SUBJECT : ADVANCE NURSING

SEMINAR ON

CARDIO-PULMONARY

RESUSCITATION

GUIDE

MADAM : Mrs. ABHILEKHA BISWAL

VICE PRINCIPAL

P.G. COLLEGE OF NSG., BHILAI

SUBMITTED BY:

Mrs. SUCHITRA PAUL

Msc. (N) 1 yr Student

INDEXS.No. Contents Page No.

1. Objective 1

2. Introduction 1

3. Definition 2

4. Purpose of CPR 3

5. Indications for CPR 3

6. Cardio-Respiratory Failure 4-5

7. Cardiac Arrest 6-8

8. Sign and Symptom of cardiac arrest 9-10

9. General Instruction for Effective CPR 11-13

10. Sight for Cardiac compression 14-15

11. Preparation of Article 16-17

12. Steps of Procedure 18-23

13. Precaution 24-25

14. Specific Medical Therapy 26-27

15. Post Resuscitation Complication 28

16. Post Resuscitation Measures and Nursing

Management

28-30

17. Summary 30

18. Bibliography 31-32

CARDIO-PULMONARY RESUSCITATION

OBJECTIVE

1) Enumerate purpose, principles and indications of cardio pulmonary

resuscitation (CPR).

2) Discuss general instructions to be considered for effective CPR.

3) Explain cardio-respiratory failure.

4) Discuss procedure of CRP and specific activities involved there in with

special emphasis on nurses role.

5) Lost down complication of CPR and preventive measures.

INTRODUCTION

Cardio-pulmonary resuscitation (CPR) is a technique of basic life support

for oxygenating the brain and heart until appropriate definitive medical treatment

can restore normal heart and ventilatory action. Cardio-pulmonary resuscitation

techniques are used to artificially maintain both circulation and ventilation in

persons suffering from cardiac arrest.

IT INVOLVES

External cardiac massage (manual heart compressions).

Artificial ventilation by either mouth to mouth, mouth to nose or mouth to

airway techniques.

Management of foreign body or airway obstruction, cricothyroidotomy may

be necessary to open the airway before CPR can be performed.

DEFINITION

Resuscitation: is a method which includes all measures that are applied to revive

patients who have stopped breathing suddenly and unexpectedly due to either

respiratory or cardiac failure.

CARDIO PULMONARY RESUSCITATION: is a technique of basic life support

for oxygenating the brain and heart until appropriate definitive medical treatment

can restore normal heart and ventilatory action.

PURPOSE OF CPR

A - To maintain an open and clear airway

B – To maintain breathing by artificial ventilation.

C – To maintain blood circulation by external cardiac massage.

To save life of the patient.

To provide basic life support till medical and advanced life support arrives.

INDICATIONS FOR CPR

1) Cardiac Arrest:

A : Venttricular fibrillation (VF)

B : Ventricular tachycardia (VT)

C : Asystole

D : Pulseless electrical activity

2) Respiratory Arrest

A : Drowning

B : Stroke

C : Foreign body in throat

D : Smoke inhalation

E : Drug overdose

F : Electrocution or injury by lighting

G : Suffocaton

H : Accident injury

I : Coma

J : Epiglottis paralysis

CARDIO-RESPIRATORY FAILURE

The respiratory and cardiovascular systems are interdependent. Heart

consumes more oxygen per minute than any other organ in the body because it

is constantly beating. Consequently, when the lungs stop working, the heart fail

occurs. Conversely, the ventilation of the lungs fails soon after the heart stops.

This is because the respiratory center in the medulla oblongata canal function

without the continuous supply of oxygen that is normally transported to it by the

cardio-vascular system.

The cardio-respiratory failure is masked by Hypoxia- a sudden fall in the

arterial oxygen tension and a rise in the arterial carbon dioxide content.

If there is an insufficient pressure of oxygen in the blood to load the

haemoglobin molecules with oxygen, the oxygen content of blood falls

(Normal 80-100mg).

When the heart fails to get an adequate supply of oxygen, arrhythmia

occurs.

If hypoxia is severe cardiac stands still or arrest occurs.

At the same time, other tissues of the body are also affected e.g.

confusion and disorientation are indications of cerebral hypoxia.

Brain is less tolerant of hypoxia than the heart. Brain tissue begins to

deteriorate with uncorrected hypoxia and irreversible changes take place

in brain tissue.

When a person stops breathing spontaneously his heart also stops

breathing, and clinical death occurs within 4-6 minutes the cells of the

brain, which are sensitive to the paucity of oxygen, begin to deteriorate. If

the oxygen supply is not restored, the patient suffers irreversible brain

damage and biological death occurs.

CARDIAC ARREST

DEFINITION

Cardiac arrest may be defined as the abrupt cessation of cardiac function.

The heart may be in one of the two states during cardiac arrest, either asystole or

fibrillation.

CPR is indicated as an emergency treatment.

CAUSES

1) Causes associated with surgery

Hypotension

CO2 Retention

Reactions to anaesthesia

Depression from anaesthesia.

Coronary occulusion.

Acute myocardial infarction.

Inadequate ventilation of lungs.

Anoxia due to airway obstruction.

2) Causes not associated with surgery

Acute myocardial infarction

Electrical Shock.

Hypersensitivity or anaphylactia reactions.

Hypothermia.

Suffocation e.g. in plastic bag or abandoned refrigerator.

Airway obstruction e.g. due to a foreign body.

Digitalis poisoning.

Cardiac catheterization.

Drowning.

Poisoning example carbon monoxide, cyanide, tricyclic antidepressants.

Pulmonary Embolism.

SIGN OF CARDIAC ARREST

Absence of heart beat and blood pressure.

Fixed pupils.

A bluish colour of skin, lip and nail.

Ineffective respiration gasping may occur.

Seizure may occur or may not occur.

Hypoxia.

Dilated pupil.

SIGN AND SYMPTOM OF CARDIAC ARREST

Sudden loss of consciousness.

Absence of carotid pulse.

Cessation of respiration. No chest wall movement.

Dilatation of pupils.

Marked cyanosis.

The three cardinal sign of cardiac arrest are:

Apnoea.

Absence of carotid and femoral pulse.

Dilated pupils.

APNOEA

Apnoea indicated respiratory failure. It can be diagnosed by the ansence

of movements of the chest and abdominal muscles. Retractions of soft tissue are

to be noted at suprasternal and intercostals space which indicate airway

destruction.

ABSENCE OF CAROTID AND FEMORAL PULSE

Pulse in the large arteries close to the heart are palpable even when the

peripheral pulse is absent. Carotid pulse can be checked

Carotid pulse can be palpated by gentle pressure over the depression

between the trachea and the sterno-aleido mastoid muscle at the level

with Adam’s apple.

Absence of carotid pulse indications cardiac arrest.

DILATED PUPILS

Cerebral hypoxia causes loss of muscle control in the entire body

including eyes, pupils that are dilated and do not react to light indicate that the

patients is having cardiac arrest. It is because centers in the brain that control the

movement of the iris of the eyes are not receiving enough oxygen to cause

normal response (constriction of pupils) of the iris to light.

CYANOSIS

It is due to lack of oxygenation of blood resulting from hypoventilation of

lungs and circulating failure.

UNCONSIOUSNESS

Hypoxia of the cerebral cortex cause unconsciousness. To make sure

whether the patient is sleeping or drowsy with alcoholism etc. call the patient by

name shouting the patient by name shouting in his ear and then shaking him,

mild hypoxia leads to confusion and disorientation.

FIT : This can also occur due to cerebral anoxaemia.

PRINCIPLES OF CPR

1) To restore effective circulation and ventilation.

2) To prevent irreversible cerebral damage due to anoxia. When the heart

fails to maintain the cerebral circulation for approximately four minutes the

brain may suffer irreversible damage.

GENERAL INSTRUCTIONS FOR EFFECTIVE CPR

1) CPR techniques are used in persons whose respirations and circulation of

blood have suddenly and unexpectedly stopped.

2) There is no need of attempting CPR techniques in patients in the last of an

incurable illness and in persons whose heart beat and respirations have

been absent for more than six minutes.

3) The immediate responsibilities of the resuscitator are:

a. To recognize the signs of cardiac arrest.

b. Protect the patients brain from anoxia by immediately starting

artificial ventilation of the lungs and external cardiac massage.

c. Call for help

4) The cardio-pulmonary resuscitation must be initiated within three to four

minutes in order to prevent permanent brain damage.

a. Strike the center of the chest sharply with the side of the clenched

first twice.

b. Call for assistance.

c. Clear the airway of false teeth, vomital food material etc.

d. Initiate ventilation and external cardiac massage without wasting

time.

5) The CPR techniques should not be discontinued for more than five

seconds before normal circulation and ventilation of lungs are established

except.

a. When the patients is moved to a hard surface.

b. When endotracheal intubation is being carried out (maximum time

allowed for these two procedures is 15 seconds).

6) Before CPR is attempted in a patient, make sure that the airway is clear. It

may be obstructed due to many reasons. So keep the patient’s neck hyper

extended after confirming that he is having any cervical injury

THE PRECORDIAL THUMP

1) Use of “precordial thump” is effective in case of witnessed cardiac arrest,

precordial thump in case of witnessed Cardiac arrest. Predicted thump is a

blow, which is delivered to the lower half of the patient’s sternum with the

fleshy part of the first from with the fleshy part of the first from 8-12 inches

above the patient’s chest.

a. This blow generates a small current of electricity, which shock the

myocardium and stimulates cardiac beating and circulation.

b. To be effective it must be done within a minute of cardiac arrest. If

delayed it may precipitative ventricular fibrillations.

2. Cardiac compression help to stimulate the circulation. Locate correctly the

lower half of the sternum when cardiac compression are used :-

a. If hands are placed too far to the right ribs may be fractured.

b. If hands are placed too high-collar bone may be fractured.

c. If hands are placed too low-Liver may be damaged.

SIGHT FOR CARDIAL COMPRESSION

First of all trace the last rib and follow the rib to the notch where the ribs meet

sternum. Then place the head of the other hand on the lower part of the sternum

about 1-1½ inch above the palpating hand. The palpating hand is then placed on

the top of the hand, which is resting on the sternum. Both hands should be

parallel.

a. Keep fingers off the chest or interlocked.

b. If fingers are resting on the chest, force will be dissipated.

c. The artificial breathing and the cardiac massage should correspond

to the normal application and pulse rate.

d. The ratio of cardiac compression to ventilation is 5:1. (5 cardiac

compression to one ventilation cardiac compression is given at the

rate of 60 per minute.

e. Ventilations are given between the cardiac compression without

interrupting or slowing the rate of compressions. 60 cardiac

compression and 12 ventilations per minute are achieved.

f. The ratio is 5:1 when there are two rescuers.

g. When there is only one rescuer, interrupt compressions after every

15 compressions to give two quick deep lung infections. This

results in a cardiac compression to the ventilation ratio of 15:2.

PROCEDURE

Preparation of the patient and the environment :

1. No time is lost in explaining the procedure to the patient or his relatives.

2. The patient may be shifted to a hard surface or a hard board is placed

under his thorax.

3. Remove or push aside the clothing, which covered the patient’s chest to

observe for cardiac beats and respirations.

4. Place the patients back on his back with any pillow. This position helps in

maintaining airways and giving external cardiac compressions.

5. Tight clothing around the neck and chest should be removed.

6. Ensure fresh air in the room by opening windows and doors.

7. Extend cardiac massage must be started within four to six minutes

following cardiac arrest or irreversible brain damage will occur as a result

of oxygen deprivation and lack of circulation.

PREPARATION OF ARTICLE

Equipment :

A tray containing the following articles :

1. Endofraechead tubes of various sizes (7, 7.5,8).

2. An ambu bag with mask

3. a) Stillent (in a plastic cover)

b) Megal’s forceps (in a plastic cover)

4. A section tube or catheter.

5. a) Laryagoscope with different sizes of blodes.

b) Nasal Airway.

c) Oral Airway.

d) A bowl with gauze pieces.

e) Lubricating Jelly.

6. Adhesive type with scissors.

7. Local Anaestetic (Drug) Spray.

8. Gloves in cover.

9. A kidney fray.

10. A paper bag.

11. Masks for various sizes.

12. Disposable syringes with needles.

13. Intravenous (I/V) set and a cut down set.

OTHERS

a) Oxygen Inhalation (Central Supply)

b) Suction point (Central Supply)

c) Defibrillator.

A Tray containing emergency drugs.

1. Injection Adrenaline.

2. Injection Atropin

3. Injection Digoxine.

4. Injection Sodium Bicarbonate.

5. Injection Dopamine

6. Injection Gycolin.

7. Injection Decadron.

8. Injection Aviv

9. Injection Calcium Gluconate.

10. Injection Lasix.

11. Injection Aminophyline

12. Injection Isoptin.

13. Injection Compose.

14. Injection 20% Dextrose.

15. Injection Deriphydine.

16. Syringes with needles.

17. Cannulas on cotton pad.

18. Gloves in cover.

STEPS OF PROCEDURE

1. Determine unresponsiveness observe for spontaneous respiration,

palpate carotid pulse, and ask the victim. “Are You Ok”?

2. Call for help.

3. Patient supine on a firm, flat surface or use a board.

4. Kneel at the patient’s side.

5. Open the patient’s airway.

a) Place one hand on the patient’s forehead and apply firm backward

pressure with the palm to tilt the head back.

b) Then place fingers of the other hand under the bony part of the lower

jaw near the chin and lift up to bring the jaw forward and the teeth almost

to occlusion.

c) Grasp the angles of the potentials lower jaw and lifting with both hands,

one on each side, displace the middle forward, while lifting the head

backward.

6. Prepare for artificial respiration.

a) For mouth to mouth resuscitation of an adult, pinch the patients

nose and occule mouth. For an infant place your mouth over the

infants nose and mouth.

b) For Ambu loage resuscitation use a proper size face mask and

apply it over the patients mouth.

c) For artificial respiration with an ambu bag in an adult, compress the

bag fully for two breath.

d) For ambu bag resuscitation in a child use two small compressions

of the bag.

7) Observe for rice and fall of the chest wall with each respiration. If lungs do

not inflate reposition head and neck and check for visible airway

obstruction. Such as vomitus.

8) Suction any secretions from the airway. If suction is unavailable, turn the

patients head one side.

9) Assess for pressure of carotid pulse.

a) Carotid pulse is the most central and accessible artery in children

over year. However, in an infant the short stubby neck makes

carotid difficult to palpate. Brachial artery is recommended instead.

b) Fingers are removed up the ribcage to notch where ribs meet the

lower sternum in the center of the lower part of the chest.

c) Place heel of the hand on the lower half of sternum and place other

hand or top of the hand on sternum so that hands are parallel.

d) Fingers may be extended or interlaced but should be kept off the

chest.

10) Lock elbows, maintain arms straight and shoulders directly over hands on

the patient’s sternum.

- compress chest 3-5 cms. (1½-2 inches)

a) Compress chest 80-100 times/min. perform 15 external

compressions with “one and two and three and ------- to 15”

b) Ventilate lungs with two slow rescuer breath.

c) Re-assess the patient after four complete cycles (15 compressions,

2 ventilations each cycle)

11) While resuscitation proceeds simultaneous efforts are made to obtain and

we special resuscitation equipment to manage breathing and circulation

and provide definitive case.

INFANT (1-12 months)

PROPER HAND POSITION

1) Draw an imaginary line between nipples over the breast bone (sternum).

2) Place the index finger on the hand farthest from the infant’s head just

under the infra mammary line where it intersect sternum.

3) Using two or three fingers compress 1.3-2.5cm (½ -1 inches) at least

100 times/ mt.

4) At the end of every fifth compression allow a pause for ventilation (1½

seconds)

5) Re-assess the victim after 10 cycles (five compression one ventilation

each cycle).

CHILD (1-7 years)

PROPER HAND POSITION

1) Locate the lower margin of the patient rib one on the side next to the

rescuer with middle and index finger.

2) Follow margin A rib cage with the middle fingers to notch where ribs and

sternum meet.

3) Place the index finger next to the middle finger.

4) Place heel of the hand next to the point where the index finger was

located, with long axis of the heel parallel to sternum.

a. The rescuer’s other hand maintains the child’s head position.

b. Compress sternum with one hand 2.5-3.8 cm (1-1½) at the rate of

100 times/mt.

c. At the end of every fifth compressions allow a pause for ventilation.

d. Re-assess the patient after 10 cycles (five compression ventilations

each cycles).

PHASES STEPS AND MEASURES OF CPR

Phase Steps Measures Performed without

equipment

Measures Performed with

equipment

1) Basic Life

support

A) Airway

control

Backward tilt of the head.

Supine aligned position

stable side position.

Lung inflation attempts.

Triple airway maneuver

(jaw thrust, open mouth)

Manual cleaving of the

mouth and throat.

Back blows manual

thrusts.

Suction

Endo-trachial

intubation.

Tracheostomy

B) Breathing

support

Mouth to mouth ventilation Manual bag mask

ventilation with or

without mechanical

ventilation.

C) Circulation

support

Manual chest compression

Pulse checking

Open chest direct

cardiac compressions.

2) Advanced

life support

D) Drugs and

fluids.

E) Electro-

cardio graphy

F) Fibrillation

treatment

I/V line E.C.G.

monitoring defibrillation

3) Prolonged

life support

G) Gauging

H) Human

mentation.

I) Intensive

care

Determine and treat

cause cerebral rescue.

Multiple organ support

PERCAUTIONS

The circulation of blood is initiated with the external cardiac massage because

the pressure exerted on the pliable sternum squeezes the heart against the

supine fencing blood out of the heart into aorta.

The following points to be taken into consideration

1) The patient should be placed on a hard surface.

2) The body of the patient should be horizontal because the blood pressure

generated is not adequate to pump the blood upto the head.

3) Assess properly and indicate CPR within three minutes of arrest.

4) Do not interrupt CPR for more than seven seconds.

5) Give CPR by maintaining basic steps (A.B.C.)

6) Give compression only over sternum not on ribs.

7) When you are giving cardiac compression fingers should be in upward

direction to prevent rib fracture.

SIGN OF EFFECTIVE RESUSCITATION

As resuscitation efforts continue, the resuscitator must decide whether the

attempts to re-establish the patient’s circulation are effective for resuscitation.

Efforts to be judged effective at least one of the following signs must be present:

Constriction of pupils, key sign that brain is sufficiently oxygenated.

Distinct carotid pulsation with each cardiac compression.

Blinking upon stimulation of the eye lids.

Breathing that begins spontaneously.

Movement and struggling.

Decreased cyanosis.

SIGN OF INEFFECTIVE RESUSCITATION

Factors responsible for ineffective resuscitation include the following :

Incorrect resuscitative techniques.

Heart is drained of its blood by haemorrhage or cardiac dampened.

Blood supply to the heart is disturbed by the presence of pulmonary

embalus.

Severe chronic lung disease has destroyed lungs ‘capacity’ to oxygenate

blood.

Lungs are filled with vomits as a rescue of aspiration during cardiac

massage.

SPECIFIC MEDICAL DELIVERY

The patient has been admitted to the emergency room or a special resuscitation

team has arrived to take over the patient’s care. It will be based on :

The undergoing cause of the cardiac arrest and whether it can corrected.

Types of arrest have occurred asystole or ventricular fibrillation present.

Apply a cardiac monitor to the person and identify the rhythm.

Record electro-cardiac events that occur during resuscitation.

Quickly attend to the persons airway and oxygenation.

Insert an oral (artiyicial) airway to maintain the fougue in a forward

position.

Replace mouth-to-mouth breathing with a ventilator bay and mask.

Administer 100 percent oxygen.

Insert an endotracheal tube as soon as possible to achieve maximal

airway clearance and oxygenation.

Suction the person as necessary to maintain a patent airway.

Start an IV line for administration of resuscitation medication.

DRUG USED IN CARDIAC RESUSCITATION

S. No. Medication Indication

1. Oxygen Hypexemia

2. Morphine sulfate Pain of acute MI

3. Lidocaine Ventricular tachicardta and fibrillation

4. Atropine sulfate Sinus brady cardia

5. Isoproterenol

hydrochloride

Brodycardia

6. Epinephrine

hydrochloride

CPR (increase myocardiacl and CNS blood

flow

7. Norepinephrine Severe hypotension and low peripheral

resistance

8. Dopamine hydrochloride Severe hypotension

9. Dobutamine

hydrochloride

Heart failure

10. Debutamime

hydrochloride

Hyperkalemia Hypocaucemia

11. Calcium gluconate Atrial flutter atrial fibrillation

12. Digitadis preparations Heart failure or unstable angina

13. Nitroglycerin Severe and base imbalance

14. Sodium Bicarbonate Cerebral edema or acute pulmonary edema.

POST RESUSCITATION COMPLICATIONS

1) Trauma, fractured ribs and sternum.

2) Pneumothorax.

3) Ruptured spleen.

4) Aspiration pneumonia.

5) Anoxia Encephalopathy.

6) Renal failure.

7) Congestive heart failure.

8) Cardiac tamponade.

9) Skin burns.

10)Oral, tracheal and laryngeal damage.

11)Cervical neck injury

POST RESUSCITATION MEASURES

1) Skilled after care is essential for the patient who has suffered an arrest.

2) Continuous vigilance must be ensured by a skilled person for 48-72 hours.

3) If the patient is not in the intensive care unit shift him there for constant

observation and expert care.

4) Monitor ECG, CUP and Blood pressure.

5) Check the oral cavity and jaw position as his tongue may fall and obstruct

the airway.

6) Temperature is taken every hour. A high temperature usually indicates

cerebral damage or cerebral edema.

7) Blood gas and pH determinations are done to detect metabolism acidosis

which may have developed owing to poor oxygenation.

8) Amoborbital sodium is given intravenously in case of convulsions, which

may occur because of brain damage or acidosis Dilantin is given if

convulsion continues.

9) A chest X-ray film is obtained using portable equipment. Ribs often are

accidentally fractured during cardiac massage.

10)Maintains an open airway for the unconscious patient who cannot clear

secretions by coughing.

11)Give oxygen continuously for 48 hours following resuscitation by an

endotracheal tube or mask. This is required because respiration are

depressed for sometime after arrest.

12)Insert foley’s catheter. Urine output is one of the measures of the

cardiovascular status. Report if the urinary output is below 30ml per hour.

13)Start I/V infusion to administer enough fluids in the patient.

14)Record the procedures on the nurse’s record with late and time.

15)A nasogastric intubation and aspiration of stomach are necessary for a

patient with a full stomach to prevent vomiting and aspiration of vomitus

into lungs.

SUMMARY

Cardio-pulmonary resuscitation (CPR) is an immediate therapy that may

be initiate for cardio-respiratory failure evidence that an individual is breathless

and pulseless is sufficient to warrant immediate resuscitation efforts knowledge

of CPR enhances the safety of both rescuer and rescuee.

BIBLIOGRAPHY

1) Keshav Swarnakar, Nursing Practicals and Procedures basic to Advance

Skills published by N.R. Brothers Indor P.P. 257-262.

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publication Mumbai, 40031, P.P. 37-51.

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Edition W.B. Saunders Company Philodelphia, London P.P.

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P.P. 287-288.

5) Brunner & Suddharth’s, Text book of Medical Surgical Nursing Lippincott

Philadelphia, New York, P.P. 676-678.

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488.

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10)Luckmann Joan & Karen Creason Sorenson. Medical Surgical Nursing

Third Edition, W.B. Saunders Company. P.P. 921-926.