1 Basic Life Support BLS Automated External Defibrillation

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Basic Life Support ( BLS ) Automated External Defibrillation (AED ) Farhad Heydari Emergency Medicine Deprtment Isfahan University Of Medical Sciences 2

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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 rescue breathing. How to place an unconscious breathing victim in the recovery position. 4

BACKGROUND Despite important advances in prevention, cardiac arrest remains a substantial public health problem and a leading cause of death in many parts of the world. Cardiac arrest occurs both in and out of the hospital. approximately 350 000 people/year (approximately half of them in-hospital) suffer a cardiac arrest and receive attempted resuscitation. 5

� Survival to hospital discharge presently approximately 5 -10% � Early resuscitation & prompt defibrillation (within 1 -2 minutes) can result in >60% survival 6

CHAIN OF SURVIVAL GUIDELINE 2010

Immediate recognition and activation Early CPR Defibrillation,

Advanced life support Integrated postcardiac arrest care.

LOOK , LISTEN , FEEL 12

Start CPR When …… : Unresponsiveness Abnormal Start Breathing CPR

A B C SINCE 1960 C A B GIUDELINE 2010 16

Arterial Blood O 2 Content (ABC) O 2 Content Arrest Resuscitation Rescue Breathes Chest Compression Time

Arterial Blood O 2 Content (CAB) O 2 Content Arrest Resuscitation Chest Compression Time

O 2 Content CAB ABC Time

BASIC LIFE SUPPORT � * Approach safely �Check response �Check breathing �Shout for help & Call 115 � 30 chest compressions � 2 rescue breaths 21

APPROACH SAFELY! Scene Rescuer Victim Bystanders �Approach safely �Check response �Check breathing �Shout for help & Call 115 � 30 chest compressions � 2 rescue breaths 22

CHECK RESPONSE - CHECK BREATHING Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 2 rescue breaths 23

CHECK RESPONSE Shake shoulders gently Ask “Are you all right? ” If he responds • Leave as you find him. • Find out what is wrong. • Reassess regularly. 24

AGONAL BREATHING & GASPING Occurs shortly after the heart stops in up to 40% of cardiac arrests Described as barely, heavy, noisy or gasping breathing Recognise as a sign of cardiac 25

SHOUT FOR HELP Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 2 rescue breaths 26

Call 115 �Approach safely �Check response �Check breathing �Shout for help & Call 115 � 30 chest compressions � 2 rescue breaths 27

Call 115 How? How many? When? Where? 28

v Once a cardiac arrest is identified, dispatchers can then give CPR instructions to a bystander over the phone until further help arrives. v Telephone instructions have been shown to increase the rates of bystander CPR and enhance outcomes. v Studies have also shown that the time to initiation of chest compressions is more rapid if the caller is given hands-only instructions (ie, no rescue breaths) rather than standard CPR instructions. (2012) 29

Check pulse Only for healthcare provider Feel within 10 sec 1. definite pulse give 1 breath / q 5 -6 s 2. recheck pulse q 2 min. 3. no pulse or suspicious pulse next step 30

Chest compressions are the foundation of CPR All rescuers, regardless of training, should provide chest compressions to all cardiac arrest victims.

Number of Compressions Delivered The total number of compressions delivered during resuscitation is an important determinant of survival from cardiac arrest. rate and the compression fraction. (the portion of total CPR time during which compressions are performed). 32

Minimal Interruptions During Chest Compression Cardiac Output Time 2 min

Minimal Interruptions During Chest Compression Cardiac Output Time 2 min

Cardiac Output Without Interruptions With Interruptions Time 2 min

CHEST COMPRESSIONS Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 2 rescue breaths 36

CHEST COMPRESSIONS v Proper positioning of the patient and rescuer is fundamental to proper compression delivery. v The recommended position in out-of-hospital scenarios is to kneel perpendicular beside the patient’s torso. v For in-hospital cardiac arrest response, the rescuer should stand beside the bed at the level of the patient’s torso. (2012) 37

CHEST COMPRESSIONS • supine victim on a hard surface • Place the heel of one hand in the centre of the chest ( lower half ) • Place other hand on top • Interlock fingers 38

CONTINUE CPR 30 2 39

CHEST COMPRESSIONS • Push hard and fast the chest: – Rate at least 100 /min – Depth 5 cm – Equal compression / relaxation – Minimize interruptions in chest compressions. • When possible change CPR operator every 2 min 40

v Providers delivering chest compressions should rotate every 2 minutes to minimize the effects of rescuer fatigue, and the switch should take less than 5 seconds. v One technique to minimize the interruption is to position a rescuer on either side of the patient for more seamless transitions. (2012) 41

v Interposed abdominal compression (IAC) is another strategy that has been proposed to increase cardio cerebral perfusion. v The first provider performs conventional chest compressions, while the second compresses the abdomen with similar hand position and depth midway between the xiphoid process and umbilicus during chest wall recoil. The third provider delivers intermittent ventilation, typically via an advanced airway management device. (2012) v This technique could be considered for victims of in-hospital cardiac arrest if a sufficient number of trained providers are present. (2012) 42

RESCUE BREATHS Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 2 rescue breaths 43

OPEN AIRWAY (head tilt , chin lift - jaw thrust ) Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 44

Give 2 BREATH ● Deliver each breath over 1 second • Give a sufficient tidal volume produce visible chest rise. ● Avoid rapid or forceful breaths. 45

2 RESCUE BREATHS �Pinch the nose �Take a normal breath �Place lips over mouth �Blow until the chest rises �Take about 1 second �Allow chest to fall �Repeat 46

v However, an advanced airway device should be inserted and used to provide ventilations only after the patient has received 2 to 3 minutes of chest compressions and attempted defibrillation, if appropriate. (2012) 47

BASIC LIFE SUPPORT Approach safely Check response Check breathing Shout for help & Call 115 30 chest compressions 2 rescue breaths 49

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cardiocerebral resuscitation (CCR) v CCR aims to improve outcomes through refocusing certain interventions in CPR to maximize myocardial and cerebral perfusion. v In CCR, chest compressions are started immediately and continued for 200 continuous compressions. During this time, oxygen is given via a noninvasive airway (ie, no endotracheal intubation), and defibrillator pads are placed on the patient. The rhythm is analyzed, and, when appropriate, a shock is given followed immediately by another interval of 200 compressions without pulse check. (2012) 51

v. Epinephrine is given early, and endotracheal intubation is delayed until after 3 rounds of chest compressions are completed. vthe first 3 years of this data was presented in percentages, CCR showed a survival to hospital discharge increase of 5. 4% versus 1. 8%. (2012) 52

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AUTOMATED EXTERNAL DEFIBRILLATOR 54

�In settings with 1 -lay rescuer AED programs (AED on-site and available) 2 -in-hospital environments 3 -EMS rescuer witnesses the collapse, collapse The rescuer should use the defibrillator as soon as ( within first 3 -5 min) it is available for children and adults.

cardiac arrest not witnessed by EMS personnel EMS may initiate CPR while checking the rhythm with the AED or on the electrocardiogram (ECG) and preparing for defibrillation. In such instances, 1½ to 3 minutes of CPR may be considered before attempted defibrillation. 56

v CPR Before Defibrillation The rate of survival-to-hospital discharge is higher among patients who experienced an unwitnessed SCA and received 1. 5 to 3 minutes of CPR followed by defibrillation. v In witnessed SCA, early defibrillation is imperative; CPR should be performed while the defibrillator is being prepared. (2012) 57

AED Use in Children Now Includes Infants 2010 (New) For infants (<1 year of age), defibrillator is preferred. If a manual defibrillator is not available, an AED with pediatric dose attenuation is desirable. If neither is available, an AED without a dose attenuator may be used. 58

The precordial thump 2010 (New) should not be used for unwitnessed out-of-hospital cardiac arrest. 1 -for patients with witnessed monitored, 2 -unstable VT (including pulse less VT) 3 -if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery. 59

The precordial thump v Percussion pacing, an extension of the precordial thump, is essentially rhythmic percussion of the chest wall with a fist to pace the myocardium. v Several case reports and small case series have documented successful resuscitation with this technique, but there is insufficient evidence to support its routine use. (2012) 60

�*Approach safely �Check response �Check breathing �Shout for help and call 115, get AED �Attach AED �Follow voice prompts 61

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SWITCH ON AED �Some AEDs will automatically switch them-selves on when the lid is opened 63

ATTACH PADS TO CASUALTY’S BARE CHEST 64

ANALYSING RHYTHM DO NOT TOUCH VICTIM 65

SHOCK INDICATED Stand clear Deliver shock 66

NO SHOCK ADVISED resume CPR immediately for 5 cycles 30 2 67

v studies have affirmed that it is extremely safe to continue compressions during defibrillation when a biphasic defibrillator is used with self-adhesive electrodes and the rescuer wears standard examination gloves. v The simulated rescuers in these studies perceived no electrical charge, despite voltage delivery during the compressions. v Therefore, uninterrupted manual chest compressions are feasible during shock delivery, without risk of harm to the rescuer. v The AHA did not adopt this practice until now (2012) 68

Approach safely Check response Check breathing Shout for help & Shout for help Call 115 30 chest compressions 2 rescue breaths and call 115, get AED Attach AED Follow voice prompts 69

If victim starts to breathe normally place in recovery position 70

Recovery position 1 2 4 3