygen flow / litre per minute
SpO2 and ABGsSpO2 and ABGs
SuctionSuction
Blood, saliva and gastric contentsBlood, saliva and gastric contents
Intact gag reflex (vomiting)Intact gag reflex (vomiting)
30. VENTILATIONVENTILATION
Mouth to mouth breathingMouth to mouth breathing
Instant availability /no equipment requiredInstant availability /no equipment required
Oxygen content 16-17%Oxygen content 16-17%
Aesthetically unpleasantAesthetically unpleasant
Risk of acquiring infection (TB,SARS,HBV,HCV)Risk of acquiring infection (TB,SARS,HBV,HCV)
Pocket resuscitation masksPocket resuscitation masks
Transparent just like anesthesia masksTransparent just like anesthesia masks
Uni-directional valveUni-directional valve
Connection for addition of O2Connection for addition of O2
Large Vt or excessive inspiratory flow gastric distentionLarge Vt or excessive inspiratory flow gastric distention
and regurgitationand regurgitation
31.
32. SELF INFLATING BAGSELF INFLATING BAG
Can be connected to faceCan be connected to face
mask/ETT/LMA/combitubemask/ETT/LMA/combitube
Oxygen deliveryOxygen delivery
room air 21%room air 21%
O2 attachment 45%O2 attachment 45%
reservoir bag 85% (10 L/min flow)reservoir bag 85% (10 L/min flow)
Difficult for one person to ventilateDifficult for one person to ventilate
Two person techniqueTwo person technique
33.
34. ENDOTRACHEAL TUBESENDOTRACHEAL TUBES
ADVANTAGESADVANTAGES
Optimal method of managing the airwayOptimal method of managing the airway
Maintenance of a patent airwayMaintenance of a patent airway
Protection from aspiration of gastric contents orProtection from aspiration of gastric contents or
bloodblood
Provision of adequate tidal volume with uninterruptedProvision of adequate tidal volume with uninterrupted
chest compressionschest compressions
Rescuers hand free for other tasksRescuers hand free for other tasks
Ability to suction airway secretionsAbility to suction airway secretions
Provision of a route for giving drugsProvision of a route for giving drugs
DISADVANTAGESDISADVANTAGES
Technically trained and experienced personnelTechnically trained and experienced personnel
requiredrequired
Unrecognized esophageal intubationUnrecognized esophageal intubation
Dislodgment of the tubeDislodgment of the tube
Passage of tube in right main bronchusPassage of tube in right main bronchus
Laryngeal and upper airway traumaLaryngeal and upper airway trauma
Prolonged attempts( compromised coronary &Prolonged attempts( compromised coronary &
cerebral flowcerebral flow
37. LARYNGEAL MASK AIRWAYLARYNGEAL MASK AIRWAY
(LMA) cont…(LMA) cont…
Successful ventilation 72-98%Successful ventilation 72-98%
Better than bag mask ventilationBetter than bag mask ventilation
Inflation pressures less than 20 cm of H2OInflation pressures less than 20 cm of H2O
Interruption of chest compressions required forInterruption of chest compressions required for
proper ventilation ( main disadvantage asproper ventilation ( main disadvantage as
compared to ETT)compared to ETT)