5. IntroducFon
• “In many communiFes, the Fme interval from
EMS call to EMS arrival is 7 – 8 minutes or
longer.
• This means that in the first minutes aLer
collapse, the vicFm’s chance of survival is in
the hands of bystanders.”
• AHA Guidelines 2005
7. CPR Facts
• “About 75 percent to 80 percent of all out‐of‐
hospital cardiac arrests happen at home, so
being trained to perform cardiopulmonary
resuscitaFon (CPR) can mean the difference
between life and death for a loved one.”
• AHA Guidelines 2005
14. Chain of Survival
• Early DefibrillaFon
– CPR plus defibrillaFon within 3 – 5 min produce survival rates as
high as 49% ‐ 75%
– In first few minutes aLer successful defibrillaFon, asystole or
bradycardia maybe present (ineffecFve pumping)
16. “Push Hard, Push Fast”
EffecFve CPR
• Compress at a rate of about 100 compression
per minute
• Depth of 1½ to 2 inches (approximately 4 to 5
cm)
• Allow chest to recoil completely aLer each
compression
– To improve venous return
– Reduce intrathoracic pressure
– Improve coronary perfusion
18. Minimal InterrupFons During Chest
Compression
• Ideally, compressions should only be
interrupted for
A. VenFlaFon (unFl an advanced airway is
placed)
B. Rhythm check
C. Shock delivery
20. One SHOCK versus THREE STACKED
SHOCKS
Guidelines 2000 Guidelines 2005
For VF/Pulse‐less VT, give For witnessed VF/ pulse‐
three stacked shocks less VT, ONE SHOCK only,
without interrupFons (NO followed by immediate
CPR) in between CPR without pause to
check pulse
21. Four Reasons Why Single Shock With
Immediate CPR
1. High first shock efficacy
2. Post terminaFon iniFal non‐perfusing rhythm (PEA
or asystole)
3. Prolonged interrupFon to CPR (29‐37 seconds) if
giving stacked shocks and pulse check
4. Even if a perfusing rhythm is already restored,
giving chest compressions does not increase the
chance of VF recurring
23. PaFent brought in
Dead or alive?
Dead Alive
CPR started? No Start CPR? stable?
Yes
No
Yes
Shockable rhythm?
No Refer and treat
Yes
accordingly Consider
CPR & Defib CPR Electrical therapy
50. Hands‐Only CPR
• On March 31, 2008, the American Heart
AssociaFon changed its guidelines to include
hands‐only CPR, a new version using chest
compressions only.
• Hands‐only CPR is intended for untrained
rescuers and only for witnessed cardiac arrest.
52. Hands‐Only CPR
• “Bystanders who witness the sudden collapse of
an adult should immediately call 9‐1‐1 and start
what we call Hands‐Only CPR. This involves
providing high‐quality chest compressions by
pushing hard and fast in the middle of the vicBm’s
chest, without stopping unBl emergency medical
services (EMS) responders arrive….”
• Michael Sayre, M.D., chair of the statement wriFng
commipee and associate professor in the Ohio State
University Department of Emergency Medicine in Columbus.
56. PaFent brought in
Dead or alive?
Dead Alive
CPR started? No Start CPR? stable?
Yes
No
Yes
Shockable rhythm?
No Refer and treat
Yes
accordingly Consider
CPR & Defib CPR Electrical therapy
61. The drugs to be given at this Note that by this
stage are vasopressors Fme, if 3rd shock is
required, it is the
DRUG →SHOCK→
CPR sequence. It is
the same
sequence
thereaLer
63. When Should Drugs Be Administered?
• Inadequate evidence to idenFfy an opFmal
number of CPR cycles and defibrillaFon before
drugs.
• IF VF/VT persists aLer delivery of 1 – 2 shocks
plus CPR, give a vasopressor (adrenaline every
3 – 5 min during cardiac arrest; one dose of
vasopressin may replace either first or second
dose of adrenaline)
66. Types of Defibrillator Waveforms and
Energy
• It is the transmyocardial current flow that
defibrillates (not the energy)
• Monophasic
– Monophasic Damped Sinusoidal Waveform
– Monophasic Truncated ExponenFal Waveform
• Biphasic
– Biphasic Truncated ExponenFal Waveform
– RecFlinear Biphasic Waveform
69. Oxygen Safety and DefibrillaFon
• In an oxygen enriched atmosphere, sparking
from poorly applied defibrillator paddles can
cause a fire
Minimize risk by
• Take off any oxygen mask or nasal cannula and
place them at least 1 m away from paFent’s
chest
• Leave the venFlaFon bag connected to
tracheal tube or other airway adjunct
85. Why?
• If VF/pulseless VT been present for more than
a few minutes, the myocardium is depleted of
oxygen and metabolic substrates.
• A brief period of chest compressions can
deliver oxygen and energy substrates to
increase the likelihood that a perfusing
rhythm will return aLer shock delivery.
86. Rhythm and Pulse Check
Rhythm checks
should be brief
Pulse checks should
be performed only if
an organized rhythm
is observed.
93. DefibrillaFon Cardioversion
Synchronised on the R
Not synchronised
wave
For periarrest
For cardiac arrest tachyarrhythmias
(unstable)
Higher energy joules Lower energy joules
No escalaFng energy for Escalate for next shock
next shock (100 ‐ 200 ‐ 300 ‐ 360J)
94. Cardioversion
CondiFons Joules with monophasic
defibrillator
Atrial FibrillaFon Start with 200 J
(Too high, e.g. 360 J may cause
myocardial damage)
Atrial Fluper Start with 100 J
Ventricular Tachycardia Start with 200 J
Supraventricular Tachycardia Start with 100 J
95. • Cardioversion up to 3 apempts
• But if first cardioversion fails to restore NSR, and
paFent remains unstable, give IV amiodarone 300
mg loading over 20 min; then re‐apempt
• Serial DC shocks not appropriate for recurrent
paroxysms of AF, esp with ongoing precipitaFng
factors like sepsis
• Cardioversion does not prevent subsequent
arrhythmias – for recurrent, treat them with
drugs
100. Tachyarrhythmias
• Narrow QRS tachyarrhythmias
– Regular
• Sinus Tachycardia, PSVT, atrial fluper with regular AV conducFon
– Irregular
• Atrial FibrillaFon, Atrial fluper with variable AV Block
• Wide (Broad) QRS tachyarrhythmias
– Regular
• Ventricular Tachycardia, SVT with BBB
– Irregular
• Polymorphic VT, AF with BBB
101. Management of Narrow Complex
Tachycardia
• Vagal maneuver
– Valsalva maneuver is the most effecFve
– Blow into a 20ml syringe with enough force to
push back the plunger
• Adenosine
• Successful terminaFon pf a tachyarrhythmias
by vagal maneuver or adenosine indicates that
it is almost certainly AVNRT or AVRT.
103. Atrio‐Ventricular Tachyarrhythmias
AVNRT AVRT
Micro‐reentry due to two pathways within Macro‐reentry due to an accessory
the AV Node pathways or bypass tracts
Affects all ages, but associated with IHD, Tends to present at earlier age than
RheumaFc HD, etc AVNRT; male: female = 2:1; seen in WPW;
also associated with Ebstein anomaly
Most common form of Paroxysmal SVTs 2nd most common form of PSVTs
Causes rapid, almost simultaneous Called orthodromic AVRT if anterograde
depolarizaFon of both ventricles and atria conducFon through normal His‐Purkinje
pathway and retrograde conducFon
through accessory pathway
Called anFdromic if anterograde
conducFon through accessory pathway;
retrograde conducFon through normal
pathway
104. Atrio‐Ventricular Tachyarrhythmias
AVNRT AVRT
QRS complex typically narrow and regular; Orthodromic
rate 120 – 250bpm Because ventricle depolarizaFon occurs
along normal pathway, QRS narrow.
Because atrial depolarizaFon and Because atria depolarized late along
ventricle depolarizaFon occur accessory pathway, P wave follows QRS
simultaneously, P wave maybe “buried” ; complex;
or visible just aLer or immediately before Difficult to differenFate from AVNRT
QRS complex
AnFdromic
Because ventriicles are aberrantly
depolarized, a bizarre wide QRS complex
tachycardia results; difficult to
differenFate from VT or SVT with
aberrancy
113. Note
• 3 of more consecuFve PVCs = VT
• <30 seconds of VT = non sustained VY
• >30 seconds of VT = sustained VT
• Non sustained VTs do not require treatment
• Torsades de pointes – a type of polymorphic
VT with a cyclical papern of alternaFng
electrical polarity and amplitude
119. Four Rhythms at Risk of Developing
Asystole
1. Recent asystole
2. Mobitz II 2nd degree AV Block
3. Complete Heart Block (especially with broad
QRS or iniFal heart rate <40/min)
4. Ventricular standsFll more than 3 sec
For these, consider also electrical therapy
124. Pre‐cordial Thump
• Only by trained healthcare providers
immediately confirm cardiac arrest
• Use ulnar edge of Fghtly clenched fist
• Deliver a sharp impact to the lower half of the
sternum from a height of 20 cm
• ALer that, immediately retract the fist
125. Four Features SuggesFve Ventricular
Origin
• Concordance Polarity
• Fusion beats and Capture beats
• Bizzare QRS complexes
• AV DissociaFon