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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.
2) Kusum Samant, First Aid Manual Accident and Emergency Voro Medical
publication Mumbai, 40031, P.P. 37-51.
3) Luckmann Joan, Karen Creason, Sorenson, Medical Surgical Nursing, 3rd
Edition W.B. Saunders Company Philodelphia, London P.P.
4) Lippincott, Medical Surgical Nursing, 8th Edition Philadelphia New York.
P.P. 287-288.
5) Brunner & Suddharth’s, Text book of Medical Surgical Nursing Lippincott
Philadelphia, New York, P.P. 676-678.
6) The Trained Nurses Association of India. Fundamentals of Nursing. A
procedure manual published be Secretary General New Delhi. P.P. 477-
488.
7) J.K. Indrani, First Aid for Nurses. Jaypee Brothers. Medical Publishers (P)
Ltd. New Delhi. P.P. 31-40.
8) Potter & Perry. Basic Nursing Theory and Practice, Third Edition. Mosby
Publishers Ltd. London. P.P. 1017-1020
9) Suzanne C. Smeltzer Brenda G. Bare Brunner & Suddharth’s. Text book of
Medical And Surgical Nursing, Lippincott Williams & Wilkins. P.P. 810-812.
10)Luckmann Joan & Karen Creason Sorenson. Medical Surgical Nursing
Third Edition, W.B. Saunders Company. P.P. 921-926.