pediatric

bls

Basic Life Support

Page 1 of 26 PBLS 2009

Supervisors
Prof Mona el-samahy Head of the fifth unit of Pediatric medicine

Assistant Prof Mervat Jamal

EDITED BY
MOHAMED AHMED AED 841
MOHAMED AHMED BADR 842
MOHAMED AHMED BADAWY 843
MOHAMED AHMED AMER 845
MOHAMED AHMED ABAS 846
MOHAMED AHMED ABD EL-HALEEM 847
MOHAMED AHMED SAKR 848
MOHAMED AHMED MOSA 850
MOHAMED AHMED GHANEM 851
MOHAMED AHMED F OUAD 852
Page 2 of 26 PBLS 2009

INDEX
CALENDAR

ACKNOWLEDGMENT

TITLE

OBJECTIVES

DEFINITION

INTRODUCTION

THE BLS SEQUENCE FOR INFANTS AND CHILDREN

SAFETY OF RESCUER AND VICTIM

CHECK FOR RESPONSE AND ACTIVATE THE EMS SYSTEM

POSITION THE VICTIM

OPEN THE AIRWAY

CHECK BREATHING

PULSE CHECK

CHEST COMPRESSIONS

COORDINATE CHEST COMPRESSIONS AND BREATHING

COMPRESSION ONLY CPR

ACTIVATE THE EMS SYSTEM AND GET THE AED

DEFIBRILLATION

FOREIGN-BODY AIRWAY OBSTRUCTION (CHOKING )

SPECIAL RESUSCITATION SITUATIONS
DIFFERENCES BETWEEN EUROPEAN AND AMERICAN GUIDELINES

STATISTICS BLS

RESULTS

SUMMARY

REFERENCES
Page 3 of 26 PBLS 2009

Calendar
DAY ACTION
2-11-2009 First meeting for discussion and choosing the subject.
5-11-2009 Choosing BLS. As a subject. Studying the American and UK
guidelines.
12-11-2009 Practical learning BLS.
14-11-2009 Distribute responsibilities
19-11-2009 Discussing the questionnaire.
20-11-2009 Remolding of the questionnaire by dr. Mervat.
21-11-2009 Pre-teaching questionnaire distribution. Teaching our colleges.
23-11-2009 Post-teaching questionnaire distribution.

Acknowledgment
We are grateful to Prof. Prof Mona el-samahy the Head of the fifth unit of Pediatric medicine,
dr. Mervat Jamal who gives us a lot of her time, effort and patience, to our colleges
whose were positive participant in practical part of the search and to all the members of
the team.
Page 4 of 26 PBLS 2009

Title: Pediatric Basic life support

Objectives:
• Save lives.
• Filling our gap of knowledge about basic life support.
• Teaching our colleges BLS Technique: Successful participants will be
able to: Demonstrate the ability to identify patients who require BLS.
Demonstrate recognition of major life threatening situations including
full arrest, respiratory arrest and foreign body airway obstruction.
Demonstrate understanding of new BLS for Healthcare guideline
changes and perform the guidelines in an emergency situation.
• Follow most recent guide lines in BLS.

Definition
Basic life support (BLS) is a level of medical care which is used for patients with life-
threatening illness or injury until the patient can be given full medical care. It can be
provided by trained medical personnel, including emergency medical technicians, and
by laypersons who have received BLS training. BLS is generally used in the pre-hospital
setting, and can be provided without medical equipment.

Introduction
BLS generally does not include the use of drugs or invasive skills, and can be
contrasted with the provision of Advanced Life Support (ALS). Most laypersons can
master BLS skills after attending a short course. Firefighters and police officers are
often required to be BLS certified. BLS is also immensely useful for many other
professions, such as daycare providers, teachers and security personnel.

CPR provided in the field buys time for higher medical responders to arrive and provide
ALS care. For this reason it is essential that any person starting CPR also obtains ALS
support by calling for help via radio using agency policies and procedures and/or using
an appropriate emergency telephone number.

An important advance in providing BLS is the availability of the automated external

defibrillator or AED, which can be used to defibrillation or delivery. This improves
survival outcomes in cardiac arrest cases.
Page 5 of 26 PBLS 2009

Basic life support consists of a number of life-saving techniques focused on the

medicine "ABC"s of pre-hospital emergency care:

• Airway: the protection and maintenance of a clear passageway for gases

(principally oxygen and carbon dioxide) to pass between the lungs and the
outside of the body
• Breathing: inflation and deflation of the lungs (respiration) via the airway
• Circulation: providing an adequate blood supply to the body, especially critical
organs, so as to deliver oxygen to all cells and remove carbon dioxide, via the
perfusion of blood throughout the body,

Healthy people maintain the ABCs by themselves. In an emergency situation, due to

illness (medical condition) or trauma, BLS helps the patient ensure his or her own
ABCs, or assists in maintaining fir the patient who is unable to do so. For airways, this
will include maintaining optimal angles or possible insertion of oral or nasal adjuncts, to
keep the airway unblocked. For breathing, this may include artificial respiration, often
assisted by emergency oxygen. For circulation, this may include bleeding control or
Cardiopulmonary Resuscitation (CPR) techniques to manually stimulate the heart and
assist its pumping action. In each case, the BLS provider is trained to detect ABC
problems and attempt to correct them.

BLS also typically includes considerations of patient transport such as various forms
immobilization to prevent additional injury, including cervical collars, splinting limbs, and
full body splints (backboards).

THE BLS SEQUENCE FOR INFANTS AND CHILDREN:

S AFETY OF RESCUER AND VICTIM

Always make sure that the area is safe for you and the victim. Move a victim only to
ensure the victim’s safety. Although exposure to a victim while providing CPR carries a
theoretical risk of infectious disease transmission, the risk is very low. (1)

Check for Response and activate the EMS system:

-Gently tap the victim and ask loudly, “Are you okay?” Call the child’s name if you know it.
-Look for movement:
Page 6 of 26 PBLS 2009

(1) IF THE CHILD IS RESPONSIVE,

he or she will answer or
move. Quickly check to see
if the child has any injuries or
needs medical assistance. If
necessary, leave the child to
phone EMS, but return
quickly and recheck the
child’s condition frequently.
Children with respiratory
distress often assume a
position that maintains
airway patency and
optimizes ventilation. Allow
the child with respiratory
distress to remain in a
position that is most
comfortable.
(2)IF THE CHILD IS
UNRESPONSIVE AND IS NOT
MOVING, shout for help and
start CPR.
If you are alone, continue
CPR for 5 cycles (about 2
minutes). One cycle of CPR
for the lone rescuer is 30
compressions and 2 breaths
then activate the EMS.
If you are alone and there is
no evidence of trauma, you
may carry a small child with
you to the telephone. The
EMS dispatcher can guide
you through the steps of
CPR.
If a second rescuer is present, that rescuer should immediately activate the EMS
system and get an AED (if the child is 1 year of age or older) while you continue CPR.
If you suspect trauma, the second rescuer may assist by stabilizing the child’s cervical
spine . If the child must be moved for safety reasons, support the head and body to
minimize turning, bending, or twisting of the head and neck.
Page 7 of 26 PBLS 2009

Position the Victim:

If the victim is unresponsive, make sure that the victim is in a supine (face-up) position
on a flat, hard surface such as a sturdy table, the floor, or the ground.
If you must turn the victim, minimize turning or twisting of the head and neck.

Open the Airway:

FOR LAY RESCUER: Open the airway using a head tilt-chin lift maneuver for both injured and
non-injured victims. The jaw thrust is no longer recommended for lay rescuers because

• IT is difficult to learned perform

• It is often not an effective way to open the airway
• may cause spinal movement

FOR HEALTH CARE P ROVIDER: A health care provider should use the head tilt-chin lift
maneuver to open the airway of a victim without evidence of head or neck trauma. If there is
cervical spine injury, open airway using jaw thrust without head tilt. (2, 3, 4)

Check Breathing:

While maintaining an open airway, take no more than 10 seconds to check whether the
victim is breathing:

• Look for rhythmic chest and abdominal movement.

• Listen for exhaled breath sounds at the nose and mouth.
• Feel for exhaled air on your cheek. (5, 6)

If the child is breathing and there is no evidence of trauma: turn the child onto the side
(recovery position) .This helps maintain a patent airway and Decreases risk of
aspiration.

GIVE RESCUE BREATHS:

If the child is not breathing: maintain an open airway and give 2 breaths. Make sure that
the breaths are effective (i.e. the chest rises) .

In an infant, use a mouth-to-mouth-and-nose technique.

In a child, use a mouth-to-mouth technique but pinch the nose closed to avoid passage
of air outside from the nose. (7)
Page 8 of 26 PBLS 2009

BARRIER DEVICES:

Some health care providers and lay rescuers may hesitate to give mouth-to-mouth

Rescue breathing and prefer to use a barrier device (8-10). Barrier devices have not
reduced the risk of transmission of infection, and some may increase resistance to air
flow. If you use a barrier device, do not delay rescue breathing.

BAG-MASK VENTILATION (HEALTH CARE PROVIDERS)

Bag-mask ventilation can be as effective as end tracheal intubation and safer when
providing ventilation for short period (11-14). But, bag-mask ventilation requires training
and special skills.

VENTILATION BAGS

A self-inflating bag with a volume of at least 450 to 500 mL(15); smaller bags may not
deliver an effective tidal volume(16).

PRECAUTIONS :

(1) AVOID HYPERVENTILATION; USE ONLY THE FORCE AND TIDAL VOLUME NECESSARY TO
MAKE THE CHEST RISE .

(2) DURING CPR FOR A VICTIM WITH AN ADVANCED AIRWAY (E. G., ENDOTRACHEAL TUBE,
ESOPHAGEAL -TRACHEAL COMBITUBE OR LARYNGEAL MASK AIRWAY ) IN PLACE , RESCUERS
SHOULD NO LONGER DELIVER “CYCLES ” OF CPR. THE COMPRESSING RESCUER SHOULD
COMPRESS THE CHEST AT A RATE OF 100 TIMES PER MINUTE WITHOUT PAUSES FOR
VENTILATIONS , AND THE RESCUER PROVIDING THE VENTILATION SHOULD DELIVER 8 TO 10
BREATHS PER MINUTE . TWO OR MORE RESCUERS SHOULD CHANGE THE COMPRESSOR ROLE
APPROXIMATELY EVERY 2 MINUTES TO PREVENT COMPRESSOR FATIGUE AND
DETERIORATION IN QUALITY AND RATE OF CHEST COMPRESSIONS .

IF THE VICTIM HAS A PERUSING RHYTHM (I.E., PULSES ARE PRESENT) BUT NO BREATHING, GIVE
12 TO 20 BREATHS PER MINUTE (1 BREATH EVERY 3–5 SECONDS).

OXYGEN SUPPLY:

(1) Masks: Provide o2 concentration of 30% to 50% to a victim with spontaneous

breathing.

(2) Nasal cannulas: Concentration of delivered o2 depends on: child`s size, respiratory
rate, respiratory effort (17)
Page 9 of 26 PBLS 2009

Two-finger chest compression technique in infant (1 rescuer). Two thumb-encircling hands

chest compression in infant (2 rescuers).

Pulse Check

Try to palpate pulse (brachial in infant or carotid and femoral in a child). No more than
10 seconds to start chest compression. Compression is recommended when pulse is
<60bpm and there is poor perfusion (pallor-cyanosis)

Chest Compressions

Compress lower half of the sternum but not the xiphoid process. Allow chest recoil by
lifting hand slightly off chest. Push hard and fast and minimize interruptions. In infant,
use 2 fingers placed just below mammary line BUT, the 2 thumb encircling technique is
preferred when 2 rescuers are present. In a child, use the heel of 1-hand or 2-hands.103,
104,109,110.

Coordinate Chest Compressions and Breathing

IN 2000, compression\ventilation ratio was 5:1 with 100 compression rate per minute.
Ventilations are less important during 1st minutes of CPR in arrhythmia induced cardiac
arrest. FOR 1- RESCUER the ratio is 30:2 FOR 2-RESCUERS CPR, the ratio is 15:2 (one
should make CPR while the other maintain ventilation) Don’t ventilate and compress at
the same time.

Once an advanced air way is placed,2 rescuers no longer deliver cycles of

compressions interrupted with pauses for ventilation .1The rescuer delivers 100
compressions per minute without pauses for ventilation.29,130

They should change the role every 2 minutes to prevent fatigue and deterioration in
quality(no more than 2 seconds).
Page 10 of 26 PBLS 2009

Compression only CPR

In asphyxia induced arrest, both ventilations and compressions are a mast. But in VF
induced arrest, CPR is more necessary than ventilations. If person unable to do both,
compression is better than no CPR.

Activate the EMS System and Get the AED

In the case of 1 RESCUER, he must do 5 cycles of compression before activating EMS

system.

In the case of 2 RESCUERS, one makes CPR while the other activates EMS system.

Defibrillation

Children with sudden collapse during an athletic event are likely to have VF or
pulselesss VT need rapid defibrillation. They are referred to as "shockable rhythms"
because they respond to electric shocks. It was shown that it is safe and suitable for
children1to8 years of age. However there is no sufficient data for infants less than
1year.36-138

Foreign-Body Airway Obstruction (Choking)

EPIDEMIOLOGY AND RECOGNITION More than 90% of deaths from foreign body airway
obstruction occur in children <5years of age 65 % are infants.

SIGNS OF FBAO Includes respiratory distress with coughing, gagging, stridor, or

wheezing. The characters that distinguish it from other causes are sudden onset and
absence of fever or respiratory symptoms.

RELIEF OF FBAO

In mild cases Don’t interfere and allow him to cough while you observe only.

In severe cases, abdominal thrust (hemlich maneuver) is used in a child while 5 back
slaps followed by chest thrust is used in infant. Abdominal thrust leads to liver damage
in infants. If the victim unresponsive, make CPR but first try to remove foreign body.
Page 11 of 26 PBLS 2009

Special Resuscitation Situations

TRAUMA Remove any dental fragments or any blood debris, stop any external bleeding
by pressure. Use jaw thrust method not head tilt and chain lift.

DROWNING Don't waste time to remove water from the victim. Start CPR by opening
airway, giving 2 effective breaths followed by chest compressions.

Differences between European and American guidelines

European guidelines and American guidelines are almost the same and the main difference is in the
sequence:

• The American guidelines activate EMS system before starting resuscitation while in
European guidelines checks breathing first then call the ambulance.
• In American guidelines cycle of CPR continues for 2 minutes while in European
guidelines it continues for 1 minute
• In American guidelines 2 effective rescue breaths are given while in European 2
effective breaths out of 5
• European guidelines added: If you suspect that there may have been an injury to the
neck, try to open the airway using chin lift or jaw thrust alone. If this is unsuccessful, add
head tilt a small amount at a time until the airway is open
• European guidelines put a criteria for diagnosis of FBAO (foreign body airway
obstruction):

General signs of FBAO Ineffective coughing Effective cough:

 itnessed episode

W
Unable to vocalize
Crying or verbal

Coughing or
Quiet or silent response to
choking cough questions

Sudden onset
Unable to breathe
Loud cough

Recent history of
Cyanosis
Able to take a
playing with or
Decreasing level of breath before
eating small objects Consciousness Coughing

Fully responsive

European guidelines 2005 differ from previous versions in a number of ways:

They allow the rescuer to diagnose cardiac arrest if the victim is unresponsive and not
breathing normally.

Rescuers are taught to give chest compressions in the centre of the chest, rather than
measuring from the lower border of the sternum.
Page 12 of 26 PBLS 2009

Rescue breaths should be given over 1 second rather than 2 seconds.

Rescuers should use the ratio of 30:2 for compressions to breaths, rather than the previous
15:2 or 5:1 ratios.

For an adult victim, the initial 2 rescue breaths should be omitted, so that 30 chest
compressions are given immediately a cardiac arrest has been diagnosed.

These changes were introduced to simplify the algorithm, to allow for faster decision making
maki
and to maximize the time spent giving chest compressions; this is because interruptions in chest
compressions have been shown to reduce the chance of survival. It is also acknowledged that
rescuers may either be unable, or unwilling, to give effective rrescue
escue breaths; in this situation,
continuing chest compressions alone is advised
advised, although this is only effective for about 5
minutes
COMPRESSION-VENTILATION RATIO

Following Guidelines 2005, the compression

compression: ventilation ratio has increased from 15:2 to 30:2,
already emphasizing the importance of minimally interrupted highhigh-quality
quality chest compressions.
Furthermore, unlike the AHA guidelines
guidelines, the ERC guidelines indicate that 30 compressions are
given before attempting ventilation.

CHEST COMPRESSION ONLY:

The European Resuscitation Council continues to recommend the teaching and administration
of high quality, minimally interrupted chest compressions at a rate of 100/minute
minute alternated with
two mouth-to-mouth
mouth ventilations in a ratio of 30:2. For those rescuers who ho are unwilling or
unable to give mouth-to-mouth
mouth ventilations, chest compression
compression-only
only is much more acceptable
than performing no CPR at all. (1818)

Survival with chest compression with and without

assisted ventilation. Five minutes after ventricular
fibrillation, swine were treated for 8 additional minutes
with simulated mouth-to-mouth
mouth exhaled gas ventilation
(17% O2 and 4% CO2) plus chest compression (CC &
vent), chest compression alone (CC alone), or no CPR.
No differences could be detected between groups with
or without ventilation if chest compression was provided.
Both CPR groups tended toward improved survival
compared with no CPR. Open bar indicates return of
spontaneous circulation; solid bar bar, 24-hour survival.
Data from Berg et al.(19)
Page 13 of 26 PBLS 2009

ACTIVE COMPRESSION DECOMPRESSION CPR (ACD CPR):

Background Recent studies have demonstrated improved cardiopulmonary circulation during

cardiac arrest with the use of a hand-held suction device (Ambu Cardio Pump) to perform active
compression-decompression

ACD CPR significantly increased arterial blood pressure, coronary perfusion pressure,
minute ventilation, and negative inspiratory pressure compared with standard CPR.
(20)

Statistics BLS
Studies showed that incidence of cardiac arrest in pediatrics are about 9.8 / 100,000
inhabitants less than 16 years old. (1)

CONCERNING OUT-OF HOSPITAL CARDIAC ARRESTS, the most common causes were
sudden infant death syndrome (SIDS), trauma, and airway related cardiac arrest and
finally near drowning. 78.9% of cardiac arrests were presented as Asystole. 13.5% as
pulseless electrical activity and 3.8% as ventricular fibrillation (VF). (1)

Survival to hospital discharge varied between studies. In one study, survival rate was
12.1% with 4% were neurologically free. Cardiac arrests due to submersion injury have
22.7% overall survival with 6% neurologically free. Trauma (21.9% overall survival and
6.8% neurologically free). Rigorous cardiac arrest (1.1% and 0.3%) (3)

As we see the overall survival rates of CPR are generally very poor. May factors affect
survival after a CPR. Factors associated with favorable outcome are collapse in a public
place, the near-drowning etiology of arrest, bystander initiated CPR and short duration of
resuscitation. (1)

This very poor outcome of CPR isn't in fact due to the ineffectiveness of this procedure,
but the real cause is that most cases of cardiac arrests are unwitnessed and so most
cases receive delayed CPR. This delay is usually associated with poor outcomes.(3).
Unfortunately only 34% of cardiac arrest patients are witnessed, and in 32% of cases
CPR are started by a lay rescuer while 66% of cases are unwitnessed. (4)

In fact studies showed that early access is the weakest link in the chain of survival and
so should receive major attention in the near future.(5)

BUT IN FACT THE PICTURE ISN'T THAT BLACK, many studies showed that CPR is beneficial
in many situations. In a study to determine the effect of immediate resuscitation on
children with submersion injury, it was found that Children with a good outcome were
4.75 times more likely to have a history of immediate resuscitation than children with
Page 14 of 26 PBLS 2009

poor outcome. (6) Another study showed that Survival to discharge in a cardiac arrest
was more common among children and adolescents than infants or adults. (7) Another
study stated that Precounter shock CPR can result in substantial physiologic benefits
and superior response to initial defibrillation attempts compared with immediate
defibrillation in the setting of prolonged ventricular fibrillation. i.e. it's better to begin with
CPR then do Defibrillation that begging defibrillation from the start. (13)

This means that although the overall outcomes of CPR are seemed to be poor, this is not
the case in every situation. As we mentioned above this poor overall outcomes are due
to either late resuscitation in unwitnessed arrest or due some causes of the arrest like
arrests of cardiac origin. So studies always stress that immediate resuscitation is always
advised in a cardio-pulmonary arrests.(6)

BUT WHAT ARE THE NEGATIVE IMPACTS THE CPR MAY HAVE?

In a study assessing injuries during CPR, it was found that injuries occurred in 42.5% of
cases , but almost all of these injuries were of minor nature consisting principally of
bruises and abrasions. The likelihood of injury increased with the length of resuscitation.
In children resuscitated for less than 60 minutes the incidence of injury was 27%
compared with 62% for children resuscitated for longer.(8) In another study it was found
that 7% had at least one injury as a result of CPR; 3% had injuries that were considered
medically significant. These included retroperitoneal hemorrhage, pneumothorax ,
pulmonary hemorrhage , epicardial hematoma , and gastric perforation , in spite of
prolonged resuscitation performed with variable degrees of skill, only one patient was
noted to have rib fractures.(9) In a systematic review to find out if CPR causes rib
fracture, 3 cases only of 923 children had a rib fracture which was anterior.(10) This
means that rescuer should begin CPR immediately without hesitating because of fear of
causing injuries.

BUT WHAT ABOUT GETTING INFECTION DURING CPR ESPECIALLY DURING MOUTH-TO-MOUTH
BREATHING ?

In a study about the risk of getting HIV infection through saliva during mouth to mouth
(MTM) breathing, it was found that the risk of transmission of HIV and other infectious
diseases by saliva during CPR training practice is extremely low because of low
infectious virus titers and properties of saliva that inhibit HIV. (11) In another study it was
found that although pathogens can be isolated from the saliva of infected persons,
salivary transmission of blood-borne viruses is unusual and transmission of infection has
been rare: Only 15 documented cases have been reported. Most of these cases involved
a bacterial pathogen, such as Neisseria meningitides. Transmission of hepatitis B virus,
hepatitis C virus, or cytomegalovirus during CPR has not been reported; all three
reported cases of HIV infection acquired during resuscitation of an infected patient
Page 15 of 26 PBLS 2009

resulted from high-risk cutaneous exposures. There have been no reports of infection
acquired during CPR training. (12) In fact, the benefit of initiating lifesaving resuscitation
in a patient in cardiopulmonary arrest greatly outweighs the risk for secondary infection
in the rescuer or the patient.

All the above studies show that the benefits of doing CPR are much more the rare
drawbacks.

BUT WHY DOCTORS MAY STOP CPR?

In a study comparing CPR in adults and children it was found that: 1) several laboratory
and clinical factors significantly influence physician's decisions regarding termination of
resuscitative efforts. 2) Regardless of setting, time of pulselessness does appear to be
an influential factor in determining when to terminate resuscitation in children for most
physicians; 3) Pediatric physicians are more likely to terminate resuscitative efforts than
are General physicians if return of spontaneous circulation is not achieved by 25
minutes. (14)

CPR IN THE EYES OF OTHERS:

WILLING TO DO MOUTH- TO-MOTH BREATHING:

In one study it was found that only 50% of health care providers were willing to perform
mouth-to-mouth breathing for an unknown adult. The nice thing is that their percentage
increased as the person is more familiar to the rescuer. Overall, the group was willing to
do mouth-to-mouth resuscitation on victims known to them: their neighbors (84%),
children at a pool (88%), spouses (94%), and parents (93%). In the hospital setting,
knowing a patient's human immunodeficiency virus (HIV) status greatly influenced the
willingness to do mouth-to-mouth rescue. If a patient's HIV status was unknown, only a
third of providers would do mouth-to-mouth resuscitation; if the HIV status was known to
be negative, two thirds would do mouth-to-mouth resuscitation. Children in the hospital
whose HIV status was unknown would receive mouth-to-mouth resuscitation by 57% of
the respondents. Children known to be HIV-negative would be resuscitated by 79% of
the respondents. Co-workers were more willing to resuscitate a known physician or
nurse than an unknown co-worker, with physicians more willing than nurses to do mouth-
to-mouth resuscitation on an unknown co-worker. Experienced providers of mouth-to-
mouth wanted to receive mouth-to-mouth resuscitation less frequently 75% than
inexperienced providers 84%. (15) In another study which was done on homosexual
males to detect their willingness to perform mouth-to-mouth (MTM) breathing, it was
found that the willingness of male homosexuals to perform MMR is high, in contrast to
the general reluctance of internists and medical nurses to perform MMR in the same
outpatient scenarios. The different perceived risks of male homosexuals and physicians
acquiring infectious diseases by performing MMR is probably responsible for the
Page 16 of 26 PBLS 2009

difference in willingness of these two groups to perform MMR. The HIV positive
homosexual males were less willing to perform MTM breathing than HIV negative (85%
& 93% respectively) (16)

CPR IN THE EYES OF LAY PEOPLE:

Despite numerous scientific advances in information about treatment modalities and

outcomes available to physicians, the knowledge of the general public regarding
resuscitation is greatly inadequate and inaccurate. Numerous studies have found
inaccurate beliefs regarding CPR and the expected outcomes among the general public.
Many laypersons believe that the success rate of cardiopulmonary resuscitation is
between 40% and 60%. This is mainly due to the effect of media which usually
exaggerate benefits of the CPR. In fact CPR is usually shown to be successful on
television. (23)

REALLY IT WORTH WORKING:

As CPR is needed in many situation efforts should be done to improve CPR skill in
different levels. For example, it was found that School-based established emergency
response plan programs provide a high survival rate for both student athletes and older
non-students who suffer sudden cardiac arrest on school grounds. High schools are
strongly encouraged to implement onsite established emergency response plan
programs as part of a comprehensive emergency response plan to sudden cardiac
arrest. In one study in western countries it was found that 83% of schools have an
established emergency response plan for sudden cardiac arrest. (18)

Even in primary schools, Students as young as 9 years are able to successfully and
effectively learn basic life support skills including AED deployment, correct recovery
position and emergency calling. As in adults, physical strength may limit depth of chest
compressions and ventilation volumes but skill retention is good. (28)

Another study showed that CPR training can be disseminated in a population by

distributing personal resuscitation manikins among children even in primary schools.(19)

Really it deserves trying. In the state university of New York There was a 78 per cent
rate of initial response to therapy and a 47 per cent survival rate. This is almost twice the
survival rate of the best previously reported study and five times the average.(20) Wile in
developing countries it was found that : Cardiopulmonary arrest after admission has a
very poor prognosis in hospitals. Infectious diseases are the main underlying causes of
arrest. If a child fails to respond to the basic tenements within 15 min then it is unlikely
that further efforts to sustain life will be fruitful in hospitals where ventilation facilities are
not present. (21)
Page 17 of 26 PBLS 2009

SOME ETHICAL CONSIDERATIONS:

In all emergency cases if no advance decision has been made or is known, CPR should
be attempted unless:

• The patient has refused CPR.

• The patient is clearly in the terminal phase of illness.
• The burdens of the treatment outweigh the benefits.

CPR AND MEDICAL FUTILITY:

Medical futility is defined when medical treatment “offers no reasonable hope of recovery
or improvement or when the person is permanently unable to experience any benefit”.
(23)

Many cases are in their end-stage disease and wouldn't really get benefits from CPR. In
these circumstances – according to ethical statements – there is no obligation for a
physician to render treatment that is of little or no benefits for the patient. So in this
situation no CPR will be done. (24)

But if the patient's family wanted a CPR- although of no benefit - to be done Can
physicians withhold CPR against family wishes in an end-state case most probably
wouldn't benefit from CPR? The answer is yes according to many ethical statements but
many authors see this unethical and against the dignity principle of ethics. (23)

Also we should be aware that medical futility is as defined above and isn't a reflection of
the quality of life. The quality of life is determined only by the patient himself. So if the
CPR could succeed but with low quality of life e.g. with a great neurological insult, the
only one to determine whether to proceed with CPR or not is the patient himself. The
physician doesn't have the right to stop CPR even with a poor quality of life according to
his point of view. (22)

CPR SHOULD BE DONE IN THE PRESENCE OF OTHER FAMILY MEMBERS OR NOT?

Traditionally, family members have not been allowed to witness resuscitation attempts.
However, several recent reports have shown positive results of allowing family to be
present during resuscitative efforts. When asked if they favor the presence of relatives
during the resuscitation process or not, most survivors indicated that they favor the
presence of their relatives and most of them believed that their relatives benefit from
such experience. (25) And concerning the patients' relatives, most of them also preferred
to witness the resuscitation of their patient relatives. Most common causes were to take
care of the patient and to witness the intervention. Males were more common to prefer
this. But those who already witnessed this intervention before on one of their relatives
showed unwillingness to witness it again. (26) When asking parents of resuscitated
Page 18 of 26 PBLS 2009

children about if they prefer to be present during the resuscitation or not, most of them
preferred that they prefer to be present and believed that this would comfort their
children and help them accept the fact of their death after that. (27) In fact despite
concerns of physicians that family members may be traumatized by witnessing such
procedures, or may interfere with medical care, data do not support such concerns. (22)

Results
The questionnaire was made over students of the fifth year of medical school of Ain
Shams. The questionnaire designed to assess the general knowledge about the basic
life support and the technique of cardiopulmonary resuscitation. It was designed to
distribute the questionnaire among the sample, then BLS tutorial will be taught to the
sample, and finally the same questionnaire is distributed again to evaluate the BLS
tutorial. The analysis of the first questionnaire revealed the following:

1. 37.5% of the sample answered the question no. 4 correctly.

2. 25% of the sample answered the question no. 5 correctly.
3. 68.75% of the sample answered question no. 6 correctly.
4. 87.5% of the sample answered question no. 7 correctly.
5. 75% of the sample answered question no. 8 correctly.
6. 81.5% of the sample answered question no. 9 correctly.
7. 93.75% of the sample answered question no. 10 correctly.
8. 68.75% of the sample answered question no. 11 correctly.
9. 37.5% of the sample answered question no. 12 correctly.
10. 50% of the sample answered question no. 13 correctly.
11. 12.5% of the sample answered question no. 14 correctly.
12. 62.5% of the sample answered > 50% of the questionnaire correctly.
13. The most answered questions were question no. 10.
14. The least answered questions were question no. 14.
When the same questionnaire is distributed after the BLS tutorial among the
same sample which received the pre - tutorial questionnaire. The analysis
revealed the following:
1. All students had answered the questions no. 8, 9 and 10 correctly.
2. 50% of the student had answered the questions no. 4, 5 and 6 correctly.
3. Students who get score above 6/11 were 5 students.
4. Students who get score below 6/11 were 1 student.
Page 19 of 26 PBLS 2009

Summary
CPR Is an emergency medical procedure for a victim of cardiac arrest or, in some
circumstances, respiratory arrest. CPR is performed in hospitals or in the community by
laypersons or by emergency response professionals.

CPR involves physical interventions to create artificial circulation through rhythmic

pressing on the patient's chest to manually pump blood through the heart, called chest
compressions, and usually also involves the rescuer exhaling into the patient (or using a
device to simulate this) to inflate the lungs and pass oxygen in to the blood,
called artificial respiration. Some protocols now downplay the importance of the artificial
respirations, and focus on the chest compressions only.

CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated
blood to the brain and the heart, thereby delaying tissue death and extending the brief
window of opportunity for a successful resuscitation without permanent brain
damage. Advanced life support and defibrillation, the administration of an electric shock
to the heart, is usually needed for the heart to restart, and this only works for patients in
certain heart rhythms, namely ventricular fibrillation or ventricular tachycardia, rather
than the 'flat line’ asystolic patient although CPR can help bring a patient in to a
shockable rhythm.

CPR is generally continued, usually in the presence of advanced life support (such as
from a medical team or paramedics), until the patient regains a heart beat (called "return
of spontaneous circulation" or "ROSC") or is declared dead.

The practical part of this research was to assess the knowledge of medical students and
to teach our colleagues the basic life support steps.
Page 20 of 26 PBLS 2009
Page 21 of 26 PBLS 2009

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