BLS ATLS presentation Basic Life Support

DR.PRIYANKA JAIN
2ND
PGT
MAXILLOFACIAL SURGERY
BIDSH,PATNA

OBJECTIVES
• Define BLS
• Explain steps & components of BLS
• Explain chain of survival
• Explain about defibrillator

WHAT IS BLS ?
8
• Basic Life Support (BLS) refers to the care
healthcare providers and public safety
professionals provide to patients who are
experiencing respiratory arrest, cardiac arrest or
airway obstruction.
• BLS includes psychomotor skills for performing
high-quality cardiopulmonary resuscitation (CPR),
using an automated external deﬁbrillator (AED)
and relieving an obstructed airway for patients of
all ages
World J Emerg Med 2012; 3(2): 141–145.

9
• According to recent statistics sudden cardiac arrest is
rapidly becoming the leading cause of death.
• Once the heart ceases to function, a healthy human brain may
survive without oxygen for up to 4 minutes without suffering
any permanent damage.
• Unfortunately, a typical EMS response may take 6, 8 or
even 10 minutes.
• It is during those critical minutes that CPR (Cardio Pulmonary
Resuscitation) can provide oxygenated blood to the victim's
brain and the heart, dramatically increasing his chance of
survival.
• And if properly instructed, almost anyone can learn and
perform CPR.
World J Emerg Med 2012; 3(2): 141–145.

WHAT IS CARDIAC ARREST?
• Cessation of normal circulation of blood due to failure of
heart to contract effectively.
• It is sudden cessation of mechanical activity of heart with
some or no electrical activity.
Ritter G, Wolfe RA, Goldstein S, Landis JR, Vasu CM, Acheson A, et al. The effect of by-stander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J. 1985;110:932–937

OHCA & IHCA
• IHCA is in hospital cardiac arrest
While
• OHCA is out of hospital cardiac arrest

HOW IT WORKS?

Pathophysiology
CARDIAC ARREST
No blood or tissue oxygenation
Brain sustain damage for 4 min and after 7 min irreversible damage occurs
After 1-2 hrs, cells of body die
CPR
Causes blood to circulate to brain and heart
Enough blood to brain delaying brain death and allows heart to remain responsive till
defibrillation

RECOGNITION OF ARREST
• First step is to Ensure scene safety
• Check for response
• Shout for help/activate resuscitation team at the time or after
checking pulse and breathing
• Activation of AED/emergency equipments either by lone rescuer or
person sent by rescuer must occur as soon as possible after checking
pulse and breathing (ideally should be done simultanously)
• Immediately begin CPR and use AED/defib when available
Wik L, Steen PA, Bircher NG. Quality of bystander cardiopulmonary resuscitation influences outcome after prehospital cardiac arrest. Resuscitation. 1994;28:195–203

Check breathing?
• Inspecting the chest rise of patient while palpating carotid
pulse (saves time)
• OR Lay rescuer can check by keeping our fingers in front
of nostrils/keeping ears close to nose to check if any blow
of expired air is present or not.
• Agonal gasps or abnormal breathing patterns may get
confused with normal respiration by lay man rescuer.

Steps
After recognition of arrest
C Compressions
A Managing airway
B Rescue breathing

Chest Compressions
• Technique-
o Position yourself at patient’s side
o firm, flat surface and
o remove all the clothings
o Put the heel of one hand on the centre of chest (sternum) at the level
of nipples and put your other hand on the top of that hand.

Chest Compression
• Technique-
o Lock all joints ; movement is allowed only at hip joint
o Push hard and fast (100 - 120 times / min)
o At the end of each compression, chest is allowed to recoil completely
o Avoid excessive ventilation
o Then give next compression immediately
o This cycle should be repeated until patient revives or any EMS arrives.

Chest Compressions
• Rate- 100 to 120/min
• Depth- 5 cms to 6 cms (2 inches to 2.4 inches)
• While giving chest compression only resuscitation (COLS)
by lay or untrained rescuer give chest compressions only
• Ratio – 30:2
• Minimum/no interruptions

Mechanisms
• Cardiac Pump –
1. Blood pumping is assured by compression of heart between
sternum and spine
2. Between compressions, thoracic cage expands and heart gets
filled with blood.

Mechanisms
• Thoracic pump –
1. Blood circulation restored due to changes in intra-thoracic
pressure and jugular and subclavian vein valves.
2. During chest compressions,blood is directed from
pulmonary circulation to systemic circulation.

Thoracic Pump

FOR INFANTS
Gwinnutt C, Columb M, Harris R. Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation. 2000;47:125–135

AIRWAY
Open Airway
Jaw thrust maneuver
Head tilt and chin lift
No blind finger sweep
28
Cooper S, Johnston E, Priscott D. Immediate lifesupport training. Impact in a primary care setting? Resuscitation. 2007;72:92–99

AIRWAY OBSTRUCTION
ADULT- Conscious
29
Cooper S, Johnston E, Priscott D. Immediate lifesupport training. Impact in a primary care setting? Resuscitation. 2007;72:92–99

BREATHING
• Check breathing.
• No “look, listen, feel” for signs of breathing in new
guidelines.
• After the first set of chest compressions, the airway
is opened and the rescuer delivers 2 breaths.
30
Cardiopulmonary resuscitation: statement by the Ad Hoc Committee on Cardiopulmonary Resuscitation of the Division of Medical Sciences, National Academy of Sciences, National Research Council. Cardiopulmonary Resuscitation. JAMA. 1966;198:372–379

GIVING RESCUE BREATHS
• Use a barrier device of some type while giving breaths.
• Deliver each rescue breath over 1 second.
• Give a sufficient tidal volume to produce visible chest rise
(500- 600ml).
• Avoid rapid or forceful breaths.
• When an advanced airway is in place during 2-person CPR,
ventilate at a rate of 8 to 10 breaths per min.
31

METHODS OF RESCUE BREATHS
• Mouth-to-Mouth Rescue Breathing
• Mouth-to–Barrier Device Breathing
• Mouth-to-Nose and Mouth-to-Stoma Ventilation
• Ventilation With Bag and Mask
• Ventilation With an Advanced Airway
32

33
VENTILATION WITH BAG AND MASK
Document 2005 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (CoSTR)

34
MOUTH-TO–BARRIER DEVICE
BREATHING
Chamberlain D, Smith A, Woollard M, Colquhoun M, Handley AJ, Leaves S, et al. Trials of teaching methods on basic life support: comparison of simulated CPR performance after first training and at 6 months, with a note on the value of retraining. Resuscitation. 2002;53:179–187

Carotid Artery
Osinaike BB, Aderinto DA, Oyebamiji EO, Dairo MD, Diya KS. Evaluation of knowledge of doctors in Nigerian tertiary hospital about CPR. Nigerian Medical Practitioner. 2007;52:16–18

Head tilt-Chin lift
Biomed Res Int. 2014; 2014: 376871.

Cardiopump
McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance: cardiac arrest registry to enhance survival (CARES), United States, October 1, 2005–December 31, 2010. Morbidity and Mortality Weekly
Report. 2011;60(8):1–19

Cardiopump
• Handheld device
• Piston having a suction cup that sticks to patient’s chest
• Manual form of CPR device
• Operator operates the device by hand
• Alternate compression with active decompression increases
venous return by decreasing intrathoracic pressure and
increases overall flow

CPR RsQ assist
• Light and compact
• It has a handle which provides support for active compression
during CPR
• Manual device, operated by rescuer
McNally B, Robb R, Mehta M, et al. Out-of-hospital cardiac arrest surveillance: cardiac arrest registry to enhance survival (CARES), United States, October 1, 2005–December 31, 2010. Morbidity and Mortality
Weekly Report. 2011;60(8):1–19

CPR PRO cradle
• Manual device
• Have to be operated by rescuer
• Can be used for compression only because there is no
decompression
Report. 2011;60(8):1–19

Lifebelt
• Manual device
• For compression only, no decompression
• A provided levarage is pushed against the chest
Report. 2011;60(8):1–19

Lifestick
• Manual device
• Dual handled rigid bar with two short pistons with adhesive pads
• Performs an interposed abdominal compression cardiopulmonary
resuscitation (IAC-CPR) that is abdominal compression alternated with
chest compressions
• This cyclic compressions doubles the flow and allows to decrease
depth of
compression and decrease injury to sternum and ribs
• Compressions should be less vigorous so as to prevent any injury to vital
organs
• So it requires lower compression rates because of its double pumping
effect and danger to injure the abdomen
Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation. 2010;81(10):1305–1352

Autopulse
• Electricaly operated
• Consists of a load distributing band and a backboard
• The band is placed around the chest and tightened and
loosened by the motor
• It has a fixed compression rate of 80/min because it has a
greater effect on hemodynamics at lower compression rates

LUCAS
• Electrically operated
• Piston mounted on a removable frame placed around the
chest
• The frame is fixed on a rigid backboard
• It provides alternate compression with active decompression
by a suction cup that forces thorax back to its uncompressed
volume (recoil)

EM-CPR
• Electrically operated
• Do not exert any force on thorax
• Stimulates contraction of both abdominal muscles and diaphragm by
magnetic impulses generated by coils and such a rhythmic contraction
of abdominal muscles pump blood from abdomen which contains 20-
25% of the total blood
• It also provides negative pressure ventilation with this
mechanism which aids in circulatory output
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2010;122(3):S729–S767

Thumper
• Pneumatically operated
• It has piston mounted on a arm fixed on a supporting column
• Rigiod backboard
• It gives compressions with the rate of 100 compressions per
min
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation. 2010;122(3):S729–S767

When to stop CPR?
• A general approach is to stop CPR after 20 minutes
if there is no ROSC or viable cardiac rhythm re-
established, and no reversible factors present that
would potentially alter outcome.
Nolan JP, Soar J, Zideman DA, et al. European resuscitation council guidelines for resuscitation 2010 section 1: executive summary. Resuscitation. 2010;81(10):1219–1276

• Reasons to cease CPR generally include:
o ROSC -
Resuscitation guidelines require 2 min of CPR post defibrillation prior
to checking for ROSC; may be identified by an upsurge in ETCO2
o Pre-existing chronic illness preventing meaningful recovery ie.
nursing home resident with dementia, disseminated cancer
o Acute illness preventing recovery
ie. 100% burns, non-survivable injuries, catastrophic TBI with no
brain stem reflexes
o No response to ACLS after 20min of efficient resuscitation in absence
of
ROSC, a shockable rhythm or reversible causes

•In the pre-hospital setting a validated rule has been described :
Stop CPR if:
o No return of spontaneous circulation
o No shocks are administered, and
o The arrest is not witnessed by emergency medical-services
personnel
•Otherwise, the rule recommends transportation to the hospital, in
accordance with routine practice

• Other special situations:
oIn a newly born baby with no detectable heart rate that remains undetectable
for 10 minutes, it is appropriate to consider stopping resuscitation
oTraumatic arrest (perform emergency thoracotomy if appropriate;
closed-chest CPR is ineffective)
o When rescuers are exhausted (in the prehospital setting)
oIf the patient is irrefutably dead!! (e.g. rigor mortis, decomposition,
hemisection, decapitation)

PALS
• It is pediatric advanced life support
• For pediatric
1. Cardiac arrest
2. Bradyarrythmias
3. Tachyarrhytmias etc
Part 9: Pediatric Basic Life Support Originally published22 Aug 2000Circulation. 2000;102:I-253–I-290

PALS
• Pediatric CPR is followed with 1-rescuer and 2- rescuer guidelines
• Start with chest compressions as soon as cardiac arrest is detected (no responsiveness, no breathing and
no pulse)
• Chest compressions –
o For children – 1.5 inches to 2 inches deep
o Once the child reaches puberty we can give 2 inches to 2.4 inches deep compressions same like adult
guidelines
o For 1-rescuer –ratio of 30:2 (30 compressions: 2 rescue breath)
o For 2- rescuer – ratio of 15:2
o Compression rate should be 100-120/min

Open the airway

Check for Breathing
LOOK, LISTEN & FEEL

Check for Pulsation
Carotid, Brachial or Femoral

Chest compression

Give 15 effective chest compression
2 fingers technique 2 thumbs technique

2 hands technique 1 hand technique

Give 2 effective Rescue Breaths
Mouth to mouth &
nose technique
Mouse to mouth
technique

PALS
• Mouth to mouth or mouth to nose breathing can be given after
perfoming chin lift head tilt or jaw thrust giving 1 breath every 3-5
seconds with a goal of 12-20 breaths per minute
• Bag and Mask ventilation is always batter and commonly used in
IHCA (In Hospital Cardiac Arrest)
• There is no role of atropine prior to intubation to avoid bradycardia
• Once the AED is available, attach paddles immediately and
simulteneously continue compressions with minimum/no interruptions

PALS
• After giving 2 breaths, immediately give 30 compressions. The
lone rescuer should continue this cycle of 30 compressions
and 2 breaths for approximately 2 minutes (about 5 cycles)
before leaving the victim to activate the emergency response
system and obtain an automated external defibrillator (AED) if
available

PALS
• When child is intubated then give 1 breath every 6 seconds
• Goal in intubated children is to maintain breathing rate of 10
breaths per min
• Defibrillation in pediatric ALS-
o 1ST SHOCK – upto 2 joules per kg
o 2ND SHOCK – upto 4 joules per kg
o SUBSEQUENT SHOCKS – should be more than 4 joules per
kg , maximum upto 10 joules per kg

DRUGS IN PALS
• Adrenaline –
o Dose - 0.01mg/kg
o Repeated every 3-5 mins
o Can be given via endotracheat route with a dose of 0.1 mg/kg
• Amiodarone –
o Dose - 5mg per kg during cardiac arrest
o May repeat 2 times in case of refractory VF or pulseless VT

DRUGS IN PALS
• Lignocaine –
o Loading dose : 1mg per kg
o Maintainance dose : 20-50 micgm per kg per min infusion
o Can repeat bolus dose if infusion started more than 15 mins
after the loading dose

PREGNANCY & CPR
• In pregnant woman, because of gravid uterus and IVC
compression, enough venous return is not achieved so CPR
with 2 – rescuers is recommanded with one rescuer pushing
the uterus to the left side s and 2nd rescuer to give chest
compressions
• Patient should on a flat surface or if IHCA situation and table
can be tilted then slight leftward tilt can be allowable
• Compression rate – 30 compressions: 2 breaths
BMJ. 2003 Nov 29; 327(7426): 1277–1279

Pregnancy & CPR
• Risk of aspiration of gastric content more
• Advanced airway management can be used if available which reduces risk of aspiration
• Emergency C-section should be done
BMJ. 2003 Nov 29; 327(7426): 1277–1279

CONCLUSION
• Understanding BLS and more than that, practicing these techniques is by far
the most challenging task confronting first aid. Taking everything into
consideration, i believe that an adequate education in first aid and basic life
support should be considered an essential aspect of our medical curriculum.
• The simulation-based intervention offers a positively evaluated possibility to
enhance surgeon’s skills in recognizing and handling emergencies.
• Being the sole care-givers for maxillofacial trauma we as maxillofacial
surgeons must be prepared and trained with BLS skills to manage or provide
first aid to the victim.

THE NEED
According to the most current information from the World Health
Organization (WHO) and the Centers for Disease Control (CDC), more
than nine people die every minute from injuries or violence
Motor vehicle crashes (referred to as road traffic
injuries in FIGURE 2)
alone cause more than 1 million deaths annually and
an estimated 20 million to 50 million significant
injuries; they are the leading cause of death due to
injury worldwide.
Improvements in injury control efforts are
having an impact in most developed countries, where
trauma remains the leading cause of death in persons
Significantly, more than 90% of motor vehicle crashes
occur in the developing world.

HISTORY
In February 1976, tragedy occurred that changed trauma care in the “first hour” for injured patients in the United States
and in much of the rest of the world. An orthopedic surgeon was piloting his plane and crashed in a rural Nebraska
cornfield. The surgeon sustained serious injuries, three of his children sustained critical injuries, and
one child sustained minor injuries. His wife was killed instantly. The care that he and his family subsequently
received was inadequate by the day’s standards. The surgeon, recognizing how inadequate their treatment
was, stated: “When I can provide better care in the field with limited resources than what my children
and I received at the primary care facility, there is something wrong with the system, and the system has to
be changed.
A group of private-practice surgeons and doctors in Nebraska, the Lincoln Medical Education Foundation,
and the Lincoln area Mobile Heart Team Nurses, with the help of the University of Nebraska Medical Center,
the Nebraska State Committee on Trauma (COT) of the American College of Surgeons (ACS), and the Southeast
Nebraska Emergency Medical Services identified the need for training in advanced trauma life support. A
combined educational format of lectures, lifesaving skill demonstrations, and practical laboratory experiences
formed the prototype ATLS course.

‘The development of standardized trauma
training, better prehospital care, and trauma
centers with dedicated trauma teams and
established protocols to care for
injured patients has altered the picture’

INITIALASSESSMENT AND MANAGEMENT

Prehospital Phase
• Emphasize airway maintenance, Control of
external bleeding
• Shock
• Imobilization of the patient
• Immediate transport to the closest appropriate
facility

‘Timing is crucial’
A systematic approach that can be rapidly and accurately applied is essential.This approach, termed
the “initial assessment,” includes the following elements:
•Preparation
•Triage
•Primary survey (ABCDEs) with immediate resuscitation of patients with life-threatening injuries
•Adjuncts to the primary survey and resuscitation
•Consideration of the need for patient transfer
•Secondary survey (head-to-toe evaluation and patient history)
•Adjuncts to the secondary survey
•Continued postresuscitation monitoring and reevaluation

AIRWAY AND VENTILATORY
MANAGEMENT

Supplemental oxygen must be administered to all severely injured trauma patients
Early preventable deaths from airway problems after trauma often result from:
• Failure to adequately assess the airway
• Failure to recognize the need for an airway intervention
• Inability to establish an airway
• Inability to recognize the need for an alternative airway plan in the setting of repeated failed intubation
attempts
• Failure to recognize an incorrectly placed airway or to use appropriate techniques to ensure correct tube
placement
• Displacement of a previously established airway
• Failure to recognize the need for ventilation

Patients with facial burns and/or potential inhalation
injuries are at risk for insidious respiratory compromise, so
consider preemptive intubation
‘’Maintaining oxygenation and preventing
hypercarbia are critical in managing trauma
patients, especially those who have sustained
head injuries’’

• Trauma to the face demands aggressive but careful airway management .
• This type of injury frequently results when an unrestrained passenger is thrown into the windshield or dashboard during
a motor vehicle crash.
• Trauma to the midface can produce fractures and dislocations that compromise the nasopharynx and oropharynx.
Trauma to the face demands aggressive but careful
airway management.

Facial fractures can be associated
• Hemorrhage
• Swelling
• Increased secretions
• Dislodged teeth
• Which cause additional difficulties in maintaining a patent airway
Fractures of the mandible, especially bilateral body fractures, can cause loss of normal airway structural
support, and airway obstruction can result if the patient is in a supine position.

AIRWAY MAINTENANCE TECHNIQUES
The Chin-Lift Maneuver to
Establish an Airway.
Providers should avoid
hyperextending the neck when
using this maneuver
The Jaw-Thrust Maneuver to Establish an Airway.
.

Alternative Technique for Inserting Oral Airway.
• In this technique, the oral airway is inserted upside down
until the soft palate is encountered.
• The device is then rotated 180 degrees and slipped into place
over the tongue.
Do not use this method in children.
Note: Motion of the cervical spine must be
restricted, but that maneuver is not shown in order to emphasize
the airway insertion technique.

Needle Cricothyroidotomy
Needle Cricothyroidotomy. This
procedure is performed by placing a
catheter over a needle or over a wire
using the Seldinger
technique.
Note: Motion of the cervical spine must be restricted, but that
maneuver is not shown in order to emphasize the airway insertion technique.

Surgical Cricothyroidotomy.
A. Palpate the thyroid notch, cricothyroid
interval, and sternal notch for orientation.
B. Make a skin incision over the cricothyroid
membrane and carefully incise the membrane
transversely.
C. Insert a hemostat or scalpel handle into the
incision and rotate it 90 degrees to open the
airway.
D. Insert a properly sized, cuffed endotracheal
tube or tracheostomy tube into the cricothyroid
membrane incision, directing the tube distally
into the trachea

SHOCK
The first step in the initial management of shock
is to recognize its presence.

The most effective method of restoring adequate cardiac output, end-organ
perfusion, and tissue oxygenation is to restore venous return to normal by
locating and stopping the source of bleeding. Volume repletion will allow
recovery from the shock state only when the bleeding has stopped.
Definitive control of hemorrhage and restoration of adequate circulating
volume are the goals of treating hemorrhagic shock.
The presence of shock in a trauma patient warrants the immediate involvement of a
surgeon.
Strongly consider arranging for early transfer of these patients to a trauma center when
they present to hospitals that are not equipped to manage their injuries.

Assessment of circulation includes rapidly determining the site
of blood loss. In addition to the floor, blood may be in four
other places (“on the floor plus four more”): A. the chest; B. the
abdomen; C. the pelvis and retroperitoneum; and D. major long
bones and soft tissues.
Using ultrasound (FAST) to search for the cause
of shock

HEAD TRAUMA
The primary goal of treatment for patients with
suspected TBI is to prevent secondary brain injury

The three layers of the meninges are the dura mater, arachnoid mater, and pia mater.

Unequal pupils: the left is greater than the right.
Lateral (Uncal) Herniation. A lesion of the middle
meningeal artery secondary to a fracture of the
temporal bone
may cause temporal epidural hematoma. The uncus
compresses the
upper brain stem, involving the reticular system
(decreasing GCS),
the oculomotor nerve (pupillary changes), and the
corticospinal

The Monro–Kellie Doctrine Regarding Intracranial
Compensation for Expanding Mass.
The total volume of the intracranial
contents remains constant.
If the addition of a mass such as a hematoma compresses an
equal volume of CSF and venous blood, ICP remains
normal. However, when this compensatory mechanism is
exhausted, ICP increases exponentially for even a small
additional increase in hematoma volume.
(Adapted with permission from Narayan RK: Head Injury. In:
Grossman RG, Hamilton WJ eds., Principles of Neurosurgery.
New York, NY: Raven Press, 1991.)

Algorithm for Management of Mild Brain Injury.
(Adapted with permission from Valadka AB, Narayan
RK, Emergency room
management of the head-injured patient. In: Narayan
RK, Wilberger JE, Povlishock JT, eds., Neurotrauma. New
York, NY: McGraw-Hill, 1996.)

PEDIATRIC TRAUMA
Injury remains the most common cause of death and
disability in childhood. Injury morbidity
and mortality surpass all major diseases in children
and young adults, making trauma the
most serious public health and health care problem in
this population.

GERIATRIC TRAUMA
When managing geriatric patients with trauma, the
effects of aging on physiological function
and the impact of preexisting conditions and
medications cannot be overemphasized.

BLS ATLS presentation Basic Life Support

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