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Cardio-Pulmonary and Cerebral Resuscitation Lecture 1 Department of Anesthesiology and Intensive Care The head of a department : I.Titov, DrPh. The theme of lecture N 1. Cardiopulmonary resuscitation. Symptoms of clinical death . Safar’s triple manoeuvre. Breathing.

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Cardio-Pulmonary and Cerebral Resuscitation

Lecture 1

Department of Anesthesiology and Intensive Care

The head of a department: I.Titov, DrPh.

The theme of lecture n 1
The theme of lecture N 1

  • Cardiopulmonary resuscitation. Symptoms of clinical death. Safar’s triple manoeuvre. Breathing.

  • Cardiopulmonary resuscitation. Chest compression. Complications of the CPR.

Part ii cardiopulmonary resuscitation
Part II. Cardiopulmonary resuscitation


  • For normal functioning all cells of the body require oxygen. If oxygen is not provided, death of organism appears within 4..5 minutes.

  • Brain is the tissue most susceptible to anoxia (absence of oxygen).

Part ii cardiopulmonary resuscitation1
Part II. Cardiopulmonary resuscitation

Process of the death

Is not a momentary but stepwise process, which can take certain time.

Five steps of the death:

  • Preagony

  • Terminal pause

  • Agony

  • Clinical death (reversible injury)

  • Biological death (irreversible injury)

Part ii cardiopulmonary resuscitation2
Part II. Cardiopulmonary resuscitation

Agony isa stage which precede to the death. Function of vital organs is severe disturbed, and conditions required for survival of organism cannot be met.

  • Unconsciousness

  • Blood pressure is undetectable

  • No pulse on arteries

    Clinical death: circulation stops completely and that leads to the cessation of breathing and nervous system activity.

Part ii cardiopulmonary resuscitation3
Part II. Cardiopulmonary resuscitation

Symptoms of clinical death

  • No pulse on arteries(carotid or femoral)

  • Change of skin colour

  • Unconsciousness

  • Gasping, cessation of breathing

  • Dilatation of eye pupils

    Duration of clinical death is 3(5) minutes

Part ii cardiopulmonary resuscitation4
Part II. Cardiopulmonary resuscitation

Biological death is irreversible condition. Metabolism and functioning of vital organs has completely ceased. Organ damage is as extensive that resuscitation of the body is impossible.

Evident symptoms of the death:

  • Rigor mortis

  • Death spots on the body

  • Drop of body temperature to the level of the surrounding

Part ii cardiopulmonary resuscitation5
Part II. Cardiopulmonary resuscitation

  • Adult BLS sequence

    Basic life support consists of the following actions:

    1. Make sure that the victim, any bystanders, and you are safe.

    2. Check the victim for a response (gently shake his shoulders and ask loudly, “Sir. Or Ms., are you all right?”)

    3 A. If he responds:

  • Leave him in the position in which you find him provided there is no further danger.

  • Try to find out what is wrong with him and get help if needed.

  • Reassess him regularly.

Part ii cardiopulmonary resuscitation6
Part II. Cardiopulmonary resuscitation

  • Adult BLS sequence

    3 B. If he does not respond:

  • Shout for help, call 911 (USA and Canada) or 03 (Ukraine and Russian Fed)

  • Turn the victim onto his back and then open the airway using head tilt and chin lift:

    - place your hand on his forehead and gently tilt head back.

    - with your fingertips under the point of the victim’s chin, lift the chin to open the airway.

Part ii cardiopulmonary resuscitation7
Part II. Cardiopulmonary resuscitation

  • Adult BLS sequence

  • 4. Keep the airway open, look, listen, and feel for normal breathing.

  • Look for chest movement

  • Listen at the victim’s mouth for breath sounds.

  • Feel for air on your cheek

    Look, listen and feel for no more than 10 sec to determine if the victim breathing normally.

Opening the airway
Opening the airway

  • Head tilt

  • Chin lift

  • If cervical spine injury suspected:

    • jaw thrust

Assess breathing
Assess Breathing

  • Look for chest movement

  • Listen for breath sounds

  • Feel for expired air

  • Assess for 10 seconds before deciding breathing is absent

Rescue breathing expired air ventilation
Rescue breathing(Expired air ventilation)

If he is not breathing normally:

Ask someone to call for an ambulance.

  • Kneel by the side of the victim.

  • Pinch the soft part of the victim’s nose, using the index finger and thumb of your hand on his forehead.

  • Allows his mouth to open, but maintain chin tilt.

  • Take a normal breath and place your lips around his mouth, making sure that you have a good seal.

Part ii cardiopulmonary resuscitation8
Part II. Cardiopulmonary resuscitation

  • Blow into his mouth and look on his chest, chest must rise; take about one second to make his chest rise as in normal breathing; this is an effective rescue breath.

  • Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest.

  • Take another normal breath and blow into the victim’s mouth once more to give a total of two effective rescue breaths.

  • Give each rescue breath over 1 sec rather than 2 sec.

Assess circulation
Assess Circulation

Check the victim’s pulse.

A. If pulse on the carotid artery is not palpable – begin chest compression.

  • Place the heel of one hand in the centre of the victim’s chest.

  • Place the heel of your other hand on the top of the first hand.

  • Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs. Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone).

Part ii cardiopulmonary resuscitation9
Part II. Cardiopulmonary resuscitation

  • 30 compressions : 2 breaths for

    • 1-person CPR

    • 2-person CPR

Part ii cardiopulmonary resuscitation10
Part II. Cardiopulmonary resuscitation

  • Chest compressions:

  • Depress sternum 4-5 cm

  • Rate: 100 per minute

Precordial blow

  • Indications:

  • Confirmed of blood circulation stop

Continue resuscitation until
Continue resuscitation until:

  • Qualified help arrives and takes over

  • The victim shows signs of life

  • You become exhausted

Airway management and ventilation
Airway management and ventilation

  • Basic airway management and ventilation

  • The laryngeal mask airway and Combitube

  • Advanced techniques of airway management

  • Basic mechanical ventilation

Safar s triple manoeuvre
Safar’s triple manoeuvre

  • Open mouth

  • Head Tilt and Chin Lift

Ventilation by mouth through a mask
Ventilation by mouth through a mask

  • Advantages:

  • Allows to avoid direct contact

  • Reduces probability of infected

  • Allows to raiseO2

  • Restrictions:

  • Tightness maintenance

  • Stomach inflating

Ventilation by means of bag mbu


Direct contact allows to avoid

Allows to increase concentration О2 - to 85 %

Can be used with an obverse mask, LМ, Combitube, endotracheal tube


At use with an obverse mask:

Risk of inadequate ventilation

Risk of inflating of a stomach

4 hands are necessary for optimum use

Ventilation by means of bag Аmbu

Laryngeal mask


Speed and simplicity of installation

Presence of the different sizes

More effective ventilation in comparison with an obverse mask

Allows to avoid laryngoscopy


Does not protect from aspiration

Does not approach in situations when high pressure use on a breath is required

It is impossible to aspirate from bottom BP

Laryngeal mask

Installation of pharyngo oral an air line
Installation of pharyngo-oral an air line

Installation of pharyngonasal an air line
Installation of pharyngonasal an air line



Speed and simplicity of installation

Allows to avoid laryngoscopy

It is possible to use, when pressure upon a breath the high


It is accessible only 2 sizes

There is a risk of ventilation through a gastric gleam

Damage of cuffs at installation

Trauma in an installation time

Only for disposable use


Intubation of t racheas
Intubation oftracheas

Attempt of intubation:

  • Preoxygenation of the patient

  • 30 seconds on each attempt

  • Spend a tube through a vocal crack under the control of direct sight

  • At any doubts or complexities, reoxygenation the patient before the subsequent attempts

  • Patients are harmed by unsuccessful attempts of oxygenation, instead of intubation!

Installation of endotracheal tube
Installation of endotracheal tube

Intubation of trachea


Allows to increase PO2 to 100 %

Isolates BP, preventing of aspiration

Allows aspirated of BP

Alternative way for introduction of medicine


Training and experience are absolutely necessary

Unfortunate attempt, esophageal intubation

Risk of deterioration of damage back and a brain during laryngoscope

Intubation of trachea

Confirmation of correct position of ett in a trachea
Confirmation of correct position of ETT in a trachea

  • Direct visualisation during laryngoscope

  • Auscultation:

    • With two sides, on average axillary's lines

    • Over epigastrium

  • Symmetric movements of thorax during ventilation

Sellick s manoeuvre
Sellick”s manoeuvre

  • Pressure on cricoid cartilage on purpose of occlusion a gullet about cervical department of a backbone

Sellick s manoeuvre1


Decrease of risk of aspiration and regurgitation

It can be applied at intubation, and also ventilation by means of an obverse mask and LM


Can complicate intubation

Can complicate ventilation by means of an obverse mask or LM

Avoid at active vomiting

Sellick”s manoeuvre



  • Impossibility of maintenancepassableness of BP in another way


  • Displacement of cannula

    • Emphysema

    • Bleeding

    • Gullet punching

  • Hypoventilation

Rhythm of a stop of blood circulation
Rhythm of a stop of blood circulation

  • Fibrillation of ventricles

  • Ventricle's tachycardia «without pulse»

  • Asystole

  • Electro-mechanical dissociation (EMD)


  • There is no activity of ventricles (complex QRS)

  • Activity of auricles (waveP) can be

  • Seldom straight line

  • Possibility of small waves ofVF

The mechanism of defibrillation
The mechanism of DEFIBRILLATION

  • Definition

    • “The termination of fibrillation or absence VF/VT in 5 seconds after the discharge”

  • Depolarized all weight of a myocardium

  • Natural pacemeker renew job

Automatic external defibrillator
Automatic external DEFIBRILLATOR

  • Analyze a heart rhythm

  • Make the discharge

  • Specificity in recognition of the rhythm in subject which is defibrillation comes nearer to 100 %

Automatic external defibrillator1
Automatic external DEFIBRILLATOR

  • Attach sticky electrodes

  • Follow the sound and visual instruction

  • The automatic analysis of an electrocardiogram - do not touch the patient

  • The automatic discharge at a corresponding rhythm

  • +/-a manual overload

Manual defibrillation

It is based on:

  • The rhythm is recognised by the operator

  • The operator puts the discharge

  • It can be used for synchronised cardioversion

Safety of defibrillation
Safety of defibrillation

  • Never hold both electrodes in one hand

  • Charge only when electrodes on a breast of the victim

  • Avoid direct or indirect contact

  • Wipe dry a breast of the patient

  • Remove oxygen from a zone of defibrillation

Manual defibrillation 1

  • Diagnostics VF/VTandsigns of a stop of blood circulation

  • Choice of suitable energy of the discharge

  • To load condensers (electrodes on the patient)

  • The command “all to depart”

  • Visual check of a zone of defibrillation

  • To check up the monitor

  • The discharge

Manual defibrillation 2

  • Repeatedly to estimate a rhythm

  • To hold electrodes on a breast between discharges

  • To increase energy

    • The assistant makes, or

    • To place an electrode on defibrillator and to choose energy level independently

  • Not to spend BLS between discharges if there is no long delay

The conclusion
The conclusion

  • Defibrillation it is unique effective at restoration of circulation at patients with VF or VT without pulse

  • Defibrillation should it is spent quickly, effectively and safely

  • New technologies increase possibilities of equipment and simplify use

The central venous access
The central venous access

  • Internal jugular vein

  • Subclavianvein

Complications of catheterization the central veins
Complications of catheterization the central veins

  • Artery puncture

  • Hematoma

  • Hemothorax

  • Pneumothorax

  • Air embolism

  • Damage of surrounding fabrics

  • Аrrhythmias

Intatracheal introductin of medicines

Preparations whichcanit is entered into a trachea:





Preparations whichcannotbe entered into a trachea:


Sodium bicarbonate


Intatrachealintroductin of medicines



  • Any rhythm at a blood circulation stop

  • Bradycardia

  • Special circumstances:

  • Anaphylactic shock



  • 1 mg I\Vin10 1:10,000 (1 ml 1:1,000) every 2-3 minat resuscitation

  • 2-3 mgthrowEТТ

  • 2–10 mkg min-1 atbradycardia resistant to atropine

  • 0.5ml 1:1,000 i/m, 3-5 ml 1:10,000 i/v

    at anaphylactic shock, in depending on weight



  • a-agonist:

    - arterial vasoconstriction

    ­ ОПСС

    ­ a cerebral and coronary blood-groove

  • b-agonist ­ ↑ HC

    ­ ↑forces of heart reductions

    ­ requirements of a myocardium for oxygen (can strengthen an ischemia)



  • Asystole

  • Bradycardia

  • EMD (F of HC< 60 in min)



  • Blockade of effects of nervus vagus

  • Strengthening of automatism of sinoatrial node

  • Increase А-В of conductivity



  • Asystole / EMD (F of HC< 60 in min)

    • 3 mgi/v, unitary

    • 6 mgthrowEТТ

  • Bradycardia

    • 0.5mgi/v, to repeat at necessity, maximum 3 mg



  • RefractoryVF / VT without pulse

  • Hemodynamic stable VT

  • Other resistant tachyarrhythmia



RefractoryVF / VT without pulse

300 mg in 20 ml 5% dextrose, i/v


  • 150 mg in 20 ml 5% dextroseduring10 min

  • Repeat 150 mg at necessity

  • 300 mgin100 ml 5% dextroseduring1 hour



  • Increases duration of potential of action

  • Extends interval Q-T

  • Weak negative inotropic action - can call a hypotension



  • RefractoryVF / VT without pulse

    • at inaccessibility of amiodaroni

  • Hemodynamic stable VT

    • as alternative for amiodaroni



  • RefractoryVF / VT without pulse

    • 100 mgi/v

    • afterboluses 50 mg, max 200 mg

  • Hemodynamic stable VT

    • 50 mgi/v.

    • afterboluses 50 mg, max 200 mg

  • To lower a dose at elderly and at hepatic insufficiency

Sodium bicarbonate
Sodium bicarbonate


  • Heavy metabolic acidosis (pH <7.1)

  • ↑ K in blood

  • Special circumstances

  • Poisoning by energizers

Sodium bicarbonate1
Sodium bicarbonate


  • 50 mmol (50 ml 8.4% solution) i/v

Sodium bicarbonate2
Sodium bicarbonate


  • Alkaline agent (increase pH)

  • Butcan call:

    • Increase in loading СО2

    • Reduction of liberation О2 in fabrics

    • Decrease contractility of myocardium

    • Increase Na in blood

  • Co-operates with adrenaline


  • Action:

  • It is necessary for normal reduction of a myocardium

  • Surplus can call arrhythmia

  • The trigger of  destruction of cages ischemic myocardium

  • Surplus can break brain restoration



  • EMDcalling by :

    • ↑ K in blood

    • ↓ Ca in blood

    • Overdose of calcium blocker

      Dose :

  • 10 ml 10% Ca Cl (6.8 mmol\l)

    Not to enter at once before or after bicarbonate sodium



  • Overdose of opiates

  • Oppression of breath after appointment of opiates



  • 0.2 - 2.0 mgi/v

  • It can be demanded repeatedly, possible to 10 mg

  • Infusion can be demanded

To estimate


+/- check up pulse


Defibrillation X 3

if necessary

Ventricle fibrillation

/ Ventricletachycardia

without pulse

СРR 1 min


Discharge200 J*

Discharge 200 J*

Discharge 360 J*

  • To make 3 dischargesif it is necessary, in a current of 1 minute

  • Not to interrupt defibrillation for BLS

  • After the discharge, palpate pulse on carotids, only if on an electrocardiogram a rhythm correspondingto job of heart

During СРR

Correction of the reversible reasons

If it is not made:

To check up electrodes, an arrangement and contact

To provide / to check up

- Passableness BP and O2

- Venous access

Adrenaline each 3 mines

To consider:

amidaroni, atropine / pacing buffers

Compression respiratory ways and ventilation
Compression, respiratory ways and ventilation

  • Passableness of respiratory ways:

    • Endotracheal tube

    • LM

    • Combitube

  • After maintenance of passableness of BP do not interrupt a compression for ventilation

Venous access and preparations fv vt
Venous access and preparationsFV/VT

  • The central or peripheral vein

  • Adrenaline of 1 mg i/v or 2-3 mg endotracheal

  • To consider amiodaroni 300 mg if FV/VT present after 3rd category

  • Alternatively - lidocaine of 100 mg

  • To consider magnesium 8 mmol

False asystole
False asystole

  • When monitoring with paddle-gel pads

  • More likely with increasing number of shocks and high chest impedance

  • Displays apparent “asystole”

  • Confirm rhythm with monitoring leads