EMERGENCY CARDIAC

CARE (E.C.C.)

Basic Life Support (B.L.S.)

and Advanced Cardiac Life
Support (A.C.L.S.) are all
part of a spectrum of
Emergency Cardiac Care
(E.C.C.)
Basic Life Support
1. Improves survival following cardiac
arrest through quick:

· Recognition
· Intervention

2. Supports circulation and respiration

when arrest has already occurred
Advanced Cardiac Life
Support
A.C.L.S. is BLS + use of
drugs/equipment to:

1. Support airway/ventilation
2. Establish intravenous access
3. Give drugs
4. Monitor
5. Control arrhythmias
Chain of Survival
 5 critical interventions
 Not done or delayed => death
 Called the “Chain or Survival”
B.L.
S

RESCUSCITATION DEFIBRILLATION
ACCESS
ADVANCED CARE
A.C.L.S

MULTIDISCIPLINARY
POST-ARREST CARE
 Chain of Survival
1. Early Access
– Recognition of collapse, unresponsiveness,
arrested state
– Rapid arrival of help
2. Early Cardiopulmonary
Resuscitation
– The nearer to time of collapse
resuscitation begins, the more effective
3. Early Defibrillation
– Automated External Defibrillator
4. Early advanced care
– Access to drugs and trained medical staff
5. Integrated Post-arrest care
– Access to multidisciplinary intensive care,
coronary reperfusion facilities etc
 ADULT BLS

0 min
4 min 4min – brain
6 min
damage
10
min begins

4 – 6 min –
brain
damage
likely
Time is of essence

6min – brain
damage
Unstable Patient

Adverse Signs

 Pallor
 Sweating
 Cold, clammy extremities
 Impaired consciousness
 Hypotension (Sys <90)
 Chest pain
 Unstable Patient

1st steps

1. Oxygen
2. I.V. access
3. 12 lead E.C.G. (if possible)
4. Electrolytes - Correct
Brady arrhythmias
 HR < 60
 Absolute bradycardia HR < 40
 Unstable?
– Sys BP < 90 mmHg
– HR < 40
– Ventricular arrhythmias
– CCF
 Sequence for Brady
arrhythmias
YES Presence
of adverse NO
signs
Atropine
0.5mg

YES
Responds?
Risk of
NO YES asystole?
• Repeat • Mobitz II NO
atropine up to • 30 Block Observe
max 3mg • Ventricular
• Adrenaline 2 – pause >
*Other Drugs
10mcg/min 3s • Glycopyrrola
• Other drugs* te
OR • Isoprenaline
• Transcutaneo • Dopamine
Transvenou • Aminophylli
us pacing s pacing ne
• Glucagon
 Tachyarrhythmias (with pulse)
• ABCs
UNSTABLE
Synchronised Shock (x3) • O2
• i.v. line
• Monitors
• 12 lead ECG
• Amiodarone
300mg &repeat
shock STABLE
• Amiodarone
Narrow QRS
900mg/24hrs Broad QRS IRREGULAR
REGULAR
• Vagal Irregular
maneuvres Narrow
IRREGULAR REGULAR • Adenosine 6mg Complex Tachy
rapid push, • B-blocker
• ?VT - then 12mg, • Amiodarone
• AF with BBB then 12 mg 300mg then
Amiodaron
(Rx as 900mg/24hrs
e 300mg
Narrow QRS)
• AF (consider then Normal SR
900mg/24h
amiodarone) YES
• Polymorphic rs
• SVT with ?Re-entry PSVT NO
VT (MgSO4 • 12 lead ECG
BBB -
2g over • Repeat ?atrial Flutter
Adenosine
10mts (control rate e.g.
Adenosine
• Give anti- B-blocker
arrythmic
prophylaxis
 C.P.R.

Definition:
 A series of actions performed on a

victim of cardiac arrest that

improve the chances of survival
 C.P.R.
 1st published use of chest
compressions 1960 – 14 survivors
JAMA 1960; 173:1064-67
 1st use of defibrillator – 1962
 1st published CPR guidelines -
1966
 C.P.R. Today
MAIN EMPHASIS
 High quality Chest Compressions
– Adequate rate and depth
– Complete recoil of chest wall
– Minimal interruptions

 Avoid excessive ventilation

Goal of Resuscitation
 Return of victim to pre-arrest
quality of life

 Return to pre-arrest state of

health
 Post Arrest
 Organized post-arrest care
 Optimize:
– Haemodynamics
– Neurological function
– Metabolic function
– Provide e.g. therapeutic
hypothermia
– Other
 A.B.C. to C.A.B.
Reasons :
1. Most survivors
1. VF & pulseless VT
2. Witnessed arrest
2. Delay of chest compressions
associated with reduced survival
3. Airway control required greater
level of ‘competence’ –
associated with delay
 Sequence of Basic Life
Support
1. Immediate recognition of arrest
and activation of emergency
response system
– Unresponsive
– Not breathing or gasping
2. Early quality CPR
– Immediate onset with minimal
interruptions of chest compressions
– Limit pulse checks 10sec
3. Early defibrillation for VF and
pulseless VT
 Post Cardiac arrest
Care
 Cardiopulmonary function –
Perfusion to vital organs
 Transport to appropriate level of
care
 Identify and intervene for Acute
Coronary Syndrome
 Temperature control –
neurological function
 Prevent and treat MODS
Cerebral Injury
 Effects of cerebral ischaemia
– Failure of ion/energy pumps at
cellular level
– Release of free radicals
– Reperfusion injury -> Release of
inflammatory mediators:
 Leucotriene B
 Arachidonic acid
 Heat-shock protein

 Cooling blunts cerebral ischaemic

injury
Cerebral Protection
 Cooling – blunts cerebral
ischaemic injury

 Normoglycaemia

 Avoid hyperoxia
Specific actions –
Immediate Recognition
 Unresponsive
 Not breathing
 Gasping
 No definite pulse palpated in 10
seconds
N.B. Look, listen and feel no longer
emphasized
Specific actions – Early
CPR: Chest
Compression
 Rate – 100/min
 Depth – 5cm
 Complete chest wall recoil in-
between
 Rotate person compressing every
2mts
 Minimal interruptions – maximum
10 seconds
Specific actions – Early
CPR: Airway
 Head tilt/chin lift
 Jaw thrust – cervical spine injury
 If untrained in airway control –
‘Hands Only’ CPR
 Airway more important in
asphyxial causes of arrest e.g.
drowning
Specific actions – Early
CPR: Breathing
 Ratio of compression:ventilation
30 : 2
 After advanced airway:
– Independent compressions 100/min
– Independent ventilation 10/min
Specific actions – Early
Defibrillation
 Once arrest recognized, collect
AED/Defibrillator or send helper
 Defibrillation should not interrupt
chest compressions for more than
10seconds
 Defibrillation more effective with
quality chest compressions
 Defibrillation the key intervention
for VF and pulseless VT
 Types of Cardiac Arrest

 Cardiac arrest associated with 2

groups of arrhythmias:

1. Shockable
 VF
 VT

2. Non-shockable
 Asystole
 PEA
Ventricular Fibrillation

Rapid, bizarre, “saw tooth” appearance

Fine ventricular
fibrillation
Ventricular
tachycardia

Wide, monomorphic, QRS complexes

Asystole
Pulseless Electrical
Activity (PEA)
 Shockable Rhythms
(VF/VT)

 For a patient coming in with

unwitnessed arrest, CPR for
2min, then defibrillation
 For in-hospital or witnessed
arrest, immediate defibrillation
Sequence for shockable rhythms

 Attempt defibrillation
– One shock
– CPR x 2min
– Check rhythm (<10sec)

 VF/VT persists
– 2nd shock
– CPR x 2min
– Check rhythm
Sequence for shockable rhythms

 VF/VT persists
– Adrenaline 1mg
– 3rd shock
– CPR x2min
– Check rhythm

 VF/VT persists
– Amiodarone 300mg
– 4th shock
– CPR x2min
– Check rhythm
Sequence for shockable rhythms

 VF/VT persists
– Adrenaline 1mg
– Shock
– CPR x2min
– Check rhythm

 Repeat sequence of Shock, CPR,

rhythm check. Give Adrenaline 1mg
after every alternate shock/CPR
sequence
Sequence for shockable rhythms

 If organised electrical activity seen

during rhythm check, feel for pulse

– Pulse present, post-resuscitation care

– Pulse absent, resuscitate as for non-
shockable rhythm

 If Asystole, continue resuscitation as

for non-shockable rhythm
 Non-shockable
Rhythms
(Asystole/PEA)
PEA
 CPR 30:2
 Adrenaline 1mg as soon as i.v. access
achieved
 CPR 30:2 until airway secured
 Once airway secured
– Chest compressions are continuous
– Ventilation given independently at 10
breaths per min
Sequence for Non-shockable
rhythms
 Recheck rhythm after 2 min
 If no change
– Continue CPR
– Recheck rhythm ever 2 min
– Give adrenaline 1mg iv every 3 – 5 min
 If organised activity seen on ECG,
check pulse
 Pulse
– Post resuscitation care
 No pulse
– Continue CPR, rhythm check, adrenaline
cycle
Sequence for Non-shockable
rhythms

Asystole & slow PEA (<60/min)

 CPR 30:2
 Adrenaline 1mg as soon as i.v. access
achieved
 Atropine 3mg stat
 CPR 30:2 until airway secured
 Once airway secured
– Chest compressions are continuous
– Ventilation given independently at 10
breaths per min
Sequence for Non-shockable
rhythms

 If no change
– Continue CPR
– Recheck rhythm ever 2 min
– Give adrenaline 1mg iv every 3 – 5
min
 If organised activity seen on ECG,
check pulse
 If VF/VT occurs, change to
shockable rhythm sequence
Preventable causes of arrest (4Hs &
4Ts)

The 4Hs
 Hypoxia
 Hypovolaemia
 Hyperkalaemia, hypokalaemia,
hypocalcaemia, acidaemia, other
metabolic disorders
 Hypothermia
Preventable causes of arrest (4Hs &
4Ts)

The 4Ts

 Tension pneumothorax
 Tamponade
 Toxic substances

 Thromboembolism (PE/MI)
CHEST COMPRESSIONS

Patient position

 Patient in horizontal supine

position
 Head should not be higher than
the heart
 Firm backboard of surface
Technique
 Heel of one hand on lower ½ of sternum

 Hands parallel

 Long axis of rescuer’s hand placed on long axis Of

sternum to keep force of compression on the sternum

 Fingers off chest either extended or interlocked

 Elbows straight

 Shoulders positioned directly over hands. Compression

straight down on the sternum.

 Depress sternum at least 5 - 6 cm

 80 – 100/min
IN-HOSPITAL Unresponsive, no
RESUSCITATION breathing or gasping
ALGORITHM
CALL FOR HELP & GET
RESUSCITATION
TROLLEY
NO YES
ASSESS PT FOR
SIGNS OF LIFE –
check pulse max 10
ACTIVATE seconds ASSESS
ICU/RESUS TEAM · RECOGNI
SE &
TREAT
CPR - CAB PROBLEM
· O2
BEGIN CYCLES 30:2
· VENTILAT
ION
· i.v.
APPLY RE-CHECK
MONITORS/DEFIBRILLATOR ACCESS
PULSE EVERY
PADS & CHECK RHYTHM 2mts
TRANSFER TO
Shockable HIGHER LEVEL
Non-shockable
OF CARE

1 SHOCK CPR 2mts

Resume CPR CHECK RHYTHM
IMMEDIATELY
?