ALS and BTLS

“ “And if anyone saved a life, it would be as And if anyone saved a life, it would be as if he saved all mankind.” (Quran: 5:32). if he saved all mankind.” (Quran: 5:32).

DateDate 2020thth JUNE 2006 JUNE 2006 Patient Lt Col XYZPatient Lt Col XYZ Age 45 yearsAge 45 years Place Place SSG CENTRE CHIRATSSG CENTRE CHIRAT ActivityActivity Routine Morning ExerciseRoutine Morning Exercise

Suddenly collapsed, became unresponsive with irregular gasping breathingSuddenly collapsed, became unresponsive with irregular gasping 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 chest compressions were Airway maintained, mouth to mouth breathing and chest compressions were

started. A bystander SSG officer was involved in CPRstarted. A bystander SSG officer was involved in CPR CPR continued and patient shifted to CMH Cherat in a military vehicle in 4-5 CPR continued and patient shifted to CMH Cherat in a military vehicle in 4-5

minutesminutes 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)

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 mins CPR 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 VF CPR 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 (irregular Carotids became palpable and patient started breathing (irregular

gasps)gasps) Chest compression stopped and breathing assisted Chest 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 and 80mg 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

Patient flown to AFIC in a military helicopter with O2 Patient flown to AFIC in a military helicopter with O2 cylinder, emergency drugs, defib., and was accompanied cylinder, 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 treatment IABP passed, supportive and symptomatic treatment

given, weaned off ventilator after 24 hours given, weaned off ventilator after 24 hours No neurological deficit noted No 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

SEQUENCESEQUENCE

European resuscitation council European resuscitation council (ERC) guidelines for resuscitation (ERC) guidelines for resuscitation 20052005

BLSBLS Chest compressionChest compression Airway managementAirway management AlgorithmsAlgorithms

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

IntroductionIntroduction 700,000 deaths/year in Europe 700,000 deaths/year in Europe

(SCA)(SCA) Causes IHD (VF/VT/ Asystole)Causes IHD (VF/VT/ Asystole) TraumaTrauma Drug over doseDrug over dose DrowningDrowning AsphyxiaAsphyxia Optimum treatment (Chest Optimum treatment (Chest

Compression, Rescue Breathing and Compression, Rescue Breathing and electrical defib)electrical defib)

SurvivalSurvival

Early recognition of SCA Early recognition of SCA

Early bystander CPR improves survival Early bystander CPR improves survival

(2 – 3 times)(2 – 3 times)

Early Defibrillation within 3 – 5 min of Early Defibrillation within 3 – 5 min of SCA (50 – 75%)SCA (50 – 75%)

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

If he does not respondIf he does not respond Shout for helpShout for help Turn the victim in supine Turn the victim in supine

positionposition Open the Air way using head Open the Air way using head

tilt and chin lifttilt and chin lift Look, listen and feel for Look, listen and feel for

normal breathingnormal breathing Look for chest movementLook for chest movement Listen at the victims mouth for Listen at the victims mouth for

breath soundsbreath sounds Feel for air on your cheek Feel for air on your cheek Don’t waste more than 10 secsDon’t waste more than 10 secs

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 Place the heel of one hand in the centre of the victim’s chestvictim’s chest Place the heel of the other hand on top of the first Place the heel of the other hand on top of the first handhand Interlock the fingers of your hands and ensure that Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs or pressure is not applied over the victim’s ribs or xiphisternumxiphisternum Position yourself vertically above the victim’s chest Position yourself vertically above the victim’s chest and with and with your arms straight, press down the your arms straight, press down the sternum 4 – 5 cmssternum 4 – 5 cms After each compression, release all the pressure on After each compression, release all the pressure on the chest the chest without losing contact between your hands without losing contact between your hands and the sternum repeat at a rate of about 100/minand the sternum repeat at a rate of about 100/min Compress and release for equal duration of time Compress and release for equal duration of time

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)

Continue resuscitation until • Qualified help arrives and takes over • The victim starts breathing normally • You become exhausted

VentilationVentilation Reduced blood flow to the lungs during CPR.Reduced blood flow to the lungs during CPR. Ventilation/ perfusion ratio maintained Vt Ventilation/ perfusion ratio maintained Vt

and RR.and RR. Hyperventilation and large Vt are Hyperventilation and large Vt are

unnecessary and harmful increased unnecessary and harmful increased intrathoracic pressure leads to reduced CO. intrathoracic pressure leads to reduced CO. and large Vt 1 ltr or more may cause gastric and large Vt 1 ltr or more may cause gastric distention/ regurgitationdistention/ regurgitation

Interruptions in chest compression should be Interruptions in chest compression should be minimal.minimal.

Chest Chest CompressionCompression

Blood flow is Blood flow is generated generated

1.1. Increased Increased intrathoracic intrathoracic pressure pressure

2.2. Direct compression Direct compression of the heartof the heart

3.3. Systolic arterial Systolic arterial pressure peaks – 60 pressure peaks – 60 – 80 mm Hg– 80 mm Hg

4.4. Low diastolic Low diastolic pressure pressure

5.5. Mean BP in carotid Mean BP in carotid 40 mm Hg40 mm Hg

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 Primary cause of cardio respiratory arrestarrest Prompt assessment control of airway and Prompt assessment control of airway and ventilation will prevent secondary ventilation will prevent secondary hypoxichypoxic damage to the brain and other damage to the brain and other vital organsvital organs

Airway obstruction in unconscious and Airway obstruction in unconscious and obtunded patient obtunded patient

1.1. Decreased muscle tone/ posterior Decreased muscle tone/ posterior displacement of the tongue and at the soft displacement of the tongue and at the soft palate and epiglottis levelpalate and epiglottis level

2. Vomitus, blood, foreign body, laryngeal 2. Vomitus, blood, foreign body, laryngeal oedema are other causes of airway obstructionoedema are other causes of airway obstruction

RECOGNITION OF AIRWAY RECOGNITION 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 1) Diminished air entry and noisy breathing indicates

partial airway obstruction partial airway obstruction 2) Inspiratory stridor is caused by obstruction at the 2) Inspiratory stridor is caused by obstruction at the

pharyngeal and supra glottic levelpharyngeal and supra glottic level 3) Biphasic stridor in glottic or cervical tracheal 3) Biphasic stridor in glottic or cervical tracheal

obstructionobstruction 4) Expiratory wheeze implies obstruction of the lower 4) Expiratory wheeze implies obstruction of the lower

airways airways 5) Gurgling is caused by liquid or semisolid foreign 5) Gurgling is caused by liquid or semisolid foreign

material in the main airwaysmaterial in the main airways 6) Snoring arises when the pharynx is partially occluded 6) Snoring arises when the pharynx is partially occluded

by the soft palate or epiglottisby the soft palate or epiglottis 7) Crowing is the sound of laryngeal spasm 7) Crowing is the sound of laryngeal spasm

AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION cont…cont…

Paradoxical breathing Paradoxical breathing Use of accessory muscles of Use of accessory muscles of

respiration*respiration* **suprasternal, intercostal and subcostal suprasternal, intercostal and subcostal

recessionsrecessions

Listening for absence of breath Listening for absence of breath soundssounds

Failure to inflate the lungs during Failure to inflate the lungs during IPPVIPPV

BASIC AIRWAY BASIC AIRWAY MANAGEMENTMANAGEMENT

Head tilt and chin liftHead tilt and chin lift

BASIC AIRWAY BASIC AIRWAY MANAGEMENT cont…MANAGEMENT cont…

Jaw thrustJaw thrust Suspected cervical spine injurySuspected cervical spine injury Finger sweep and manual removal of Finger sweep and manual removal of

foreign bodiesforeign bodies

ADJUNCTS TO BASIC ADJUNCTS TO BASIC AIRWAY TECHNIQUESAIRWAY TECHNIQUES

Oropharyngeal airwayOropharyngeal airway Sizes Sizes Vomiting and laryngospasmVomiting and laryngospasm

ADJUNCTS TO BASIC ADJUNCTS TO BASIC AIRWAY TECHNIQUES AIRWAY TECHNIQUES

cont…cont… Nasopharyngeal airwayNasopharyngeal airway IndicationsIndications 1) In patients who are 1) In patients who are

not deeply unconsciousnot deeply unconscious 2) Life saving in 2) Life saving in

patients with clenched patients with clenched jaws, trismus or jaws, trismus or maxillofacial injuriesmaxillofacial injuries

ContraindicationsContraindications 1) Fracture or 1) Fracture or

deformity of the nosedeformity of the nose 2) Fracture base of 2) Fracture base of

skullskull 3) Coagulopathies3) Coagulopathies

ADJUNCTS TO BASIC ADJUNCTS TO BASIC AIRWAY TECHNIQUES AIRWAY TECHNIQUES

cont…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 Suction Suction Blood, saliva and gastric contentsBlood, saliva and gastric contents Intact gag reflex (vomiting)Intact gag reflex (vomiting)

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 Large Vt or excessive inspiratory flow

gastric distention and regurgitationgastric distention and regurgitation

SELF INFLATING BAGSELF INFLATING BAG

Can be connected to face Can 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 reservoir bag 85% (10 L/min

flow)flow) Difficult for one person to ventilate Difficult for one person to ventilate Two person techniqueTwo person technique

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 Protection from aspiration of gastric

contents or bloodcontents or blood Provision of adequate tidal volume with Provision of adequate tidal volume with

uninterrupted chest compressionsuninterrupted chest 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 Technically trained and experienced

personnel required personnel required 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 trauma Laryngeal and upper airway trauma Prolonged attempts( compromised Prolonged attempts( compromised

coronary & cerebral flowcoronary & cerebral flow

LARYNGEAL MASK LARYNGEAL MASK AIRWAY (LMA)AIRWAY (LMA)

LARYNGEAL MASK LARYNGEAL MASK AIRWAY (LMA) cont…AIRWAY (LMA) cont…

LARYNGEAL MASK LARYNGEAL MASK AIRWAY (LMA) cont…AIRWAY (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 Inflation pressures less than 20 cm

of H2Oof H2O Interruption of chest compressions Interruption of chest compressions

required for proper ventilation required for proper ventilation ( main disadvantage as compared to ( main disadvantage as compared to ETT)ETT)

THE COMBITUBETHE COMBITUBE

CRICOTHYROTOMY/ CRICOTHYROTOMY/ LARYNGOTOMYLARYNGOTOMY

FBAOFBAO

FBAOFBAO

THANK THANK YOUYOU