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1. CARDIOPULMONARY
RESUSCITATION (CPR)
BALQEES MAJALI

2. DEFINITION
Cardiopulmonary
Resuscitation – is an
emergency lifesaving
procedure performed
when the heart stops
beating. Immediate CPR
can double or triple
chances of survival after
cardiac arrest

3. PURPOSE
Cardiopulmonary resuscitation (CPR)
consists of the use of chest compressions
and artificial ventilation to maintain
circulatory flow and oxygenation during
cardiac arrest.
Although survival rates and neurologic
outcomes are poor for patients with cardiac
arrest, early appropriate resuscitation—
involving early defibrillation—and
appropriate implementation of post–cardiac
arrest care lead to improved survival and
neurologic outcomes

4. INDICATIONS
CPR should be performed immediately on any person who has become
unconscious and is found to be pulseless. Assessment of cardiac
electrical activity via rapid “rhythm strip” recording can provide a more
detailed analysis of the type of cardiac arrest, as well as indicate
additional treatment options.
Loss of effective cardiac activity is generally due to the spontaneous
initiation of a nonperfusing arrhythmia, sometimes referred to as a
malignant arrhythmia. The most common nonperfusing arrhythmias
include the following:
- Ventricular fibrillation (VF)
- Pulseless ventricular tachycardia (VT)
- Pulseless electrical activity (PEA)
- Asystole
- Pulseless bradycardia

5. CONTRAINDICATIONS
The only absolute contraindication to CPR is a do-not-resuscitate
(DNR) order or other advanced directive indicating a person’s
desire to not be resuscitated in the event of cardiac arrest.
A relative contraindication to performing CPR is if a clinician
justifiably feels that the intervention would be medically futile.

6. The American College of Surgeons, the American College of Emergency
Physicians, the National Association of EMS Physicians, and the American
Academy of Pediatrics have issued guidelines on the withholding or
termination of resuscitation in pediatric out-of-hospital traumatic
cardiopulmonary arrest.
1. Withholding resuscitation should be considered in cases of penetrating or blunt
trauma victims who will obviously not survive.
2. Standard resuscitation should be initiated in arrested patients who have not
experienced a traumatic injury.
3. Victims of lighting strike or drowning with significant hypothermia should be
resuscitated.
4. Children who showed signs of life before traumatic CPR should be taken
immediately to the emergency room; CPR should be performed, the airway should
be managed, and intravenous or intraosseous lines should be placed en route.
5. In cases in which the trauma was not witnessed, it may be assumed that a
longer period of hypoxia might have occurred and limiting CPR to 30 minutes or
less may be considered.
6. When the circumstances or timing of the traumatic event are in doubt,
resuscitation can be initiated and continued until arrival at the hospital.
7. Terminating resuscitation in children should be included in state protocols.

7. CARDIAC ARREST
• Is very important
in detection and
dealing with
(initiating CPR)
• Loss of
consciousness
• Loss of apical and
central pulsations
• Apnea
• Mechanical
• Metabolic
• Arrhythmias
• It is loss of
cardiac function,
breathing and loss
of consciousness
Definition Causes
Time
wise
Diagnosis

9. PHASES OF CPR
Phase Definition Steps
Phase I
BLS
Basic Life Support :
without the use of special
equipment.
A : Airway
B: Breathing
C: Circulation
Phase II
ALS
Advanced Life Support :
with use of special
equipment .
- Drug
- ECG
- Defibrillation
- Invasive airway
procedures
Phase III Prolonged support Post resuscitation care

10. EARLY RECOGNITION
* Unresponsiveness :
-Check the victim for a response.
-Shake shoulders gently.
-Ask “Are you all right?”
* No breathing or no normal breathing (i.e,
only gasping)
* No pulse felt within 10 seconds.

11. BASIC LIFE
SUPPORT

12. BLS – CPR
In its full, standard form, cardiopulmonary resuscitation
(CPR) comprises 3 steps: chest compressions, airway, and
breathing (CAB), to be performed in that order in accordance
with the 2010 American Heart Association (AHA) guidelines.
For an unconscious adult, CPR is initiated using 30 chest compressions.
Perform the head-tilt chin-lift maneuver to open the airway and
determine if the patient is breathing. Before beginning ventilations, rule out
airway obstruction by looking in the patient’s mouth for a foreign body
blocking the patient’s airway. CPR in the presence of an airway obstruction
results in ineffective ventilation/oxygenation and may lead to worsening
hypoxemia.

13. CHEST
COMPRESSIONS
The heel of one hand is placed
on the patient’s sternum, and
the other hand is placed on top
of the first, fingers interlaced.
The elbows are extended and
the provider leans directly over
the patient (see the image
below). The provider presses
down, compressing the chest
at least 2 in. The chest is
released and allowed to recoil
completely (see the video
below).

14. • With the hands kept in place, the compressions are repeated 30 times at a rate of
100/min. The key thing to keep in mind when doing chest compressions during CPR is to
push fast and hard. Care should be taken to not lean on the patient between
compressions, as this prevents chest recoil and worsens blood flow.
• After 30 compressions, 2 breaths are given (see Ventilation). Of note, an intubated patient
should receive continuous compressions while ventilations are given 8-10 times per
minute. This entire process is repeated until a pulse returns or the patient is transferred to
definitive care.
• When done properly, CPR can be quite fatiguing for the provider. If possible, in order to
give consistent, high-quality CPR and prevent provider fatigue or injury, new providers
should intervene every 2-3 minutes (ie, providers should swap out, giving the chest
compressor a rest while another rescuer continues CPR).
• For COCPR (ie, CPR without rescue breaths), the provider delivers only the chest
compression portion of care at a rate of 100/min to a depth of 38-51 mm (1-1.5 in.)
without pause. This delivery of compressions continues until the arrival of medical
professionals or until another rescuer is available to continue compressions.

15. AIRWAY
BASIC TECHNIQUES FOR AIRWAY PATENCY
Head tilt, chin lift:
- One hand is placed on
the forehead
- The other on the chin
-The head is tilted
upwards to cause anterior
displacement of the
tongue.
Jaw thrust
Finger sweep:
Sweep out foreign body in
the mouth by index finger
(in unconscious pt only.
This is NOT advised in a
conscious or convulsing
patient)
Heimlich manoeuvre
if the pt is conscious or the
foreign body cannot be
removed by a finger
sweep. It is done while the
pt is standing up or lying
down.
This is a subdiaphragmatic
abdominal thrust that
elevates the diaphragm
expelling a blast of air from
the lungs that displaces
the foreign body.

16. Head tilt chin lift

20. VENTILATION
If the patient is not breathing, 2 ventilations are given via the
provider’s mouth or a bag-valve-mask (BVM).
The mouth-to-mouth technique is performed as follows (see the
video below):
- The nostrils of the patient are pinched closed to assist with an
airtight seal
- The provider puts his mouth completely over the patient’s mouth
- The provider gives a breath for approximately 1 second with
enough force to make the patient’s chest rise

21. Effective mouth-to-mouth
ventilation is determined by :
*Observation of chest rise during
each exhalation.
Failure to observe chest rise
indicates an inadequate mouth
seal or airway occlusion.
2 such exhalations should be
given in sequence after 30
compressions (the 30:2 cycle of
CPR).
When breaths are completed,
compressions are restarted. If
available, a barrier device (pocket
mask or face shield) should be
used.

22. More commonly, health care providers use a BVM, which
forces air into the lungs when the bag is squeezed. Several
adjunct devices may be used with a BVM, including
oropharyngeal and nasopharyngeal airways.
The BVM or invasive airway technique is performed as follows:
- The provider ensures a tight seal between the mask and the
patient’s face.
- The bag is squeezed with one hand for approximately 1 second,
forcing at least 500 mL of air into the patient’s lungs.

23. ASSESSMENT OF RESTORATION OF
BREATHING AND CIRCULATION
* Contraction of pupil
* Improved color of the skin
* Free movement of the chest wall
* Swallowing attempts
* Struggling movements
Signs of restored ventilation and circulation
include:
• Struggling movements
• Improved color
• Return of or strong pulse
• Return of systemic blood pressure

24. COMPLICATIONS
Performing chest compressions may result in the fracturing of
ribs or the sternum, though the incidence of such fractures is
widely considered to be low.
Artificial respiration using noninvasive ventilation methods (eg,
mouth-to-mouth, bag-valve-mask [BVM]) can often result in
gastric insufflation. This can lead to vomiting, which can further
lead to airway compromise or aspiration. The problem is
eliminated by inserting an invasive airway, which prevents air from
entering the esophagus.

25. WHEN TO TERMINATE
‘BLS’
• Pulse and respiration returns
• Emergency medical help arrives
• Physician declared patient is deceased
• In a non health setting ,another indication to stop BLS
would be that the rescuer was exhausted and physically
unable to continue to perform BLS

26. ADVANCED LIFE
SUPPORT

28. RECOGNITION OF
ARRHYTHMIA
Lethal or non lethal
Symptomatic or asymptomatic
Stable or unstable
Shockable or unshockable

29. Shockable Unshockable
VT
Monophormic or
biphormic
VF
Fine or coarse
Asystole PEA :
Pulseless electrical
activity
Electromechanical
disociation

30. Initial evaluation
• Activate emergency
response system
• Initiate adult basic
life support (BLS)
algorithm
Initial intervention
• Start high-quality
cardiopulmonary
resuscitation (CPR)
• Administer oxygen
if hypoxemic
• Attach
monitor/defibrillator
• Monitor blood
pressure and
oximetry; do not
delay defibrillation
Check rhythem
• Shockable rhythm =
Ventricular
fibrillation or
pulseless
ventricular
tachycardia (VF/VT)
• Nonshockable
rhythm =
Asystole/pulseless
electrical activity
(PEA)

31. DEFIBRILLATION
Defibrillation consists of
delivering a therapeutic dose of
electrical energy to the affected
heart with a device called a
defibrillator.
- Biphasic : 120 – 200 J
- Monophasic : 360 J
• Failure of a single adequate
shock to restore the pulse
should be followed by
continued CPR and 2nd shock
after 5 cycles of CPR
• If cardiac arrest still persist :
intubation and IV access

32. SHOCKABLE
- Defibrillate immediately.
- Continue CPR for 2 minutes.
- Obtain intravenous
(IV)/intraosseous (IO) access.
- Consider advanced airway, end-
tidal carbon dioxide tension
(PETCO 2).
Administer
vasopressor
(epinephrine
q3-5min)
Check pulse
and rhythm
every 2
minutes,
If return of
spontaneous
circulation :
Post-Cardiac
Arrest Care
-If nonshockable, see Nonshockable Rhythm
(below).
-If shockable, see Shockable Rhythm (above) and
administer amiodarone after second defibrillation
attempt.
-Rotate chest compressors.
-Identify and treat reversible causes.

33. NONSHOCKABLE
Check pulse and rhythm every 2 minutes
-If nonshockable, see Nonshockable Rhythm (above).
-If shockable, see Shockable Rhythm (above).
-Rotate chest compressors.
-Identify and treat reversible causes.
Administer vasopressor (epinephrine q3-5min)
- Continue CPR for 2 minutes.
-Obtain intravenous (IV)/intraosseous (IO) access.
-Consider advanced airway, end-tidal carbon dioxide tension (PETCO 2)

34. ADVANCED AIRWAY
- Endotracheal tube (ETT) or supraglottic airway (SGA)
- Waveform capnography to confirm and monitor ET tube
placement
- Ventilation every 6 seconds asynchronous with
compressions
- Stop CPR for no longer than 10 seconds for the placement
of an advanced airway

35. Plastic oropharyngeal
airway
Esophageal obturators
Ambu bag
Endotracheal tube

36. MEDICATIONS

37. EPINEPHRINE
- Given as a vasopressor α-1 effect (not as an
inotrope).
- Dose: 1 mg (0.01 mg/kg) IV every 4 minutes
(alternating cycles) while continuing CPR.
- Given:
1) Immediately in non-shockable rhythm (non-VT/VF).
2) In VF or VT given after the 2nd shock.
-Repeated: in alternate cycles (every 4 minutes).

38. AMOIDARONE
- Dose: 300 mg IV bolus (5 mg/kg).
- Given: in shockable rhythm after the 3rd
shock.
- If unavailable give lidocaine 100 mg IV
(1-1.5 mg/kg).

39. THROMBOLYTICS
- Fibrinolytic therapy is considered when cardiac
arrest is caused by proven or suspected acute pulmonary
embolism.
• If a fibrinolytic drug is used in these circumstances
consider performing CPR for at least 60-90 minutes before
termination of resuscitation attempts.
• Eg: Alteplase, tenecteplase (old generation:
steptokinase)

40. The 2015 AHA guidelines offer the following recommendations for the administration
of drugs during cardiac arrest
Amiodarone may be considered for or pVT that is unresponsive to CPR, defibrillation, and a vasopressor;
lidocaine may be considered as an alternative (class IIb)
Routine use of magnesium for VF/pVT is not recommended in adult patients (class III)
Inadequate evidence exists to support routine use of lidocaine; however, the initiation or continuation of
lidocaine may be considered immediately after ROSC from cardiac arrest due to VF/pVT (class IIb)
Inadequate evidence exists to support the routine use of a beta-blocker after cardiac arrest; however, the
initiation or continuation of a beta-blocker may be considered after hospitalization from cardiac arrest due
to VF/pVT (class IIb)
Atropine during pulseless electrical activity (PEA) or asystole is unlikely to have a therapeutic benefit
(class IIb)
There is insufficient evidence for or against the routine initiation or continuation of other antiarrhythmic
medications after ROSC from cardiac arrest
Standard-dose epinephrine (1 mg every 3-5 min) may be reasonable for patients in cardiac arrest (class
IIb); high-dose epinephrine is not recommended for routine use in cardiac arrest (class III)
Vasopressin has been removed from the Adult Cardiac Arrest Algorithm and offers no advantage in
combination with epinephrine or as a substitute for standard-dose epinephrine (class IIb)
It may be reasonable to administer epinephrine as soon as feasible after the onset of cardiac arrest due
to an initial nonshockable rhythm (class IIb)

41. SUMMARY

42. Untrained Lay
Responders
Trained Lay Responders Healthcare Professionals
Step 1 Ensure scene safety
Step 2 Check for response
Step 3
Responder should shout for nearby help and
phone or have another bystander phone 9-1-1;
the phone should remain on speaker for
receiving further instructions from the
dispatcher.
Responder should shout for
nearby help and activate the
emergency response system (9-
1-1, emergency response).
Ensure that the phone remains
on speaker, if at all possible.
Responder should shout for
nearby help. The resuscitation
team can be activated before or
after checking breathing and
pulse.
Step 4 Follow dispatcher’s instructions.
Check for no breathing or only
gasping; if there is none, begin
CPR with chest compressions.
A check for no breathing or only
gasping and a check of pulse
ideally should be done
simultaneously. Activation and
retrieval of the AED/emergency
equipment by either the lone
healthcare provider or by a
second person must occur
immediately after the check of
breathing and pulse identifies
cardiac arrest.
Step 5
As instructed by dispatcher to check for no
breathing or only gasping.
Answer dispatcher’s questions
and follow subsequent
instructions.
CPR begins immediately, and
the AED/defibrillator is used if
available.
Step 6 Dispatcher’s instructions are followed.
Send another person for an
AED, if one is available.
With arrival of a second
responder, two-person CPR is
provided and AED/defibrillator is
used.

45. POST–CARDIAC ARREST CARE
- Therapeutic hypothermia
- Optimization of hemodynamics and gas exchange
- Immediate coronary reperfusion, when indicated for
restoration of coronary blood flow, with percutaneous
coronary intervention (PCI)
-Glycemic control
-Neurological diagnosis, management, and prognostication

46. ORGAN DONATION
Guidelines recommend that all patients who are
resuscitated from cardiac arrest but subsequently progress
to death or brain death be evaluated for organ donation. In
addition, the AHA guidelines recommend considering kidney
or liver donation in patients who do not have ROSC after
resuscitation efforts and would otherwise have termination of
efforts.

47. THANK YOU