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CPR
GUIDELINES
It is our pleasure to present to you this work as a result of team work of the
national CPR committee at the Saudi Heart Association (SHA).
We adapted the 2010 guidelines as per
The International Liaison Council
(Committee) of Resuscitation (ILCOR)
which was published October, 2010. We modified some of the items of
2005 guidelines and kept some as it is depending on our national
need in the kingdom of Saudi Arabia. As an example, the sequence
of A.B.C in children and infants should not change because most
common cause of child and/or infant arrest is respiratory, so
respiratory assessment should take place at the
beginning.
Reviewing the international
resuscitation science since 2010 till
2012, there is a great emphasis on the
early CPR and early defibrillation
which make difference between life
and death, good outcome and bad
outcome of in hospital CPR. there is
also a great emphasis on CPR
awareness to the community through
the skillful programs.
National CPR
Committee Members
ADVANCED LIFE SUPPORT
Unresponsive?
Not breathing or only occasional gasps
Call Resuscitation Team
CPR 30:2
Attach defibrillator/monitor Minimize interruptions
AED Assesses Rythm
Shockable
(VF /Pulseless VT)
1 Shock
Immediately resume:
CPR 30:2 for 2 min
Minimize interruptions
DURING CPR
Return Of
Spontaneous
Circulation
Immediate Post Cardiac
Arrest Treatment
- Use ABCDE approach.
- Controlled Oxygenation
and ventilation.
- 12 lead ECG.
- Treat precipitating cause.
- Temperature control /
Therapeutic hypothermia.
- Entidal Co2 monitoring.
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Consider advanced airway and capnography
• Continuous chest compressions when advanced
airway In place
• Vascular access intravenous, intraosseous)
• Give epinephrine every 3-5 min
• Amiodarone 300 mg IV bolus for refractory
VF/pulseless VT
• Correct reversible causes
No Shock Advised
Immediately resume:
CPR 30:2 for 2 min
Minimize interruptions
REVERSIBLE CAUSES
• Hypoxia
• Hypervolemia
• Hypo- / hyperkalemia / metabolic
• Hypothermia
• Thrombosis - coronary or pulmonary
• Tamponade - cardiac
• Toxins
• Tension pneumothorax
ACS ALGORITHM (DIAGNOSES)
Patient with clinical signs & symptoms of ACS
12 Lead ECG
ST Elevation
≥ 0.1 mV In ≥ 2 adjacent limb leads and/ or
≥ 0.2 mV in ≥ adjacent chest leads or
(presumably) new LBBB
STEMI
Other ECG alterations
(or normal ECG)
= NSTEMI if troponins
(T or I) positive
Non-STEMI-ACS
= UA if troponins
remain negative
High risk
- Dynamic ECG changes
- ST depression
- Hemodynamic/rhythm Instability
- Diabetes mellitus
ACS ALGORITHM (TREATMENT)
ECG
Pain Relief
Nitroglycerin if systolic BP > 90 mmHg
± Morphine (repeated doses) of 3-5 mg until pain free
Antiplatelet Treatment
16o-325mg Acetylsalicylic acid chewed tablet
75 - 600 mg Clopidogrel according to strategy*
OXYGEN THERAPY
if Spo2 < 94 %
STEMI
Thrombolysis preferred if:
No contraindications and
inappropriate delay to PCI
PCI preferred if:
Within the time window &
availability of highly
specialized center.
Contraindications for
thrombolytic therapy,
cardiogenic shock (or severe
left ventricular failure)
Non-STEMI-ACS
According to risk stratification:
• Antiplatelet therapy
• Antianginal therapy
• Antithrombin therapy
• Serial cardiac enzymes
• Reperfusion for high risk
BRADYCARDIA ALGORITHM
• Assess using the ABCDE approach
• Ensure oxygen given and obtain IV access
• Monitor ECG, BP, Sp02, record12 lead ECG
• Identify and treat reversible causes
(e.g. electrolyte abnormalities)
Assess for evidence of instability signs:
1. Shock
2. Syncope
3. Myocardial ischemia
4. Heart failure
YES
NO
Atropine
500mcg IV
YES
Satisfactory
Response?
YES
NO
Risk of Asystole?
Interim Measure:
Atropine 500 mcg IV
• Repeat to maximum of 3 mg
• Isoprenaline 5 mcg/min
• Epinephrine 2-10 mcg/min
• Alternative drugs*
OR
• Dopamine/dobutamine infusion
(alternative to transcutaneous pacing)
• Transcutaneous pacing
Seek Expert help
Arrange transvenous pacing
* Alternatives include:
• Aminophylline
• Dopamine
- Recent asystole
- Mobitz 2 AV block
- Complete heart block with
broad QRS
- Ventricular pause > 3s
NO
Observe
• Glucagon (if beta-blocker or calcium channel blocker overdose)
TACHYCARDIA ALGORITHM (WITH PULSE)
• Assess using the ABCDE approach
• Ensure oxygen given and obtain IV access
• Monitor ECG, BP, Sp02 ,record 12 lead ECG
• Identify and treat reversible causes
(e.g. electrolyte abnormalities
Assess for evidence of instability signs:
le
Unstab
1. Shock
2. Syncope
3. Myocardial ischemia
4. Heart failure
Stable
Synchronized DC Shock*
Up to 3 attempts
Is QRS narrow
(< 0.12 sec)?
Narrow
Broad
• Amiodarone 300 mg
IV over 10-20 min &
repeat shock; followed by:
• Darone 900 mg over 24 h
r
Irregula
Broad QRS
Is QRS regular?
*Attempted electrical
cardioversion is always
undertaken under sedation or
anesthesia
r
r
r
Regula
Seek Expert Help
Possibilities Include:
• AF with bundle branch block
treat as for narrow complex
• Pre-excited AF consider
amiodarone
• Polymorphic VT
(e.g. torsades de pointes·
give magnesium 2 g over 10 min
Narrow QRS
Is QRS regular?
If Ventricular Tachycardia:
• Amiodarone 300 mg IV over
20-60 min; then 900 mg over 24 h
If previously confirmed
SVT with bundle branch block or
(uncertain monomorphic rhythm):
• Give adenosine as for regular
narrow complex tachycardia
Irregula
Regula
• Use vagal maneuvers
• Adenosine 6 mg rapid
IV bolus;
If unsuccessful give 12
mg;
If unsuccessful give
further 12 mg.
• Monitor ECG
continuously
Normal sinus rhythm
restored?
YES
Probable re-entry PSVT:
• Record 12·lead ECG in sinus rhythm
• If recurs, give adenosine again & consider
choice of antiarrhythmic prophylaxis
Irregular narrow complex
tachycardia
Probable atrial fibrillation
Control rate with:
• B-Blocker or diltiazem
• Consider digoxin or
amiodarone
If evidence of heart failure
Anticoagulate If duration >
48h
NO
Seek Expert Help
Possible atrial flutter
• Control rate (e.g. B-Blocker)
PAEDIATRIC ADVANCED LIFE SUPPORT
Unresponsive?
Not breathing or only occasional gasps
CPR (2 initial breaths then 15:2)
Attach defibrillator/
monitor Minimize interruptions
Assesses Rythm
Shockable
(VF /Pulseless VT)
1 Shock 4 J/Kg
Immediately resume:
CPR for 2 min
Minimize interruptions
DURING CPR
Return Of
Spontaneous
Circulation
Immediate Post Cardiac
Arrest Treatment
- Use ABCDE approach
- Controlled Oxygenation
and ventilation
- Investigations
- Treat precipitating cause
- Temperature control
- therapeutlc hypothermia
- Entidal Co2 monitoring
• Ensure high-quality CPR: rate, depth, recoil
• Plan actions before interrupting CPR
• Give oxygen
• Consider advanced airway and capnography
• Continuous chest compressions when advanced
airway In place
• Vascular access intravenous, intraosseous)
• Give epinephrine every 3-5 min
• Amiodarone 5mg / kg IV bolus for refractory
VF/pulseless VT
• Correct reversible causes
No Shock Advised
(PEA/Asystole)
Immediately resume:
CPR for 2 min
Minimize interruptions
REVERSIBLE CAUSES
• Hypoxia
• Hypervolemia
• Hypo- / hyperkalemia / metabolic
• Hypothermia
• Thrombosis - coronary or pulmonary
• Tamponade - cardiac
• Toxins
• Tension pneumothorax
NEWBORN LIFE SUPPORT
Dry the Baby
Remove any wet towels & cover Start the clock or note the time
Birth
30 sec
Assess (tone), Breathing & Heart Rate
If gasping or not breathing Open the airway
Give 2 inflation breaths
Consider Sp02 monitoring
Re-assess If no increase in heart rate
Look for chest movement
If chest not moving Recheck head position
Consider two-person airway control or other airway manoeuvres
Repeat inflation breaths
Consider Sp02 monitoring
Look for a response
If no increase in heart rate Look for chest movement
When the chest is moving
If the heart rate is not detectable or slow (< 60)
Start chest compressions
60 sec
3 compressions to each breath
Reassess heart rate every 30 seconds
If the heart rate is not detectable or slow (< 60)
Consider venous access and drugs
Acceptable*
pre-dudalSp02
2 min:60%
3 min :70%
4 min:80%
5 min :85%
10 min:90%
PERFORMANCE
Sheets
ACLS PERFORM AIRWAY
Teaching
Testing
NAME: ______
_______________________________ Batch #: ______ DATE: ________________
Skills Station 1:
Airway Adjuncts and Intubation
Objectives:
On completion of Testing Station 2, the student will have demonstrated the ability to perform or
demonstrate the following:
1. Ventilate adult manikin using mouth- to -mask technique. (Each participant must have his or her own
mask; masks must not be shared.)
2. Insert esophageal airway into adult intubation manikin and provide effective ventilation.
3. Intubate trachea of adult intubation manikin with endotracheal tube and assess that both lungs can
be inflated simultaneously.
4. Intubate trachea of adult intubation manikin with endotracheal tube while esophageal airway is in
place.
5. Intubate trachea of infant intubation manikin with endotracheal tube and assess that both lungs can
be inflated simultaneously.
Time
Skills
Pass
A. Mouth-to-Mask Ventilation W ith Supplemental Oxygen
1. Connect oxygen line with 10L flow.
30 sec
2. Establish airway by head - tilt.
3. Insert oropharyngeal airway with proper technique.
4. Establish seal with mask.
5. Ventilate mouth -to-mask & record 800ml minimumtidal volume on recording
manikin at least three times in 15 seconds.
B. Esophageal Airway (or use optional PTL airway, with appropriate procedure for insertion)
20 sec
1. Assume ventilation is in progress.
2. Grasp jaw between thumb and index finger and lift upward, but keep mouth
open; do not hyperextend neck.
3. With mask attached, insert tubeinto mouth and place it so that the curvature is
the same as that of the pharynx.
4. Advance into esophagus and seal mask firmly over mouth and nose.
5. Ventilate and see if chest rises - inflate cuff with 35 - ml syringe.
6. Check placement of esophagea
l airway by visualizing lung inflation with each
ventilation and by auscultating both sides of chest and over stomach with
stethoscope.
Fail
C.
Adult Intubation
1. Assume ventilation is in progress.
2. Connect laryngoscope blade and handle; check light: check cuff on
endotracheal tube.
35 sec
3. Hold laryngoscope in left hand.
4. Insert laryngoscope in right side of mouth, moving tongue to the left.
5. Visualize epiglottis, then vocal cords.
6. Insert ETT (endotracheal tube).
7. Inflate cuff with 4 - 6 ml of air.
8. Check placement of ETT by ventilating, visualizing lung inflations, and
auscultating both sides of chest and over stomach with stethoscope.
D.
intubation of Trachea with Esophageal Airway in Place
1. Esophageal airway is in place.
2. Intubate trachea.
3. Ventilate through endotracheal tube
.
40 sec
4. Remove esophageal airway.
E.
Infant Intubation
1. Assume ventilation is in progress.
2. Connect laryngoscope blade and handle; check light.
30 sec
3. Hold laryngoscope in left hand .
4. Insert laryngoscope in right side of mouth, moving tongue to left.
5. Visualize epiglottis, then vocal cords.
6. Insert endotracheal tube.
7. Check placement of tube by mouth-to-tube or bag-to-tube ventilation,
observing chest movement and auscultating chest and over stomach
with stethoscope.
Overall Grade (circle one)
Instructor _____________________________________________________________________
Pass
Fail
ACLS PERFORM IV
Teaching
Testing
NAME: _____________________________________ batch #: ________ DATE: ______________
Skills Station 2:
PLACEMENT OF INTRAVENOUS FLUID LIFE LINE,
PERIPHERAL AND CENTRAL VEINS
OBJECTIVES:
On completion of Station 4, the student will be able to:
1. Describe the surface markings and the technique for insertion of an intravenous cannula into:
a) A peripheral vein
b) A femoral vein
c) An internal jugular or subclavian vein
2. Assemble the components of an intravenous infusion lifeline.
3. Describe the surface markings and the technique for insertion of an interoseous (IO) cannula
into the shaft of a leg.
NOTE:
Learning during practice is enhanced by utilizing the illustrations from the paper which demonstrate each
approach.
Once the student has learned the site of the venipunctureand the angles of approach for cannulation of
central veins and can demonstrate such on a model, he should practice on a cadaver and finally actually
perform these techniques on a living patient under supervision until the procedure can be performed
safely and efficiently.
Only then can he be considered "certified" to perform central venipuncture. Knowledge of these
performance criteria is only the first step toward acquiring such a skill.
Choose one of each of the following: verbalize and demonstrate landmarks rather than actually doing
venipuncture: 1) Peripheral vein; 2) Femoral vein; and 3) Internal jugular (one approach) or subclavian.
TIME
CRITERIA
I
PERIPHERAL VEINS
60 Sec.
A. ARMS OR LEGS
1.
2.
3.
4.
5.
6.
7.
8.
9.
Apply tourniquet proximally.
Locate vein and cleanse the overlying skin with alcohol or povidone
iodine.
Anesthetize the skinif a large bore cannula is to be inserted in
an awake patient.
Hold vein in place by applying pressure on vein distal to the point of
entry.
Puncture the skin with bevel of needle upward about ½ to 1
Centimeter from the vein and enter the vein either from the side or
from above.
Note blood return and advance the catheter either over or through the
needle, depending on which type of catheter
- needle device is
employed. Remove the tourniquet.
Withdraw and remove the needle and attach the intravenous tubing
.
Cover the puncture site with povidone iodine -ointment and a sterile
dressing and tape in place, excluding the point of connection of the
intravenous tubing.
PASS
FAIL
60 Sec.
B.
1.
2.
3.
4.
5.
6.
7.
II.
EXTERNAL JUGULAR
Patient in supine, at least 150 head down position, head turned away
toward opposite side.
Cleanse skin, use lidocaine if patient awake and large bore needle used.
Align needle in the direction of the vein with the point aimed toward
the ipsilateral shoulder.
Make venipuncture midway between angle of jaw and midclavicular
line; "tourniqueting" the vein lightly with one finger above the clavicle.
Note blood return.
Advance catheter and remove needle; attach to IV tubing.
Cover puncture site and affix catheter in place
CENTRAL VEINS
60 Sec.
A. FEMORAL
1.
2.
3.
4.
5.
6.
7.
8.
9.
Cleanse the overlying skin with povidone-iodine;this is especially
important in this site because the danger of contamination is great. If
the puncture is being performed electively, shave the hair around the
area.
Locate the femoral artery either by its pulsation or by finding the
midpoint of a line drawn between the anterior superior iliac spine
and the symphysis pubis.
Infiltrate the skin with lidocaine if the patient is awake.
Make the puncture with the needle attached to a 5 or 10 milliliter
syringe two fingerbreadths below the inguinal ligament, medial to the
artery, directing the needle cephalad at a 4-5 degree angle with the skin
or frontal plane (some prefer to enter at a 9-0 degree angle) until the
needle will go no further.
Maintain suction on the syring e and pull the needle back slowly until
blood appears in the syringe, indicating that the lumen of the vein has
been entered.
Remove the syringe and insert catheter with the needle more parallel to
the frontal plane.
Withdraw the needle, leaving the catheter in place.
Connect to intravenous tubing.
Cover the puncture site with povidone- iodine ointment and a sterile
dressing and secure the catheter and tubing in place.
60 Sec.
B.
SUBCLAVIAN, INFRACLAVICULAR APPROACH
1.
2.
3.
Patient in supine, at least 150 head down position, head turned away.
Cleanse skin, use lidocaine if patient awake.
Introduce needle attached to a syringe I centimeter below the
junction of the middle and medial thirds of the clavicle.
4. Hold the syringe and needle parallel to the frontal plane(the plane of
the back of the patient).
5. Direct the needle medially, slightly cephalad, and posteriorly behind
the clavicle toward the posterior superior angle of the sternal end of
the clavicle.
6. Establish a good point of reference by firmly pressing the fingertip
into the suprasternal notch to locate the deep side of the superior
angle of the clavicle and directing the course of the needle slightly
behind the fingertip.
7. Advance needle while withdrawing plunger of syringe.
8. When blood appears and vein entered, rotate bevel of needle
caudally; remove syringe and insert catheter to predetermined depth.
9. Remove needle and connect catheter to IV tubing.
10. Cover puncture site, and affix catheter in place.
60 Sec.
C. INTERNAL JUGULAR, POSTERIOR APPROACH
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patient in supine, at least 150 head down position, head turned away.
Cleanse skin, use lidocaine if patient awake.
Introduce the needle under the sternomastoid muscle near the
junction of the middle and lower thirds of the lateral
(posterior) border (5 centimeters above the clavicle or just above
where the external jugular vein crosses the sternomastoid muscle).
Aim the needle caudally and ventrally (anteriorly) toward the
suprasternal notch at an angle of 45 degrees to the sagittal and
horizontal planes and with 15-degree forward angulation
in the frontal plane.
The vein should be entered within 5 to 7 centimeters.
Advance needle while withdrawing plunger of syringe.
When blood appears and vein entered, remove syringe and insert
catheter to predetermined depth.
Remove needle and connect catheter to IV tubing.
Cover puncture site, and affix catheter in place.
60 Sec.
D. INTERNAL JUGULAR, MIDDLE OR CENTRAL ROUTE
1.
2.
3.
4.
5.
6.
7.
8.
9.
60 Sec.
Patient in supine, at least 150 head down position, head turned away.
Cleanse skin, use lidocaine if patient awake.
Introduce needle attached to syringe in the center of triangle formed
by two lower heads of sternomastoid muscle and clavicle.
Direct needle caudally, parallel to sagittal plane, at 30-posterior angle
with frontal plane.
If vein is not entered, withdraw needle and redirect it 5 to 10 degrees
laterally.
Advance needle while withdrawing plunger of syringe.
When blood appears and vein entered, remove syringe and insert
catheter to predetermined depth.
Remove needle and connect catheter to IV tubing.
Cover puncture site, and affix catheter in place.
E.
1.
2.
3.
4.
5.
6.
7.
8.
9.
INTERNAL JUGULAR, ANTERIOR APPROACH
Patient in supine, at least 150 head down position, head turned away.
Cleanse skin, use lidocaine if patient awake.
Place the left index and middle fingers (if from the right side) 3
centimeters lateral to the mid - sternal line; the carotid artery is
retracted medially away from the anterior border of the sternomastoid.
Introduce the needle at the midpoint of this anterior border (5
centimeters above the clavicle and 5 centimeters below the angle
of the mandible).
Forming a posterior angle of 30 to 45 degrees with the frontal
plane, direct the needle caudally toward the ipsilateral nipple
and toward the junction of the middle and medial thirds of the clavicle.
Advance needle while withdrawing plunger of syringe.
When blood appears and vein entered, remove syringe and insert
catheter to predetermined depth.
Remove needle and connect catheter to IV tubing.
Cover puncture site, and affix catheter in place.
7 minutes
Instructors (s): ________________________________________ (check) Pass _______ Fail _______
________________________________________ (check) Pass _______ Fail _______
INTRAOSSEOUS INFUSION
INTRODUCTION:
Bone shaft acts as non-collapsible vein through
which medication & fluids can be given. It is an old
procedure but become popular recently. It is not
the first choice. A rigid needle is Inserted into the
cavity of a long bone.
Indications:
Used for critical situations when a peripheral IV is
unable to be obtained.
Initiate it after 90 seconds or three unsuccessful IV
attempts.
SITES:
STEPS OF INTRODUCTION OF MEDICATIONS:
1. Select the medication and prepare equipment.
2. Palpate the puncture site and prepare with an
antiseptic solution.
3. Make the puncture.
4. Aspirate to confirm proper placement.
5. Aspirate to confirm proper placement.
6. Connect the IV Tubing.
7. Administer the medication.
8. Monitor the patient for effects.
COMPLICATIONS:
- Fracture
- Infiltration
- Growth plate damage
- Complete insertion
- Pulmonary embolism
- Infection
- Thrombophlebitis
- Air embolism
- Circulatory overload
- Allergic reaction
CONTRAINDICATIONS TO INTRAOSSEOUS
PLACEMENT:
- Fracture to tibia or femur on side of access.
- Osteogenesis imperfecta—congenital bone
disease resulting in fragile bones.
- Osteoporosis.
- Establishment of a peripheral IV line.
ACLS PERFORM MEGACODE
Teaching
NAME: ____________________________
Testing
batch #: ________ DATE: ________________
Objectives:
On completion of Testing Station 4, during a-5minute scenario, the Team Leader will have performed as
follows:
1. Supervised and directed arrest team in a sequence that would lead to successful resuscitation.
2. Monitored arrest team to insure that his/her directions were correctly carried out.
3. Correctly diagnosed arrhythmias and made proper treatment decisions.
4. Operated a defibrillator in the counter shockor cardio versionmode as appropriate and interposed
it into team activity in a safe and proper sequence.
5. Prescribed the appropriate drug(s) in correct dosage.
6. Ordered and interpreted lab data.
Skills (Team Leader)
Pass
Supervision and leadership
Proper sequencingincluding BLS skills
Monitoring other team members
Rhythm diagnosis
Defibrillator operation
Drugs
Ordering and interpretation of lab data
Overall Grade (Circle one)
Instructor ________________________________
___________
______Pass ______ Fail ______
Fail