CCLS

COMPREHENSIVE
CARDIOPULMONARY LIFE
SUPPORT
PRESENTED BY
R/N SURIYA PRAKASH V
PREFACE
 The cardiopulmonary Resuscitation (CPR) guideline for Comprehensive cardiopulmonary Life
Support [CCLS] is for management of adult victims with cardiopulmonary arrest inside the
hospital .
 Suggest an algorithmic approach for trained medics and paramedics to achieve optimal goal.
 The CCLS guideline emphasise the need to recognise patients at risk for cardiac arrest and their
timely management before a cardiac arrest occurs.
 The basic components of CPR include
 Chest compressions for blood circulation;
 Airway maintenance to ensure airway patency; lung ventilation to enable oxygenation and
defibrillation to convert a pathologic ‘shockable’ cardiac rhythm to one capable to maintaining
effective blood circulation. CCLS emphasises incorporation of airway management, drugs, and
identification of the cause of arrest and its correction, while chest compression and ventilation
are ongoing. It also emphasises the value of organised team approach and optimal post-
resuscitation care.
 The cardiac arrest victims require Comprehensive management , starting from basic care and
subsequent early advance care. This presentation covers all the steps of resuscitation after
cardiac arrest inside the hospital, with an aim to integrate the basic and advanced component of
CPR.
DEFINITION
 Comprehensive cardiopulmonary life support
(CCLS) for management of the patient with
cardiopulmonary arrest in adults provides an
algorithmic step-wise approach for optimal outcome of
the patient inside the hospital by trained medics and
paramedics.
CORE LINK IN CCLS
 The five essential core links of CCLS include:
1. Early recognition and management of pre‑arrest conditions
2. Early recognition of arrest and activation of Code blue
3. Early high ‑ quality CPR
4. Early defibrillation
5. Early comprehensive life support and postresuscitation care.
Early High ‑ quality
cardiopulmonary resuscitation
 Once the cardiopulmonary arrest is recognised, the cycles of 30 chest
compressions and 2 breaths should be initiated. To ensure optimised chest
compressions, patients should be placed supine on a hard bed, on the ground
or a hard board may be slipped behind the back of the patient to prevent
backward movement of the vertebral column during the compressions.
 The 30 chest compressions should be started at the speed of 120
compressions/min and compression depth of 5 cm–6 cm. The rescuer should
chant loudly 1, 2, 3, 4,....30 to optimise the speed and number of chest
compressions.
 The rescuer should allow complete chest recoil between compressions without
lifting the hand from the chest but without leaning on the patient’s chest.
 Place the palmar surface of his hand on the centre of chest by identifying the
xiphoid process and keeping heel of the hand 2 fingers above it for chest
compressions, and ensure that the elbows are locked in extension so that his
body weight rather arm movements facilitate the compression. There should
be minimum interruptions between chest compression.
The rescuer providing chest compressions and the one providing breath
should interchange their role after every 5 cycles of CPR to prevent rescuer
exhaustion and to maintain effective CCLS, especially chest compression.
After 5 cycles of 30 chest compressions and 2 breaths*, the patient should be
reassessed with carotid pulse check.
During the pulse check, the possible situations are:
• Pulse present: Check for the presence of breath. If absent, provide breath every 5 s and
reassess every 2 min. In case of the presence of breath, reassess every 2 min and shift
the patient to a monitored area and correct the underlying aetiology .
• Pulse absent: Continue with another 5 cycles of 30 chest compressions and 2 breaths
and reassess the carotid pulse.
• In case the patient’s airway is already secured with an endotracheal tube, then chest
compressions should be given continuously at a rate of 120 compressions/min without
interruption, and 1 breath should be delivered every 6 seconds (10 breaths/min), rather
than cycles of 30 chest compressions and 2 breaths. The rescuer performing
compressions must rotate, approximately every 2 min, to ensure high-quality CPR.
AIRWAY MANAGEMENT
 The definitive airway may be secured with an endotracheal
tube in case expertise is available. The use of supraglottic
devices is also advocated if rescuer is appropriately trained
and endotracheal tube placement is not feasible or
successful.
 The correct placement of these devices must be verified after
their placement. The use of end-tidal capnography is
recommended to verify their correct placement.
 However, if the BMV is optimal, then securing definitive
airway can be deferred to prevent unnecessary interruption
of chest compression. In such cases, BMV should be
continued till expert help arrives.
EARLY DEFIBRILLATION
 Defibrillator: Follow the steps to prepare for defibrillation:
 1. Switch on the defibrillator
 2. Attach electrocardiogram (ECG) leads of the defibrillator or keep paddles on
the chest (one at apex of heart at left side of the chest and other below the clavicle
on the right side in midclavicular line). Continue CPR during lead attachments
 3. Analyse the rhythm. No rescuer should touch the patient during rhythm analysis
 4. If the rhythm is shockable (ventricular fibrillation [VF] and pulseless VT),
charge the defibrillator at 120 J (biphasic). Continue chest compression during
charging. Deliver the shock after ensuring that no rescuer is touching the patient or
his bed. After delivery of the shock, resume CPR, starting with chest compression.
Subsequent shock may be same or escalated to higher dose with maximum of 200
J (biphasic). In case of monophasic defibrillator, the initial and subsequent energy
for defibrillation should be 360 J
 5. If rhythm is non-shockable (asystole and PEA), then immediately resume CPR
cycles starting with chest compressions.
Venous access
 Venous access should be secured during ongoing chest
compression and ventilation. The peripheral venous
access is the most preferred.
 In case the venous access is not secured in initial 3

attempts, then the second choice remains intraosseous

(IO) cannulation. All drugs and fluids may be
administered through the IO route similar to
intravenous access. However, it should be replaced
with intravenous access at the earliest.
Drugs including
antiarrhythmics
 Once the vascular access is secured, adrenaline (epinephrine) 1 mg
diluted in 10 mL should be administered as bolus, irrespective of the
type of heart rhythm. This bolus needs to be repeated every 3–5 min.
 All drugs administered through peripheral venous access must be flushed
with 20 mL of normal saline. Whenever feasible, the limb should also be
elevated for 10–20 s after administration of the drug to facilitate its
passage to the central circulation. Drugs should be administered during
chest compression, so as to ensure their systemic distribution.
 If arrhythmias persist even after initial 2–3 cycles of CPR, then
antiarrhythmics drugs are warranted. Amiodarone 300 mg should be
administered intravenous as a slow bolus. A second intravenous dose of
amiodarone 150 mg may be administered if arrhythmia persists.
Lignocaine may be considered as an alternate drug in patients with
persistent arrhythmia.
Assess and manage the
reversible causes
 The common causes for a cardiorespiratory arrest
include hypovolaemia, hypoxia, acidosis, electrolyte
imbalance, pneumothorax, cardiac tamponade, drug
toxicity, pulmonary embolism and myocardial
infarction. They need to be primarily addressed on
clinical examination and blood investigations.
Transfer
 After successful resuscitation, the patient needs
definitive medical care and management for underlying
aetiology of the cardiopulmonary arrest. Patient should
be shifted to a high dependency unit or critical care
unit. If the cause of cardiac arrest is underlying
neurological or cardiac disease, the patients may be
shifted to speciality setting of the hospital for an
appropriate early intervention and optimal recovery.
The patient should receive appropriate post-
resuscitation care.
 The assessment and management can be remembered
with the mnemonic “HIT THE TARGET”
H – Hypoxia
I – Increase H ions(Acidosis)
T- Tension pneumothorax
T- Toxins/poisons
H- Hypovolemia
E- Electrolyte imbalance
T- Tamponade cardiac
A- Acute Coronary Syndrome
R- Raised Intracranial Pressure(subarachnoid Hemorrhage)
G- Glucose(Hypoglycemia/Hyperglycemia)
E- Embolism(pulmonary/thrombosis)
T – Temperature(Hypothermia)
Post ‑ resuscitation care
 Once there is ROSC, patient requires specific care in a dedicated unit. During this
period, not only are maintenance of perfusion and oxygenation paramount but also the
correction of precipitating cause of cardiac arrest needs to be addressed.
 Ventilatory support may be continued as per patient assessment to maintain
normocarbia (end-tidal CO2 35–40 mmHg). During resuscitation, highest oxygen
concentration is recommended but after return of circulation, the inspired fraction of
oxygen (Fio2 ) should be titrated to maintain oxygen saturation at 95% or more.
 These ventilatory parameters and targets may be tailored as per patient need. Specialist
consultation is essential for assessment for the need of coronary or neurological
interventions. The haemodynamic monitoring should be initiated with a target of mean
arterial pressure of >65 mmHg.
 The optimal blood pressure should be ensured for optimal perfusion of vital organs. In
case, if patient remains comatose after resuscitation, active warming must be avoided.
Temperature may be kept not >36ºC and not necessarily in the range of 32ºC–36ºC, in
the absence of controlled hypothermic equipment. Prophylactic antiepileptic drugs are
not recommended but, if seizures occur, then drug therapy should be initiated.
Quality assurance of comprehensive
cardiopulmonary life support (CCLS)
 Conduct High-quality CCLS, and not just following the steps of CCLS, is paramount
for an optimal outcome after a cardio-respiratory arrest. Emphasis on continued real-
time quality check for CPR is essential. The various aspects that enhance the outcome
include:
 Chest Compressions
1. Chest compressions speed, rate and recoil: Ensure a chest compression speed of 120
compressions/min to a depth of 5–6 cm
2. Allow complete chest recoil between compression without lifting hands from the chest (do not lean
on the patient’s chest)
3. Do not stop chest compressions unnecessarily.
 Ventilation and Airway
1. Do not unnecessarily interrupt chest compression for securing the airway
2. Do not hyperventilate
3. End point for ventilation is visible chest rise after a normal tidal volume breath.
4. Monitor end-tidal capnography. If it is <10 mmhg , then the CPR quality is inadequate and needs
improvement.
 If intra-arterial pressure monitoring is available or feasible, then relaxation phase
pressure (diastolic) .
Team dynamics
DISCUSSION
TIME
 SUPRAVENTRICULAR TACHYCARDIA