Basic life support for red flag management in emergency conditions with patients, includes CPR management

1. Kiran P.S MPT (Cardio), M.Phil (HA-BITS)
Lecturer
Choithram Institute of Health Sciences
Department of Physiotherapy

5. D i s a s t e r S i t e
S e a r c h a n d R e s c u e
F i r s t A i d
F i e l d S u r g e r y
T r i a g e
T r a n s p o r t a t i o n
D e f i n i t i v e C a r e

6. How can I decide – “which one first”?

7. Triage

9.  Triare – (Fr.) – ‘To sort’
 Napoleon’s surgeon –
Dominique Jean Larre

10. Life-threatening
Urgent
Non-urgent
Non-salvageable
Dead

12. OBJECTIVES:
1. BASIC LIFE SUPPORT in the GOLDEN HOUR
of trauma
2. AIRWAY MANAGEMENT in the trauma victim.
3. CARDIOPULMONARY CEREBRAL
RESUSCITATION of the trauma victim

13. BLS (BASIC LIFE SUPPORT)
1. Airway (with cervical spine control)
2. Breathing
3. Circulation
ALS (ADVANCED LIFE SUPPORT)
1. Drugs
2. ECG diagnosis
3. Fibrillation therapy
PLS (PROLONGED LIFE SUPPORT)
1. Gauging
2. Human mentation (cerebral protection)
3. Intensive care

14. Combine rescue breathing and compression
After 15 compressions, tilt the head, lift the chin, and
give 2 effective breaths.
Continue compressions and breaths in a ratio of 15:2.
Continue resuscitation until:
The victim shows signs of life.
Help arrives.
You become exhausted

16. -recognition of signs of sudden cardiac arrest (SCA),
-heart attack, stroke, & foreign-body airway
obstruction (FBAO);
-cardiopulmonary resuscitation (CPR);
-defibrillation with an automated external defibrillator
(AED).

17.  4 Die of Hear t Attack / minute.(India)
 6th Hear t Attack is <40 yrs.
 Survival - hospital discharge - 5-10%
 Bystander CPR vital intervention before arrival of
EMS.
 Early resuscitation & prompt defibrillation (within
1-2 minutes) result in >60% survival.

18.  End of November 2005.
 281 resuscitation experts.
 Evaluation, review of the literature , focused
analysis of topics, & research over 36-
months.
 4 major changes

19. 1) Unresponsive & not breathing normally- Cardiac
arrest.
2) Hand on centre of chest, than to spend more
time using ‘rib margin’ method.
(Handley AJ. Teaching hand placement for chest compression - a simpler technique. Resuscitation 2002; 53:29-36.)
3) Rescue breath over 1 sec than 2 sec.
4) Compressions to ventilations 30:2 for adults.
..Lib CDsACLS Student CDcontentsVideosCompressions.mpg
19
MANDATORY CHANGES

20.  Chest compression alone- if rescuer
unable or unwilling to per form rescue
breathing.
 Non-responsiveness & Absence of
breathing
-Main sign of cardiac arrest.
 Checking carotid pulse-No need.
 Agonal gasp - + indication to star t CPR.
 ..Lib CDsRealPlayer DownloadsYouTube- Continuous Chest Compression CPR - Mayo Clinic.mp4
Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation., N
Engl JMed 2000;342:1546-1553.
Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation 1997;35:23-26.
20

21.  Occurs shor tly af ter hear t stops
-in 40% cardiac arrests
 Barely, heavy, noisy or gasping
breathing.
 A sign of cardiac arrest

22. BLS ACLS&PLS

24. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 108
30 chest compressions
2 rescue breaths

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

26. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 108
30 chest compressions
2 rescue breaths

27. Check the victim for a response
– SHAKE GENTLY & SHOUT LOUDLY
•Do not move the victim
•Get help if needed
•Ensure the safety of the rescuer & the victim
Look, listen, and feel for breathing
(up to 5-10 seconds)
...Lib CDsACLS Student CDcontentsVideosAssessment.mpg

28. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 108
30 chest compressions
2 rescue breaths

29. AIRWAY
Open airway is a must
Obstructed airway: Tongue falling back
Foreign body in mouth
Choking
Identify OBSTRUCTION by:
Strenuous noisy breathing
Use of accessory muscles
Paradoxical breathing

30. SAFAR’S MANOEUVER:
Head tilt (Caution: AVOID in cervical spine injury)
Chin lift / Jaw thrust
Open mouth
•Turn the victim onto his or her back
•Remove any visible obstruction from the victim's mouth

31. SOLID
 FINGER
SWEEP
 MAGILLS
FORCEPS
LIQUID
 POSTURAL
DRAINAGE
 LOG ROLLING
 RIGID SUCTION TIP

32. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 108
30 chest compressions
2 rescue breaths

33.  Look, listen & feel for NORMAL
breathing
 Never confuse agonal breathing with
NORMAL .

34. Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 108
30 chest compressions
2 rescue breaths

35. 2 rescue breaths are given over 1sec, each assuring the chest rises.
The two rescue breaths are followed by 30 chest compressions.
Approach safely
Check response
Shout for help
Open airway
Check breathing
Call 112
30 chest compressions
2 rescue breaths

36. This increased ratio of chest compressions to breaths is thought to
reduce hyperventilation of the patient, minimize interruptions of
compressions.

37. 37
xxx

38.  Late 1980s, external defibrillators delivered a
sinusoidal impulse -uniphasic characteristic.
 Biphasic defibrillation, alternates direction of
pulses, completing 1 cycle in 10 milliseconds.
 Biphasic defibrillation significantly ↓ the energy
level necessary for successful defibrillation.
 ↓ses risk of burns & myocardial damage.

39. DEFIBRILLATION SEQUENCE
ACTION ANNOUNCEMENTS
Switch On
Place Coupling Pads/Gels in correct Position
Apply Paddles
Check ECG/EKG Rhythm & Confirm No Pulse
Select Non Synchronised (VF) setting
Charge to required energy level "Charging"
Ensure no-one is in contact with anything
touching the patient
"Stand clear"
Press paddle buttons simultaneously "Shocking now"
Check ECG rhythm
Check for output if rhythm change "Check pulse"
Return to ALS algorithm for further steps

40.  A portable device.
 Automatically VF and VT.
 Delivers shock
 ...Lib CDsRealPlayer DownloadsYouTube- Automated External Defibrillator.mp4

41. 1 shock of 200 J, using a biphasic defibrillator.
360 J if using a Monophasic defibrillator.
(Old:-3 stacked shocks at 200, 300, & 360 J, were previously
recommended in the Advanced Cardiac Life Support (ACLS)
guidelines.)
The one shock is followed by 2 minutes of CPR.

42.  Some AEDs will automatically
switch themselves on when
the lid is opened.

45.  Stand clear
 U clear
 Me clear
 Every one Clear
 Deliver shock

46. 30 : 2

47. 30 : 2

50.  Adult CPR techniques can be used on
children.
 Compressions 1/3 of the depth of the
chest.

51. AED IN CHILDREN
• Age > 8 years
• use adult AED
• Age 1-8 years
• use paediatric pads /
settings if available
(otherwise use adult
mode)
• Age < 1 year
• use only if manufacturer
instructions indicate it is
safe

52. AIRWAYS: Oropharyngeal
Nasopharyngeal

53. LMA, LMA Fastrach, LMA Proseal
COMBITUBE

54. ENDOTRACHEAL INTUBATION:
Oral
Nasal - in cervical spine injury
(Equipments - laryngoscopes, endotracheal tubes, stylet, suction)
POSITIONING OF PATIENT:
Flexion at neck
Extension of head
Cricoid pressure
In cervical injury, INLINE IMMOBILIZATION required
On a Trauma Board.

55. Added modality:
HFJV (High Frequency Jet Ventilation)
can be used for:
TTJV (TransTracheal Jet Ventilation)

56. If above techniques FAIL:
Secure a SURGICAL AIRWAY by:
CRICOTHYROIDOTOMY or TRACHEOSTOMY

57. BREATHING
Assess : LOOK, LISTEN, FEEL
Less than 10 seconds
RESCUE BREATHING:
Expired air ventilation ( 16% O2)
(Atmospheric air - 21%)
MOUTH TO MOUTH
MOUTH TO NOSE - infants and children
MOUTH TO STOMA - tracheostomy tube
MOUTH TO MASK - pocket mask
BAG - VALVE - MASK (Ambu bag)
Assess effectiveness: chest movement, exhalation, auscultation

58. Assess the victim for signs of circulation
*Look for any movement, including swallowing or breathing
*Check if the carotid pulse is present, for 10 seconds
*If the victim starts to breathe but remains unconscious, place
him in the recovery position.
* Check the victim's condition; restart rescue breathing if
breathing stops

59. ABSENT PULSE:
Hypovolemia
Hypoxia
Tamponade
Tension Pneumothorax

60. •If there are no signs of circulation, start
CHEST COMPRESSION
•patient on firm surface
•the heel of one hand , with the other hand on top
•on the lower half of the sternum
•Position yourself vertically above the victim's chest, and with
arms straight, press down on the sternum to depress it 4 - 5
cm - FORCE FROM SHOULDER, MOVE FROM HIP
•Compression and release 50:50; repeat at about 100 times a
minute

61. 1mg dose given at least every 3
minutes during arrest.
Blocks vagal tone
completely & used once in
cases of asystole.
Indicated for symptomatic
bradycardia in a dose of
0.5mg - 1mg.
Prolonged arrests, Acidosis
become significant.
50ml of 8.4% solution) after
15 minutes arrest/ arterial pH
<7.1 / BE ≥ -10.

62.  Early in arrests caused by acidosis,
 Hyperkalaemia
 Tricyclic overdosage,
 But must not be given by the tracheal route or mixed with
calcium or adrenaline solutions.
ET drugs-Recommended
 Epinephrine, atropine sulfate, lidocaine hydrochloride,
naloxone hydrochloride,& metaraminol bitartrate.
 Endotracheal delivery of calcium salts, sodium bicarbonate,
and bretylium tosylate is not recommended.

63. PERIPHERAL IV Followed by Bolus of 20 ml IV fluid-To move to
Central Circulation.
Elevate Extremity for 10 to 20 secs
Intra osseous All ACLS drugs can be- (IO route)
ENDOTRACHEAL
Optimal Doses not established.
IV/IO preferred more reliable.- Delivery &Effect.
Diluted in H20/NS to 10 ml
Several Positive pressure Breath after Delivery.

64. Drug Therapy Indications/Precautions Adult Dosage
Atropine Sulfate (Can
be given via ET)
INDICATIONS
First line in Symptomatic Brady.
Second line after
Epinephrine/Vasopressin for
Asystole or Bardycardia
Organophosphate Poisoning
Asystole/Pulseless Electrical
activity
1mg-IV/IO Push-Repeat
every 3to 5mts (Max of 3
doses i.e, 3mg)
Bradycardia
0.5mg every 3 to 5mts
Using shorter dosing 3 mts
intervals & higher doses in
severe clinical Conditions.
ET-2 to 3 mg diluted in 10ml
water or NS.
PRECAUTIONS
• Caution in case of Myocardial
Ischemia –increase demand for
Myocardium.
•Doses of ≤0.5mg result in
paradoxical slowing of heart.

65. Drug Therapy Indications/Precautions Adult Dosage
Dopamine (IV
infusion)
INDICATIONS
Second line after atropine-in
Symptomatic Brady.
Hypotension of Systolic BP≤70-
100mmHg.
Infusion rate 2 to 20
micro/Kg /Min.
Titrate to response and Taper
slowly.
PRECAUTIONS
• Hypovolemia corrected by fluid
replacement before DOPA.
•Cardiogenic shock due to CHF.
•Can Cause Tachyarrhythmia,
Excessive Vasoconstriction.
•Never mix Soda bicarb.

66. Drug Therapy Indications/Precautions Adult Dosage
1 dose of vasopressin 40 IU IV/IO can replace the first or second dose
of epinephrine in pulseless arrest
Epinephrine (Can
be given Via ET)
CHANGE:
INDICATIONS
•Cardiac Arrest:
VF,Pulseless VT,
•Symptomatic Bradycardia:
After atropine an alternative infusion
to DOPA
•Severe Hypotension:
When Pacing & Atropine fails
When Hypotension accompanies
Bradycardia
• Anaphylaxis, Severe
allergic reactions
Combine with Corticosteroids and
Antihistamines
Cardiac Arrest
IV/IO 1mg (10ml of 1:10000
solution)administered every 3
to 5 mts during Resuscitation.
Follow 20ml flush elevate
arm for 10 -20 secs after dose
Continuous infusion:
Add 1 mg Epinephrine(1ml of
1:1000 solution)to 500ml NS
or D5.
Endotracheal Route:
2 to 2.5 mg Diiluted in
10ml NS.
PRECAUTIONS
↑ BP & HR- M Ischemia /Angina/- more
demand of VO2 .
Higher doses-not improve survival or
outcome & Lead to Postresuscitation
myocardial dysfunction.

67.  VF/VT not been studied in prospective trials.
 Some reports of harm,
 No recommendations are made for or against
(ACLS guidelines)

68. EFFECTIVE EXTERNAL CHEST
COMPRESSION
Appearance of carotid pulse
Pupillary reaction

69. OPEN CARDIAC MASSAGE
Flail chest
Cardiac Tamponade
Open chest (penetrating injury)
Chest wall deformities

71. Thank You!