INTRODUCTION FOR

MEDICAL DOCTOR
(SOON TO BE)

Natalia.christina@uph.edu
When you are on your way to Medical Faculty, there is a motorcycle
accident happened in front of you
What will you do?
A. Take a U-turn and pretend that you didn’t see anything
B. Scream outloud so anyone could help the victim
C. Since there is no one recognize you as a medical student, then you can just
leave the scene and pray
D. Be confident, take responsibility, do some basic life support pre hospital
and call for an ambulance
You will make a good choice, cause you had
already choose MEDICINE
 PRIMARY SURVEY
• Airway with Cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability: Neurologic status
• Exposure/ Environmental control
 SECONDARY SURVEY
The secondary survey does not begin until:
• the primary survey is completed,
• resuscitation efforts are well established,
• the patient is demonstrating normalization of vital functions.
• Head-to-toe evaluation
• Complete history and Physical Examination
You just have to be brave, smart and
have a DOCTOR spirit
But the victim is NOT breathing…. So HOW?
Basic Life Support
First Aid
 Background

• Approximately 700,000 cardiac arrests per year in Europe

Outcome:
• Survival to hospital discharge presently approximately 5-10 - 14%
• Bystander CPR = vital intervention before arrival of emergency
services
• Early resuscitation and prompt defibrillation (within 1-2 minutes)
can result in >60% survival
Chain of survival
CardioPulmonary Resuscitation
Definition:
CPR is an emergency first-aid procedure that is used to
maintain respiration and blood circulation in a person, whose
breathing and heartbeats have suddenly stopped,
(one or more vital functions failed ).
 Indication of CPR
to victims with unexpected cardiac
arrest in otherwise healthy individuals

 = to those, who can be described as

having ”heart too good to die”
 all cases accompanied
with hypoxia
extracardiac

Causes of cardiac
arrest

Primary lesion of cardiac muscle leading to

cardiac the progressive decline of contractility,
conductivity disorders, mechanical factors
14
Causes of circulation arrest
Cardiac Extracardiac
• Ischemic heart disease • airway obstruction
(myocardial infarction,
stenocardia) • acute respiratory failure
• Arrhythmias of different origin • shock
and character
• reflector cardiac arrest
• Electrolytic disorders
• Valvular disease • embolisms of different origin
• Cardiac tamponade • drug overdose
• Pulmonary artery • electrocution
thromboembolism
• poisoning
• Ruptured aneurysm of aorta 15
 Diagnosis of cardiac arrest

Blood pressure measurement

Taking the pulse on peripheral
arteries
Auscultation of cardiac tones
Loss of time !!!
Symptoms of cardiac arrest
 absence of pulse on carotid arteries – a pathognomonic symptom

 respiration arrest – may be in 30 seconds after cardiac arrest

 enlargement of pupils – may be in 90 seconds after cardiac arrest
16
Sequence of operations
 Check responsiveness
 Call for help
 Correctly place the victim and ensure the open airway
 Check the presence of spontaneous respiration
 Check pulse
 Start external cardiac massage and artificial
ventilation

17
Cardiac pump during the cardiac massage

Blood pumping is assured

by the compression of
heart between sternum
and spine

Between compressions
thoracic cage is
expanding and heart is
filled with blood
18
Thoracic pump at the cardiac massage
Blood circulation is restored
due to the change in intra
thoracic pressure and jugular
and subclavian vein valves
During the chest compression
blood is directed from the
pulmonary circulation to the
systemic circulation. Cardiac
valves function as in normal
cardiac cycle.

19
Cause of cardiac arrest and emergency system activation

different approach to the emergency system activation.

Adults
electric defibrillator is necessary as soon as possible;
therefore, if telephone is available and you are alone:
1. call for help, then
2. start with CPR

Children
1. start CPR immediately for 1 minute to provide some
tissue oxygenation
2. then call for help
 CPR is not indicated for..
 signs of definitive biological death
 witnessed information, that cardiac arrest had happened 15 or more minutes before the
rescuer arrived (time assessment in the stressing situation is not precise)
 terminal stage of incurable disease (generalised malignant disease…)
 an evident trauma without chance to survive (catastrophic head injury)
 “living will” - only in countries when constitution accepts it
 DNR - “Do not attempt resuscitation” has been written in the file (incurable disease after all
available therapy failed)
• Age of the patient is not restriction of CPR
 CPR outcome
• In first 4 minutes – brain damage is unlikely, if
CPR started
• 4 – 6 minutes – brain damage possible
• 6 – 10 minutes – brain damage probable
• > 10 minutes – severe brain damage certain

Cells of the brain cortex

• Most sensitive for the stop of pefusion and
oxygenation
Without perfusion and oxygenation
 irreversibly damaged after 3-5 minutes
Basic conditions for CPR
1. Rescuer’s safety = the first priority
2. To assess the risk of trauma, intoxication, infection …
3. a victim position: supine on to his/her back
4. on the firm flat surface to make effective chest compressions
5. victim´s position in relation to rescuer´s position
6. CPR during transfer ???
 Stop CPR if:
Victim starts to breathe normally
Medical assistance arrives and instructs you to stop CPR
When CPR has been performed for 20 minutes without
restoration of the spontaneous circulation

It can be stopped earlier, when:

 rescuer is physically exhausted
 when signs of biological death develop (post-mortal
rigidity, post-mortal cooling and gravity-dependent livid
stains)
CardioPulmonary Resuscitation
• Safar´s algorithm of CPR
• stressing conditions  an inadequate situation assessment

• Airways
• Breathing BLS
• Circulation ALS
• Drugs
• ECG ?
 New resuscitation alphabet
– in adults
EKG
Circulation BLS
Airways ALS
Breathing
Drugs
BLS sequence
Kneel by the side of
the victim
BLS sequence

Shake shoulders
Ask “Are you all right?”
BLS sequence
If he responds
• Leave as you find him
• Find out what is wrong
• Reassess regularly
BLS sequence

Unresponsive

Shout for help

BLS sequence

Unresponsive

Shout for help

Open airway
BLS sequence

Unresponsive

Shout for help

Open airway

Check
breathing
BLS sequence

• Look, listen and feel for

NORMAL breathing
• No breathing – apnea
• Gasps (agonal breathing)
 Agonal breathing
• Occurs shortly after heart stops in up to 40% of cardiac arrests

• Described as barely, heavy, noisy or gasping breathing

• Recognise as a sign of cardiac arrest

• Do not confuse agonal breathing with NORMAL breathing
BLS sequence

Unresponsive

Shout for help

Open airway

Check
breathing

Call 155 (112)

BLS sequence

Unresponsive

Shout for help

Open airway

Check
breathing

Call 112

30 chest
compressions
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock the fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
Chest compression

 Place the heel of one hand in

the centre of the chest
 Place other hand on top
 Interlock fingers
 Compress the chest
 Rate 100 min-1
 Depth 4-5 cm
 Equal compression : relaxation
 When possible (2 or more
rescuers) change CPR
operator every 2 min. to
prevent fatigue
 Unresponsive
Chest compression
Shout for help

Open airway

Check
breathing

Call 112

30 chest
compressions

2 rescue
breaths
2 rescue breaths
• Pinch nose
• Place and seal your lips over the
victim´s mouth
• Blow until the chest rises
• Takes about 1 second
• Allow chest to fall
• Repeat (10 – 12 times per
minute)
 B) Breathing
 expired air resuscitation - several
techniques:
- Mouth-to-mouth breathing

- Mouth-to-mouth + nose breathing ( small children)

- Mouth-to the barrier device ( to protect the rescuer)
- Mouth to tracheostomy

Self-inflating bag
 CardioPulmonary Resuscitation
Artificial breath during expired air resuscitation

 Volum = normal breathing volum

 Volum = 6-7 ml/ kg bw = 500 ml
 Breath duration in adults = 1 second Expiration – passive
 Check the chest rise during rescue breath
Self-inflating bag

Capacity 1500 ml Breathing by atmospheric air

1 way valve Oxygene source - conection
Volume controlled by compression Oxygene reservoir – 100% O2
Continue CPR

30 : 2
Ratio 30 : 2

One uniform ratio

• always in adults
• in children in the prehospital CPR
• in children when the rescuer is alone
Defibrillation
Defibrillation
Automated External Defibrilators (AEDs)

A new generation of “smart“ defibrilators

 Advanced computer technologies
 Ability to interprete heart (ECG) rhythm
 Ability to determine whether defibrilation is required
 Delivery of electric shock
 Guides the operator through every action
 Provides voice and message prompts
 Legal aspects
 AEDs
Easier than CPR
 Readily available on places with haevy people concentration, where can be
probably used once during 2 years
 Extendes beyon healthcare prefessional personnel to trained citizens
Switch on AED

• AEDs will automatically

switch themselves on when the
lid is opened
Attach pads to casualty’s bare chest
Analyse rhythm – do not touch victim
Shock indicated – stand clear
Rescuer giving defibrilation shock

• is responsible for his safety

• is responsible for the safety of other
people surronding the victim
Immediately resume CPR

30 : 2
If victim starts to breathe normally place him in
recovery position
Need new
picture
A. Airway management
 „A“
• head titlted
backward
• chin lift
Jaw thrust
• suspected cervical spine injury
• experienced rescuer ( anaesthesiologist)
Lower jaw pulled forward
 A. Airway management
1. Unconscious patient – tongue
tilt the head backward + lift the chin
2. Conscious patient - foreign body airway
obstruction  choking - partial airway
blockade
encourage the victim to cough
add several hits to his/her back

Cough is much more effective than

any other manoeuvre.
Foreign body airways obstruction

Potentially treatable
Mostly during eating
Commonly witnessed event
Oportunity for early intervention
Can cause mild (partial) or severe (complete) airway obstruction
Heimlich manoeuvre (several thrusts (5))
pregnant ladies, children
Signs of mild (partial) large airways obstruction

 Suffocation
 Difficult intensive inspiration
 Neck and thorax soft tissues retraction
 Hoarse (croupy) sounds accompanying
inspiration (noisy breathing)
 Barking cough
A. Airway management
Signs of severe or complete large
airways obstruction
 Difficult intensive inspiratory effort
 Powerful breathing movements
 Neck and thorax soft tissues retraction
 No breathing phenomena hearable
 Patients non-cooperation, restlessness, convulsions, coma, blue
skin color
 C: Circulation
Diagnosis:
• Signs of functional circulation
(breathing, coughing, movement, skin condition,
responsiveness, pulse)
• Pulse-less on large ( major) arteries –
only experienced rescuers
 Compression-only CPR

 New recommendation of AHA

 Witnessed collapse of the patient
 First 10 minutes
 Contraindications:
Children
Sudden cardiac arrest due to choking
 CPR in children

Who is an infant? 0 – 1 year

Landmark between child and adult: puberta

Who is a child? 1 - puberta

 CPR in children

Differencies:
 Cause of cardiac arrest –choking, trauma
 Activation of emergency system
 Hypoxia developes faster – high metabolic rate
 Ventricular fibrillation – rare
 Primary cardiac arrest uncommon,
 Precordial thump is contraindicated
 CPR in children
A) The most often cause of vital
functions failure = choking

 Foreign body airway obstruction

 Infectious diseases afecting throat by swelling (
epiglotitis, acute suffocating LTB, croup)
 Trauma
 CPR in children
Sequence of action
 Rescuers with no knowledge of pediatric resuscitation may use the adult
sequence with the exception that they should
 start with 5 initial breaths followed by
 30 compressions
 30 : 2 for 1 minute
 than call 155 (112)
but
 Generally prefered ratio in children
= 15:2 (in-hospital CPR, 2 rescuers)
 CPR in children
“A“
 Identical with adults
 More often inflamation throat diseases with
swelling and suffocation
 Foreign bodies!!! Small toys and toys that can
be dismantled for small parts!!!
 CPR in children
“B“
 Look, listen and feel no more than 10 s
 Volum 6-7 ml /kg bw
 Blow steadily over 1 – 1.5 sec.
 To make the chest visibly rise
 Start with 5 breaths
 Paediatric size of self-inflating bag
 CPR in children

“C“
 Look for signs of circulation (movements, coughing,
skin colour, breathing…)
 Check the pulse (if you are an experienced health
provider) no more than 10 s
 Lower third of the sternum (1 finger above xiphoid
process)
 One third of the depth of the chest
 100 compressions per min.
 BLS in children
FBAO
• back blows
• chest thrusts
• abdominal compression

All manouevres   intrathoracic pressure


expulsion of FB out from the airways

50% of cases – more than 1 manouevre is

necessary
Complications during CPR

 Gastric distension –often in children

Prevention:avoid overinflating the lungs appropriate
volum making the chest rise
 Rib fractures
Prevention:
correct hand´s position
do not remove hands from the chest wall
prevent “dancing on the chest“)

 Gastric content (or other fluids) aspiration

 Conclusions
• Chest Compressions are the cornerstone of resuscitation
• Rate
• Depth
• Recoil
• Minimizing Interruptions
• Feedback is probably helpful
• In some cases chest compressions aid defibrillation
• Mechanical chest compressors have not been demonstrated to be helpful
 First aid
• It is better to know first aid and not to need it
than
to need it and not to know it.

• A delay… can mean the difference between

life and death.

However
• most injuries do not require life-saving efforts