PHILIPPINE HEART ASSOCIATION

Council on CardioPulmonary Resuscitation

Adult Basic Life Support

for Healthcare Worker

A Full Member of the

The Asian Representative of

 2010
50th Anniversary of CPR
• 1960 – Kouwenhoven, Knickerbocker and Jude
– 14 patients – closed chest cardiac massage
“a method of external transthoracic cardiac massage has
been developed. Immediate resuscitative measures can
now be initiated to give adequate cardiac massage
without thoracotomy. The use of this technique has given
an over-all permanent survival rate of 70%. Anyone,
anywhere, can now initiate cardiac resuscitative
procedures. All that is needed are two hands. “

JAMA 1960; 173: 1064-1067

 ILCOR AHA CPR Guidelines

1990s- international collaboration

1993- ILCOR

1999- 1st ILCOR resuscitation

consensus conference

2000-2007: significant growth in

scientific collaboration and training
worldwide
2010 ILCOR AHA CPR Guidelines: Highlights
Sudden Cardiac Arrest – A Health Burden

• Approximately 50% of deaths from

cardiovascular disease occur as SUDDEN
CARDIAC ARREST.

 Sudden Cardiac Arrest is the most common

mode of death in patients with coronary artery
disease.
Health Burden of Sudden Cardiac Arrest

• Almost 80 percent of out-of-hospital cardiac

arrests occur at home and are witnessed by a
family member.

• Only 4-6 % of sudden cardiac arrest victims

survive because majority of those witnessing
the arrest do not know how to perform CPR .

American Heart Association

 Sudden Cardiac Arrest – A Health
Burden
• Of those who survive to hospital
admission or are revived:
– Great number succumb to the post-cardiac
arrest syndrome
– Majority remain in vegetative state and do
not wake up to functional neurologic
outcome
–  severe neurologic injury due to cardiac
arrest
 Sudden Cardiac Arrest

• Unpredictable and can happen to anyone,

anywhere, at anytime

• Risk increases with age

• Pre-existing heart disease is a common

cause

• May strike people with no history of cardiac

disease or cardiac symptoms
Effective CPR done
immediately after
cardiac arrest
can double a
victim’s chance
of survival.
If sudden cardiac death occurs outside the
hospital setting, cardiopulmonary
resuscitation (CPR) must begin within 4
to 6 minutes and advanced life support
measures must begin within 8 minutes,
to avoid brain death.
 Early CPR

• High quality early CPR – cornerstone

of care that can optimize outcome

• Each minute after SCA without CPR

(til defibrillation)
– Survival from VF decreases 7-10%
– With bystander CPR – Decrease in
survival 3-4%
Larsen et al. Ann Emerg Med 1993; 22
 The NEW Chain of Survival

• Early access: immediate recognition and activation

•Early CPR
•Early defibrillation
•Early advanced care
•Integrated post-cardiac
arrest care
The First Link- Early Access

 A well-informed person - key in

the early access link.

 Recognition of signs of heart

attack and respiratory failure

 Call for help immediately if

needed

 Activate the Emergency

Medical System
EARLY WARNING SIGNS OF
HEART ATTACK

 prolonged compressing
pain or unusual discomfort
in the center of the chest

 may radiate to shoulder,

arm, neck or jaw, usually
on the left side

 may be accompanied by
sweating, nausea, vomiting
and shortness of breath
 EARLY WARNING SIGNS OF
RESPIRATORY FAILURE
 unable to speak,
breath or cough
 clutches neck
(universal distress
signal)
 bluish color of skin
and lips
Second Link - Early CPR

 Life saving technique for

cardiac & respiratory arrest

Chest compressions +/-

Rescue breathing

 Lay persons and medical

personnel
 Why is early CPR important?

 CPR is the best treatment for cardiac arrest

until the arrival of ACLS care.
 Most common heart rhythm in cardiac arrest is
Ventricular Fibrillation (VF).
 CPR prevents VF from deteriorating to
asystole.
 CPR may increase the chance of defibrillation.
 It significantly improves survival.
“Ventricular Fibrillation”

• heart beats chaotically at 400 to 500 beats

per minute
• normal rhythmic contractions stop
• inability of the heart to pump blood and
oxygen to the rest of the body
• within seconds, brain depleted of oxygen
• person loses his/her pulse, then loses
consciousness
• if not treated immediately, the heart
ultimately stops beating, and the person
almost always dies
 How does CPR work?
Brain
(Cerebral)
All the living cells of our
body need a steady During CPR, you can breathe air into the
supply of oxygen to victim’s lungs to provide oxygen into the
keep us alive. blood.
When you press on the chest, you move
oxygen - carrying blood through the body.

Lungs Heart
(Pulmonary) (Cardiac)
When will you do CPR?

AS SOON AS POSSIBLE!

Brain cells begin to die after 4-6

minutes without oxygen.
 Who may learn about CPR?
• CPR is an easy and life saving procedure and
can be learned by anyone.

• One does not need to be a doctor to learn how

to do CPR.
THE TECHNIQUE AND STEPS IN CPR

IF YOU WITNESS A
CARDIAC ARREST
CHECK AREA Survey the scene.
See if the scene is safe to do CPR.
SAFETY. Get an idea of what happened.

CHECK UNRESPONSIVENESS.
Tap or gently shake the victim
Rescuer shouts “Are you OK?”
Quick check for normal breathing
If the victim is unconscious, rescuer
calls for help.

Rescuer ACTIVATES the

CALL FOR HELP: EMERGENCY MEDICAL
Ambulance, SERVICES.
Emergency Services, Get AED/Defibrillator!
Doctor
 NON-RESPONSIVE,
NO NORMAL BREATHING
PULSE CHECK
 Palpate for Carotid Pulse
within 10 seconds
 (at the same time CHECK
FOR BREATHING)
 For trained healthcare
providers only
If with definite pulse
but no breathing

Do Mouth to Mouth
Breathing
 Give one breath every 5-6
secs (about 12
breaths/min)
 Count “1-2-3-and 1-
blow…”
 Recheck pulse every 2
minutes
 MOUTH TO MOUTH BREATHING and
PULSE CHECK

• Deemphasized in the new guidelines

• For trained healthcare providers only
• As short and quick as possible
• Pulse check not more than 10 seconds
• If unsure, proceed directly to CHEST
COMPRESSIONS!
After determining unconsciousness,

C–A–B
C. COMPRESSION Do chest
compressions first
A.AIRWAY Does the victim have an
open airway (air passage
that allows the victim to
breathe)?
B. BREATHING Is the victim breathing?
C– C OMPRESSION
(to assist CIRCULATION)
After determining unconsciousness and
calling for help,
proceed immediately to do

CHEST
COMPRESSIONS!
 Chest Compressions

• Kneel facing
victim’s chest
• Place the heel of your
hand on the center of
the victim's chest. Put
your other hand on top
of the first with your
fingers interlaced.
Chest Compressions

Place the heel

of one hand on
the sternum in
the center 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.
Give Chest Compressions at 100 per minute
Compress breastbone at least 2 inches deep
Compress at a rate of 100 per minute or more
Compress 30 times initially
Allow the chest to return to its normal position
Give 30 Compressions

 Compress breastbone at least 2 inches

 (30 compressions should take 15-18 sec)

 Count aloud “1, 2, 3, 4,

5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,
20,21,22,23,24,25,26,27,28,29, and
ONE!”

 Minimize interruptions

 Allow recoil after each compression

A - AIRWAY
Open the Airway:
Use the head tilt/chin
lift method
 Place one hand on the victim’s
forehead

 Place fingers of other hand

under the bony part of lower
jaw near chin

 Tilt head and lift jaw--avoid

closing victim’s mouth
 Head Tilt Chin Lift Maneuver

This maneuver prevents airway obstruction by the

epiglottis.
B - BREATHING
Give 2 one-second breaths
• Maintain airway
• Pinch nose shut
• Open your mouth wide, take a
normal breath, and make a tight
seal around outside of victim’s
mouth
• Give 2 full breaths
(1 sec/ breath)
• Observe chest rise & fall; listen &
feel for escaping air
 PULSE CHECK
• RECHECK PULSE EVERY 2 MINUTES
(equivalent to 5 cycles CPR)
• Very brief pulse check – should take less
than 10 seconds (at the same time check for
normal breathing)
• In case there is any doubt about the
presence or absence of pulse, CONTINUE
CHEST COMPRESSIONS
• For trained healthcare providers only
UNTIL…
•HELP ARRIVES.
(Emergency Services, Ambulance, Doctor, AED)

•PERSON IS REVIVED.
 If the victim is breathing

THE RECOVERY POSITION

Maintain open airway & position the victim
 The unresponsive victim with spontaneous respirations
should be placed in the recovery position if no cervical
trauma is suspected.
 Placement in this position consists of rolling the victim
onto his or her side to help protect the airway.
 Summary of Key BLS Components for Adults and Children
Maneuvers Adults Children
RECOGNITION UNRESPONSIVE

No breathing, No breathing or only gasping

not breathing normally (eg. only gasping)

CPR Sequence CAB CAB

Compression Rate At least 100/min
Compression Depth At least 2 inches (5 cm) At least 1/3 AP depth; About 2 inches
Chest wall Recoil Allow complete recoil between compressions
HCPs rotate compressors every 2 minutes

Compression interruptions Minimize interruptions in chest compressions

Airway
Compression-Ventilation
ratio
Ventilations: when rescuer
untrained or trained and not
proficient
Ventilations with advanced
airway (HCP)
DEFIBRILLATION ( AED )
before and after shock, resume CPR beginning with compressions immediately after each
Attempt to limit interruptions to less than 10 seconds
Head tilt chin lift (HCP suspected trauma: jaw thrust)
30 : 2 (one or 2 rescuers) 30:2(single rescuer); 15:2(2 rescuer)
Compressions only Compressions only
1 breath every 6-8 seconds (8-10 breaths/min)
Asynchronous with chest compressions
About 1 second per breath
Visible chest rise
Attach and use AED as soon as available. Minimize interruptions in chest compressions
shock
• Majority of cardiac arrests occur in adults
– highest survival rates are reported among patients with
witnessed arrest and a rhythm of VF or pulseless VT

–  critical initial elements of CPR are chest compressions and

early defibrillation

 A-B-C sequence  chest compressions often delayed while the

responder opens the airway
 Changing sequence to C-A-B  chest compressions will be initiated
sooner
 Rationale for C-A-B
• 1st few minutes after VF
– Blood oxygen content remains high
– Myocardial and cerebral O2 supply is limited more by
decrease in cardiac output than by lack of O2 in
lungs
– Ventilation not as important as chest compression

 But...
Ventilation contributes to survival from prolonged asphyxial
arrest
Berg et al. Crit Care Med 2000;28
 Emphasis: 4 metrics of Good Quality CPR

• Adequate rate – AT LEAST 100/MIN

• Adequate depth – AT LEAST 2 INCHES (5 cm)

• Full chest recoil

• Minimize interruption
HIGH QUALITY CHEST
COMPRESSIONS
 MEMORIZE THE STEPS!
• Survey the scene.
• Check responsiveness – hey hey are you ok?
• Call for help! Activate EMS
• [Quick check pulse within 10 secs, at the same time check for breathing], IF NO
BREATHING NO PULSE,
• C – Chest Compressions: 30 x; 100/min; 2 inches deep; push hard and fast.
Count 1-2-3-4-…26-27-28-29-and 1!
• A - Airway: head tilt chin lift
• B – Breathing: 2 breaths (1 second/breath)
• Chest compressions 30 x
• Continue cycles 30:2 compression-ventilation. Count 1-2-3-4-…26-27-28-29-and
5!
• [Quick check pulse every 2 mins – approximately 5 cycles]
• If no breathing but with pulse, do artificial breathing: give 1 breath every 5
seconds. Count 1-2-3-1-blow,…up to 1-2-3-12-blow. (12 cycles)
• Until:
– EMS arrives (AED, doctor, ambulance)
– Patient has signs of life
• NOT TRAINED
• DO NOT KNOW MOUTH TO MOUTH
VENTILATION
• NOT SURE ABOUT MOUTH TO MOUTH
VENTILATION
• HESITANT TO DO MOUTH TO MOUTH
VENTILATION
• DO NOT WANT TO DO MOUTH TO MOUTH
VENTILATION
 Hands Only CPR
Compression-only bystander CPR
 Hands Only CPR
Recommendations:
• All victims of cardiac arrest should receive high-
quality chest compressions

• When an adult suddenly collapses, all bystanders

should activate their community EMS and provide
high-quality chest compressions, minimizing
interruptions (Class I).
 Hand Only CPR
Recommendations:
• If not trained in CPR, provide hands-only
CPR (Class IIa) until
– AED arrives
– EMS providers take over care of the victim

• If trained in CPR, provide either

conventional CPR using a 30:2
compression-to-ventilation ratio (Class IIa)
or handsonly CPR (Class IIa)
Hands Only CPR should only be
used for adult victims who have
suddenly collapsed or become
unresponsive.
 Key Changes in the New Guidelines

• CAB instead of ABC

• Compress first
• No more Look Listen and Feel
• Harder!  At least 2 inches compression (old: 1 ½ to 2
inches)
• Faster!  At least 100/min compression (old: up to 100/min)
• Deemphasize pulse checks
– For trained healthcare providers  not more than 10 secs
• Check for normal breathing together with check for
unresponsiveness
• Hands only CPR for the untrained lay rescuer
 Important Points
• There are no mistakes when you perform
CPR.
The only harm is to delay responding.

• Don't stop pushing.

– Push harder and faster!

• Training is now simpler and more accessible

Reduced number of steps and simplified process
• Being trained to do CPR can save a
loved one.
• Effective CPR done immediately after
cardiac arrest can double a victim’s
chance of survival.
LEARN CPR TODAY!
INQUIRE FROM THE PHILIPPINE HEART ASSOCIATION!
www.philheart.org
If you want know more about Sudden Cardiac Arrest
and CardioPulmonary Resuscitation, contact the
Philippine Heart Association Council on CPR

PHA Heart House

Suite 1108, 11th Flr. East Tower, PSE Centre Exchange Road,
Ortigas Center, Pasig City Philippines
Tel. +63 2 470-5525; +63 2 687-7797
www.philheart.org
 MEMORIZE THE STEPS!
• Survey the scene.
• Check responsiveness – hey hey are you ok?
• Call for help! Activate EMS
• [Quick check pulse within 10 secs, at the same time check for breathing], IF NO
BREATHING NO PULSE,
• C – Chest Compressions: 30 x; 100/min; 2 inches deep; push hard
and fast. Count 1-2-3-4-…26-27-28-29-and 1!
• A - Airway: head tilt chin lift
• B – Breathing: 2 breaths (1 second/breath)
• Chest compressions 30 x
• Continue cycles 30:2 compression-ventilation. Count 1-2-3-4-…26-
27-28-29-and 5!
• [Quick check pulse every 2 mins – approximately 5 cycles]
• If no breathing but with pulse, do artificial breathing: give 1 breath
every 5 seconds. Count 1-2-3-1-blow,…up to 1-2-3-12-blow. (12
cycles)
• Until:
– EMS arrives (AED, doctor, ambulance)
– Patient has signs of life
Precordial thump?
 Precordial thump

• Reported to convert VT/VF to normal rhythm in few

studies/series
Pellis et al. Resuscitation 2009;80
Bornemann 1969; Dale 2007; DeMaio 2001; Pennington 1970; Rahner 1978

• Ineffective in 98.8% in 2 larger series

Amir et al. PACE 2007;80
Haman et al. Resuscitation 2009;80

• Should not be used for unwitnessed out of hosp arrest

(Class III)

• May be considered in witnessed, monitored arrest if a

Defibrillator is NOT immediately available