Indian Society of Anaesthesiologists (ISA)

Indian Resuscitation Council (IRC)

Cardiopulmonary Resuscitation (CPR)

Guidelines 2017
 ISA
Cardiopulmonary Resuscitation Guidelines
Compression Only Life Support
(COLS)
Lay person
Basic Cardiopulmonary Life Support
(BCLS)
Trained paramedics and medics outside the hospital
Comprehensive Cardiopulmonary Life Support
(CCLS)
Trained paramedics and medics inside the hospital
 ISA
Cardiopulmonary Resuscitation (CPR) Guideline
2017

Comprehensive Cardiopulmonary
Life Support (CCLS)

By trained personnel inside the hospital

 What happens after cardiac arrest?
Following cardiac arrest,
Loss of consciousness after 10
seconds.Hypoxic brain injury starts within 4-6
minutes, irreversible within 8-10 min
CPR circulates oxygenated blood until more
advanced medical care can be provided or
spontaneous circulation returns.
An effective CPR provides one-fourth to one-
third normal blood flow and helps to maintain
cerebral perfusion pressure
Core Links in Adult CCLS
Core Links in Adult CCLS
Core Links in Adult CCLS
Core Links in Adult CCLS
Core Links in Adult CCLS
You observe a person suddenly collapsing
in front of you in hospital.
Or
Somebody is already collapsed when you
saw him/her first.
Or
A collapsed patient is brought in the
hospital.
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Tap on shoulder from

front and speak loudly
“Hello-Are you alright?
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Responsive
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds
 Assessing Pulse & Breathing
Feel for carotid pulse
• Locate thyroid prominence &
trachea (using 2 finger)
• Slide into groove between
trachea & neck muscles
(on ipsilateral side)
• Palpate for 5- 10 sec
Chant 1001, 1002, 1003,
…..1010.

Simultaneously Scan chest/abdomen

for Breathing
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse
 Rescue Breaths
The patient is in respiratory arrest. After opening
of the airway by head tilt and chin lift (only jaw
thrust or chin lift in cervical spine trauma), a normal
tidal volume breath for every 5 s (12 breaths every
minute) using bag‑mask device.
The use of oro pharyngeal or nasopharyngeal
airway if bag and mask ventilation not optimal.
 The airway may be secured using endotracheal
tube and ventilation continued using bag‑mask
device. Each breath should be delivered over 1 s.
 Reassess the patient for pulse every 2 min or
earlier for change in the vital parameters
RESCUE BREATHS
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse
 Ensure Safe place

Check Response
Tap on shoulder from front and ask loudly “Hello- Are you
alright?”

Monitor the patient

Assess the cause and Responsive
Manage
Activate Code Blue/Local Team
Get Defibrillator and Crash Cart

Check Breathing while Palpating Carotid Pulse

Perform within 5-10 seconds

Normal breathing with Definite • Reassess every 2 minutes

Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

 5 Cycles – 30 Chest Compression and 2 Breaths

30 Compressions 2 Breaths
15 Seconds approx. Each breath over 1 sec and 1
second for expiration after 1st
breath
 Chest Compression

Keep heel of hand Keep other heel of the

2 fingers above hand above the first
Xiphoid process one and interlock fingers
(Lowest End of Breast
Compress chest atleast 5 cm but not
more than 6 cm
Compress chest at speed of 120
times/min
Allow complete chest recoil between
compression without lifting hand
from the chest.
Do not stop Chest Compressions
unnecessarily.

 Chant the count loudly 1,2,3,4,

….30.

If more than one person, interchange

 Breath
 2 Breaths - Each breath over 1 sec and 1 sec pause
after 1st breath.
 Bag & mask
 Do not interrupt chest compression unnecessarily.
 End Point: Visible chest rise; normal tidal volume
breath.
If the patient’s airway is already secured
with an endotracheal tube, then chest
compressions should be given continuously at a
rate of 120 compressions/min without
interruption and 1 breath should be delivered
every 6 s (10 breaths/min), rather than cycles
of 30 chest compressions and 2 breaths.

The rescuer performing compressions must

rotate, approximately every 2 min, to ensure
high‑quality CPR.
 Airway Opening

Head tilt- chin lift

Suspected Cervical Spine fracture

NO head tilt
Jaw Thrust
Manual Spinal Motion
Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Check Carotid Pulse (5-10 seconds)

 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent
 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent
 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent
 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent
 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent

Continue the
cycles TILL
 Normal breathing with Definite • Reassess every 2 minutes
Carotid Pulse • Assess the cause and Manage

Abnormal or No breathing with • Provide 1 breath every 5 seconds using BMV

Definite Carotid pulse • Reassess every 2 minutes. Assess cause and Manage

Abnormal or No breathing without • Start Cycles of 30 Chest Compressions and 2 Breaths

Definite Carotid pulse

5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent

Continue the
cycles TILL
Defibrillator
Available
 5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent

Defibrillator Available
Attach
Analyze

• While attaching pads don’t stop •While analyzing the rhythm

don’t chest compression touch the patient

Shockable Non-Shockable
• 1 shock
• • No shock
Defibrillation: start with 120 J & escalate
• Resume CPR
to 200 J; AED: auto-selected J

5 Cycles – 30 Compression and 2 Breaths

Ensure High Quality CPR
 5 Cycles – 30 Chest Compression and 2 Breaths

Pulse Check Carotid Pulse (5-10 seconds) Pulse

Present Absent

Defibrillator Available
Attach
Analyze

• While attaching pads don’t stop •While analyzing the rhythm

don’t chest compression touch the patient

Shockable Non-Shockable
• 1 shock
• • No shock
Defibrillation: start with 120 J & escalate
• Resume CPR
to 200 J; AED: auto-selected J

5 Cycles – 30 Compression and 2 Breaths

Ensure High Quality CPR
 Arrest Rhythms

Shockable Non Shockable

• Ventricular Fibrillation • Asystole
(VF) • Pulseless electrical
• Pulseless Ventricular activity (PEA)
Tachycardia (pVT)
What is Flat line protocol?

• Is the ECG lead attached to the patient?

• Is the cable is attached to the monitor?
• Is the gain (size) setting optimised?
• Is the lead selection proper?
• Can it be fine VF?
• Rule out all these before labeling the condition as
‘ASYSTOLE’
 Routes of Access for drugs
• Intravenous (iv) route
• Give drug – bolus or as specified
• 20 mL bolus of iv fluid
• Elevate extremity for 10-20 sec
• Intraosseous (IO) route - proximal tibia
• Endotracheal route (ET) route
• Drug dose – 2-2½ times the iv dose.
• Dilute in 5-10 mL NS
• NAVEL –
– Naloxone, Atropine, Epinephrine, Lidocaine
 Drugs
Adrenaline (epinephrine)
• 1 mg diluted in10 mL should be administered as
boluses iresspective of the type of heart
rhythm.
• Needs to be repeated every 3-5 minutes.
• Administer while ongoing chest compression
Adults: 1mg every 3-5 min
Paediatric
IV and IO- Dose :0.01 mg/kg [ 0.1
ml/kg of 1: 10 Max dose: 1mg
ETT – Dose: 0.1 mg/kg [ 0.1 mg/kg
of 1:1000] Max dose: 2.5mg
 Atropine:
Removed from ACLS algorithm

Indicated only in sinus bradycardia

Dose: 1mg IV/IO every 3-5 minutes

Max dose: 3 mg
Antiarrhythmics:
 If after initial 2-3 sets of 5 cycles of CPR, the
arrhythmias persist, then antiarrhytmics drugs are
warranted.

For refractory arrhythmias, Amiodarone 300 mg is

administered as intravenous slow bolus.

The second dose of 150 mg of amiodarone is

repeated if arrthymias persists. 24 hr infusion : First 6
hrs – 1mg/kg/hr Next 18 hrs – 0.5 mg/kg/hr

 Lidocaine ( 1 – 1.5mg/kg) may be considered as an

alternate drug in patient with persistent
arrhythmias.
 Remember !!!

CPR is not a definitive treatment for

cardiac arrest but rather a means of
maintaining respiration and circulation until
the underlying pathology can be corrected.
Treat Reversible causes
Assess Action
DIFFERENTIAL
DIAGNOSIS • Search, find, treat
• Why did this patient reversible causes
develop symptoms
or arrest?
• Is there a reversible
cause that can be
treated?
 Reversible Causes
"HIT THE TARGET“
H Hypoxia
Increased H Ions (Acidosis)
I Tension Pneumothorax

T Toxins / Poisons
Hypovolemia
H Electrolyte
Imbalance
E
T (Hypo-/Hyperka
Tamponade Cardiac
lemia)
Acute Coronary Syndrome (MI)
A Raised Intracranial Pressure (Subarachnoid Hemorrhage)
Glucose (Hypo- / hyperglycemia)
R Embolism (Pulmonary Thrombosis)
Temperature (Hypothermia)
 Treat Reversible causes
• History, physical examination and medical record
needs to be reviewed
• Review from patient attendants
• Based on the findings, the suitable investigations
needs to be sent.

However it needs to be remembered, that during this

process, the chest compression and other aspects of
resuscitation must not be interrupted.
 POST RESUSCITATION CARE
Once there is ROSC, patient requires specific
care in a dedicated unit. During this period,
correction of precipitating cause of cardiac
arrest needs to be evaluated.

Ventilatory support may be continued to

maintain normocarbia (end‑tidal CO2 35–40
mmHg).

During resuscitation, highest oxygen

concentration is recommended but after return of
circulation, FiO2 should be titrated to maintain
oxygen saturation at 95% or more.
Mean arterial pressure should be maintained
above 65mm Hg.

If patient remains comatose after

resuscitation, active warming must be avoided.

Temperature may be kept not >36ºC and not

necessarily in the range of 32ºC–36ºC, in the
absence of controlled hypothermic equipment.

Prophylactic antiepileptic drugs are not

recommended but, if seizures occur, then drug
therapy should be initiated.
 Quality assurance of CPR
• The high quality CCLS and just not the steps of CCLS is
paramount for an optimal outcome after a cardio-
respiratory arrest.
• The emphasis on continued quality check is essential.
The various aspects that would enhance the outcome
include:
• Chest Compressions
– Chest compressions speed, rate and recoil: Ensure a
chest compression speed of 120 compression/minute to
a depth of 5-6 cm. Allow complete chest recoil between
compression (do not lean) without lifting hand from the
chest.
– Do not stop Chest Compressions unnecessarily.
• Ventilation and Airway
– Do not unnecessarily interrupt chest compression for
securing the airway.
– Do not hyperventilate.
– End Point for ventilation is visible chest rise; normal
tidal volume breath.
• Monitor end-tidal capnography. If it is less than 10 mmHg,
then the quality of chest compression is inadequate and
needs further improvement.
• If intra-arterial pressure is monitoring is available or
feasible, then relaxation phase pressure (diastolic) <20
mmHg indicates inadequate chest compression and needs
further improvement
COMPRESSION ONLY LIFE SUPPORT
(COLS) IN “CANNOT INTUBATE, CAANOT
OXYGENATE”
Cannot ventilate, cannot intubate’ situations
are difficult to manage and it is best to
administer high flow oxygen through a face
mask and continue with ‘compression‑only life
support’ (COLS) till experienced rescuers
arrive.
Patient revived
Post
with signs of
Resuscitati
circulation
on Care
How LONG TO CONTINUE CPR?
• Till EMS arrives with AED
• Another trained rescuer arrives
• Victim is revived (obvious signs of
life)
• Rescuer is exhausted
• Scene becomes unsafe

When NOT TO START CPR?

• Scene is not safe
• Patient breathing normally
• Obvious clinical signs of irreversible death
(rigor mortis, decapitation, dependent lividity)
• Valid signed DNR order
 Team dynamics

Effective Resuscitation: Good Team Work

Work as a team

Skills + Communication

Team Leader and Team Members

 Airway manager
Ventilation

Venous access Chest

Medications Compressor

Monitor
Recorder Defibrillator

Team Leader
 Core Concepts of Team Dynamics

 Speific Task Assignments with understanding team

members strength and weaknesses
 Avoid cross talk and follow Closed-Loop
Communication
 Clear and Directed Delegation of
Messages
 Constructive inputs

 Mutual Respect for Team members

 Debriefing
Questions and Feedback Please !!!
Thank You
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