CardioPulmo

nar
Resucitation
Departement of Internal
Medicine
Faculty of Medicine
Muhammadiyah University
Yogyakarta

HISTORICAL REVIEW
5000 first artificial mouth to mouth
3000 BC ventilation
1780
first attempt of newborn
resuscitation by blowing
1874
first experimental direct cardiac
massage
1901
first successful direct cardiac massage
in man
1946
first experimental indirect cardiac
massage and defibrillation
1960
indirect cardiac massage
1980

development of cardiopulmonary
resuscitation due to the works of Peter
Safar
2

all cases accompanied

with hypoxia

extracardiac

Causes of cardiac
arrest
cardiac
Primary lesion of cardiac muscle leading to the
progressive decline of contractility, conductivity
disorders, mechanical factors

Causes of circulation
arrest
Cardiac
Ischemic heart disease
(myocardial infarction,
stenocardia)
Arrhythmias of different
origin and character
Electrolytic disorders
Valvular disease
Cardiac tamponade
Pulmonary artery
thromboembolism
Ruptured aneurysm of
aorta

Extracardiac
airway obstruction
acute respiratory failure
shock
reflector cardiac arrest
embolisms of different
origin
drug overdose
electrocution
poisoning
4

arrest
Blood pressure measurement

Taking the pulse on peripheral arteries

Auscultation of cardiac tones

Loss of time !!!

Symptoms of cardiac
absence
of pulse on carotid arteries a
arrest
pathognomonic symptom

respiration arrest may be in 30 seconds after cardiac

arrest
enlargement of pupils may be in 90 seconds after
5
cardiac arrest

Simple BLS

Emphasis on High-Quality CPR

2005 Guidelines
blood flow is optimized by using the recommended chest
compression force and duration and maintaining a chest
compression rate of approximately 100 compressions per
minute. These guidelines recommend that all rescuers minimize
interruption of chest compressions CPR instruction should
emphasize the importance of allowing complete chest recoil
between compressions.
(Circulation. 2005; 112: IV19-IV34)

Emphasis on High-Quality CPR

2010 Guidelines
To provide effective chest compressions,
push hard and push fast. compress the
adult chest at a rate of at least 100
compressions per minute with a
compression depth of at least 2
inches/5 cm. allow complete recoil of
the chest after each compression, to allow
the heart to fill completely before the next
compression. minimize the frequency
and duration of interruptions in
compressions to maximize the number of
compressions delivered per minute.
(Berg, et al. Circulation. 2010;122;S685S705)

Highlights
This is a re-emphasis from 2005.
For effective compressions:

Push fast
Push hard
Allow chest to fully recoil
Minimize any interruptions

Applies to both lay and healthcare

providers.

Rationale For Change

High-quality chest compressions within
CPR continues to be a critical focal point.
Well-performed compressions increase the
likelihood of survival.

Compression Hand Position

2005 Guidelines
The rescuer should compress the lower half of the victims
sternum in the center (middle) of the chest, between the nipples.
The rescuer should place the heel of the hand on the sternum in
the center (middle) of the chest between the nipples and then
place the heel of the second hand on top of the first so that the
hands are overlapped and parallel.
(Circulation. 2005; 112: IV19-IV34)

Compression Hand Position

2010 Guidelines
The rescuer should place the heel of one
hand on the center (middle) of the
victims chest (which is the lower half of
the sternum) and the heel of the other
hand on top of the first so that
the hands are overlapped and parallel.
(Berg, et al. Circulation. 2010;122;S685S705)

Highlights

Hands in center of the chest.

Lower half of breastbone
Second hand on top of the first.
Not on lowest part of breastbone.
Applies to both lay and healthcare
providers.

Rationale For Change

Use of the nipple line as a landmark
for hand placement was found to be
unreliable.

Compression Rate
2005 Guidelines
There is insufficient evidence from human studies to identify a
single optimal chest compression rate. Animal and human
studies support a chest compression rate of >80 compressions
per minute to achieve optimal forward blood flow during CPR. We
recommend a compression rate of about 100 compressions per
minute.
(Circulation. 2005; 112: IV19-IV34)

Compression Rate
2010 Guidelines
It is reasonable for laypersons and
healthcare providers to compress the
adult chest at a rate of at least 100
compressions per minute with a
compression depth of at least 2 inches
(5 cm.)
(Berg, et al. Circulation. 2010;122;S685S705)

Highlights
At least 100 times per minute.
It is okay to be a little faster.
Applies to both lay and healthcare
providers.

Rationale For Change

It has been found that higher survival
rates are associated with an increase in
the number of compressions provided per
minute.

Child/Infant Compression
Rate
2005 Guidelines
Push fast; push at a rate of approximately 100 compressions
per minute.
(Circulation. 2005; 112: IV156-IV166)

Child/Infant Compression
Rate
2010 Guidelines
Push fast; push at a rate of at least 100
compressions per minute.
(Berg, et al. Circulation. 2010;122;S862S875)

Highlights
Rescuers tend to compress slower.
At least 100 compressions per
minute.
It is okay to be a little faster.
Applies to both lay and healthcare
providers.

Rationale For Change

It has been found that higher survival
rates are associated with an increase in
the number of compressions provided per
minute.

Compression Depth
2005 Guidelines
Depress the sternum approximately 1 to 2 inches
(approximately 4 to 5 cm) and then allow the chest to return to
its normal position.
(Circulation. 2005; 112: IV19-IV34)

Compression Depth
2010 Guidelines
It is reasonable for laypersons and
healthcare
providers to compress the adult chest at a
rate of at least 100 compressions per
minute with a compression depth of at
least 2 inches/5 cm.
(Berg, et al. Circulation. 2010;122;S685S705)

Highlights
At least 2 inches on an adult.
It is okay to compress a little deeper.
Not enough information to define upper
limit.
Applies to both lay and healthcare
providers.

Rationale For Change

Research indicates the tendency for CPR
providers to not compress deep enough,
even with the emphasis to "push hard."

Child/Infant Compression
Depth
2005 Guidelines
Push hard: push with sufficient force to depress the chest
approximately one third to one half the anterior-posterior
diameter of the chest.
(Circulation. 2005; 112: IV156-IV166)

Child/Infant Compression
Depth
2010 Guidelines
Chest compressions of appropriate rate
and depth. Push fast: push at a rate of at
least 100 compressions per minute. Push
hard: push with sufficient force to
depress at least one third the
anterior-posterior (AP) diameter of
the chest or approximately 1
inches (4 cm) in infants and 2 inches
(5 cm) in children.
(Berg, et al. Circulation. 2010;122;S862S875)

Highlights
At least 1/3 of the anterior/posterior
diameter of chest.
About 2 inches for children and about 1
inches for infants.
It is okay to compress a little deeper
Applies to both lay and healthcare
providers.

Rationale For Change

Research indicates the tendency for CPR
providers to not compress deep enough,
even with the emphasis to "push hard."

Breathing Assessment
2005 Guidelines
While maintaining an open airway, look, listen, and feel for
breathing.
(Circulation. 2005; 112: IV19-IV34)

Breathing Assessment
2010 Guidelines
After activation of the emergency response system, all rescuers
should immediately begin CPR for adult victims who are
unresponsive with no breathing or no normal breathing (only
gasping).
(Berg, et al. Circulation. 2010;122;S685-S705)

Highlights
No more look, listen, and feel.
Quick look for no breathing or no normal
breathing.
Agonal breaths remain a concern.
Applies to both lay and healthcare
providers.

Rationale for Change

Simplifying the breathing assessment is
intended to help laypersons respond more
quickly with chest compressions and CPR.
There is a high likelihood of agonal, or
irregular, gasping breaths to occur early in
cardiac arrest and confuse rescuers.

CPR Sequence - Lay

2005 Guidelines
For an unresponsive person who is not breathing or not breathing
normally, begin CPR by opening the airway and giving 2 rescue
breaths followed with 30 chest compressions. Repeat cycles of
30:2 (ABC method).
(Summary from Circulation. 2005; 112: IV19-IV34)

CPR Sequence - Lay

2010 Guidelines
For an unresponsive person, activate EMS,
then assess breathing. If the person is not
breathing or not breathing normally, begin
CPR with 30 compressions followed by
opening the airway and giving 2 rescue
breaths. Repeat cycles of 30:2 (CAB
method).
(Summary from Berg, et al. Circulation.
2010;122;S685-S705)

Highlights
Initial assessment steps:

Assess responsiveness
Activate EMS
Assess breathing
Perform CPR

CAB begin CPR cycles with compressions,

followed by airway and breathing.
Guideline applies to adults, children, and
infants.

Rationale For Change

The science indicates the importance of
not delaying chest compressions to
perform rescue breaths.
Early chest compression can immediately
circulate oxygen that is still in the
bloodstream.

CPR Sequence - HCP

2005 Guidelines
For an unresponsive person who is not
breathing or not breathing normally, begin
CPR by opening the airway and giving 2
rescue breaths followed with 30 chest
compressions. Repeat cycles of 30:2 (ABC
method).
(Summary from Circulation. 2005; 112:
IV19-IV34)

CPR Sequence - HCP

2010 Guidelines
For an unresponsive person who is not
breathing or not breathing normally, and
has no obvious pulse, activate EMS and
begin CPR with 30 compressions followed
by opening the airway and giving 2 rescue
breaths. Repeat cycles of 30:2 (CAB
method).
(Summary from Berg, et al. Circulation.
2010;122;S685-S705)

Highlights
Initial assessment approach:

Assess responsiveness and breathing

Activate EMS
Assess pulse
Perform CPR

CAB begin CPR cycles with compressions,

followed by airway and breathing.

Rationale For Change

The science indicates the importance of
not delaying chest compressions to
perform rescue breaths.
Early chest compression can immediately
circulate oxygen that is still in the
bloodstream.

Use of an AED on an Infant

2005 Guidelines
There is insufficient data to make a
recommendation for or against the use of
AEDs for infants 1 year of age.
(Circulation. 2005; 112: IV156-IV166)

Use of an AED on an Infant

2010 Guidelines
Many AEDs have high specificity in
recognizing pediatric shockable rhythms,
and some are equipped to decrease (or
attenuate) the delivered energy to make
them suitable for infants and children < 8
years of age. For infants an AED
equipped with a pediatric attenuator is
preferred for infants. If neither is
available, an AED without a dose
attenuator may be used.
(Link, et al. Circulation. 2010;122;S706S719)

Highlights

Success at defibrillating infants.

Use attenuator to reduce shock.
Okay to use AED set for adult.
Applies to both lay and healthcare
providers.

Rationale For Change

AEDs designed to be used on adults have
been successful when used on infants with
out-of-hospital cardiac arrest.
Minimal heart muscle damage and good
neurological outcomes were reported.

Chain of Survival
2005 Guidelines
Early recognition of the emergency and
activation of the emergency medical
services (EMS) or local emergency
response system
Early bystander CPR
Early delivery of a shock with a
defibrillator
Early advanced life support followed by
post resuscitation care delivered by
healthcare providers
(Circulation. 2005; 112: IV12-IV18)

Chain of Survival
2010 Guidelines
These actions are termed the links in the
Chain of Survival. For adults they include:
Immediate recognition of cardiac arrest
and activation of the emergency response
system
Early CPR that emphasizes chest
compressions
Rapid defibrillation if indicated
Effective advanced life support
Integrated post cardiac arrest
care.
(Travers, et al. Circulation. 2010;122;S676S684)

Highlights
Addition of fifth link in chain.
Integrated post-cardiac arrest care.

Applies to both lay and healthcare

providers.

Rationale For Change

Links in the Chain of Survival
indicate the individual actions that
must be strong in order for a person to
survive a sudden cardiac arrest.
The addition of the fifth link, integrated
post-cardiac arrest care, further
emphasizes the additional dependence
on longer-term care for long-term
survival.

Cricoid Pressure - HCP

2005 Guidelines
Cricoid pressure should be used only if
the victim is deeply unconscious.
(Circulation. 2005; 112: IV19-IV34)

Cricoid Pressure - HCP

2010 Guidelines
The routine use of cricoid pressure in adult
cardiac arrest is not recommended.
(Berg, et al. Circulation. 2010;122;S685S705)

Highlights

Cricoid may impede ventilation.

Difficult to teach.
May prevent advanced airway placement.
Aspiration may still occur.

Rationale For Change

Regardless of expertise, rescuers cannot
effectively apply cricoid pressure.

Team Approach - HCP

2005 Guidelines
When multiple rescuers are present, they should rotate the
compressor role about every 2 minutes. The switch should be
accomplished as quickly as possible (ideally in less than 5
seconds) to minimize interruptions in chest compressions.
(Circulation. 2005;112:IV-12-IV-17)

Team Approach - HCP

2010 Guidelines
The intent of the algorithm is to present the steps of BLS in a logical
and concise manner that is easy for all types of rescuers to learn,
remember and perform. These actions have traditionally been
presented as a sequence of distinct steps to help a single rescuer
prioritize actions. However, many workplaces and most EMS and inhospital resuscitations involve teams of providers who should
perform several actions simultaneously (e.g.: one rescuer activates
the emergency response system while another begins chest
compressions, and a third either provides ventilations or retrieves
the bag-mask for rescue breathing, and a fourth retrieves and sets
up a defibrillator).
(Berg, et al. Circulation. 2010;122;S685-S705)

Highlights
Tasks can be performed
simultaneously.
Integrate additional rescuers as they
arrive.
Designate team leader with multiple
rescuers.

Rationale For Change

Some resuscitations start with a lone
rescuer and builds to more, whereas other
resuscitations begin with several willing
rescuers.
Training should focus on building a team
and performing tasks simultaneously.