CARDIOPULMONARY RESUSCITATION

Presenter : Ms.Smita Das M.Sc. (N) II yr. student

CARDIO PULMONARY RESUSCITATION

Cardiopulmonary resuscitation (CPR) is an emergency technique used when a persons heart has stopped beating and breathing has stopped. It is a combination of rescue breathing and chest compressions delivered to victims thought to be in cardiac arrest.

Indications for CPR

Cardiopulmonary arrest due to an acute medical event (e.g. MI, PE, poisoning)/chronic medical illness where there is a reasonable chance of restoring the patient to a level of function/quality of life that is similar or better to that at the time of the arrest, and undergoing the procedure meets the patients goals and expectations. Unconsciousness No respirations or brief irregular, 'gasping' breaths No Pulse

CLASSIFICATION
Basic life support (BLS) Advanced cardiovascular life support (ACLS) Prolonged life support

CHAIN OF SURVIVAL
Early recognition of the emergency and activation of the emergency medical services. Early bystander CPR. CPR plus defibrillation. Advanced life support

ADULT BASIC LIFE SUPPORT

CHECK FOR RESPONSE

Rescuer should check for response:  If the client responds: Leave the client and call for help. Return as quick as possible and reassess the condition of the person.  If the client does not respond : The healthcare provider should give 5 cycles (about 2 minutes) of CPR Return as quickly as possible after informing and getting AED.

Open the airway and check breathing

Open the Airway : Head tilt chin lift : If no evidence of spinal cord injury. Jaw thrust (without head extension) : Spinal cord injury. Check Breathing : While maintaining an open airway, look, listen, and feel for breathing. Treat the victim who has occasional gasps as if he or she is not breathing.

GIVE RESCUE BREATHS

Give 2 rescue breaths, each over 1 second, with enough volume to produce visible chest rise. y Mouth-to-Mouth Rescue Breathing y Mouth-toBarrier Device Breathing y Mouth-to-Nose and Mouth-to-Stoma Ventilation y Ventilation With Bag and Mask y Ventilation With an Advanced Airway
y

Check pulse : pulse is not definitely felt within 10 seconds, proceed with chest compressions.

CRICOID PRESSURE
Pressure applied to the victims cricoid cartilage pushes the trachea posteriorly. Requires a third rescuer. Only if the victim is deeply unconscious. Prevents gastric inflation and reduce the risk of regurgitation and aspiration.

CHEST COMPRESSIONS
Chest compressions consist of rhythmic applications of pressure over the lower half of the sternum. A compression-ventilation ratio of 30:2 is recommended. Advance airway - The compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. Heimlich Maneuver If foreign body is suspected.

CHEST COMPRESSIONS
Victim should lie supine on a hard surface. The rescuer should compress the lower half of the victims sternum in the centre (middle) of the chest, between the nipples. Place the heel of the hand on the sternum in the centre (middle) of the chest between the nipples and then place the heel of the second hand on top of the first so that the hands are overlapped and parallel. Depress the sternum approximately 12 to 2 inches. Allow complete chest recoil.

Healthcare providers should interrupt chest compressions as infrequently as possible and try to limit interruptions to no longer than 10 seconds except for specific interventions such as insertion of an advanced airway or use of a defibrillator

Characteristics Of Good Compression

Push hard: push with sufficient force to depress the chest approximately one third to one half the anteriorposterior diameter of the chest. Push fast: push at a rate of approx. 100 / minute. Release completely to allow the chest to fully recoil. Minimize interruptions in chest compressions.

Mouth-to-Mouth Rescue Breathing

Open the victims airway, pinch the victims nose and create an airtight mouth-to-mouth seal. Give 1 breath over 1 second, take a regular (not a deep) breath. If the victims chest does not rise with the first rescue breath, perform the head tilt chin lift and give the second rescue breath.

Mouth-toBarrier Device Breathing

Rescuers may hesitate to give mouth-to-mouth rescue breathing thus prefer to use a barrier device. Barrier devices : Face shields are clear plastic or silicone sheets that reduce direct contact between the victim and rescuer but do not prevent contamination of the rescuers side of the shield. Masks used for mouth-to-mask breathing should contain a 1-way valve that directs the rescuers breath into the patient while diverting the patients exhaled air away from the rescuer.

Mouth-to-Nose &Mouth-to-Stoma Ventilation

  

Recommended if: It is impossible to ventilate through the victims mouth. The mouth cannot be opened. Mouth-to-mouth seal is difficult to achieve.

A case series suggests that mouth-to-nose ventilation in adults is feasible, safe, and effective. A reasonable alternative to mouth stoma method is to create a tight seal over the stoma with a round paediatric face mask.

Ventilation With Bag and Mask

Rescuers can provide bag-mask ventilation with room air or oxygen. A bag-mask device provides positive-pressure ventilation without an advanced airway and therefore may produce gastric inflation and its complications. Provide each breath over a period of 1 second and provide sufficient tidal volume to cause visible chest rise.

Ventilation With an Advanced Airway

When advance airway in position 2 rescuers no longer deliver cycles of CPR. The compressing rescuer should give continuous chest compressions at a rate of 100 per minute without pauses for ventilation. The rescuer delivering ventilation provides 8 to 10 breaths per minute. The 2 rescuers should change compressor and ventilator roles approximately every 2 minutes to prevent compressor fatigue and deterioration in quality and rate of chest compressions.

Recovery Position
The recovery position is used for unresponsive adult victims who have normal breathing and effective circulation. Designed to maintain a patent airway and reduce the risk of airway obstruction and aspiration. The victim is placed on his or her side with the lower arm in front of the body.

PEDIATRIC BASIC LIFE SUPPORT

Check for Response

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 the child is unresponsive and is not moving, shout for help and start CPR. If rescuer is alone, continue CPR for 5 cycles (about 2 minutes).

Activate the EMS System and Get the AED

Provide about 5 cycles (about 2 minutes) of CPR to child victim before leaving to get help and get an AED. If two rescuers are present, one rescuer should begin CPR while the other rescuer activates the EMS system and gets the AED.

Open the Airway and Check Breathing

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. Minimize turning or twisting of the head and neck, if turning a victim. Open the Airway : Head tilt chin lift maneuver (no evidence of spinal injury) Jaw thrust maneuver

Look for rhythmic chest and movement, listen for exhaled breath sounds at the nose, and feel for exhaled air on your cheek.

If the child is breathing and there is no evidence of trauma: turn the child onto the side. This helps maintain a patent airway and decreases risk of aspiration. Maintain an open airway and give 2 breaths.

Pulse Check
Palpate a pulse (brachial in an infant and carotid or femoral in a child). Take no more than 10 seconds. If despite oxygenation and ventilation the pulse is 60 bpm and there are signs of poor perfusion (i.e. pallor, cyanosis), begin chest compressions. If the pulse is 60 bpm but the infant or child is not breathing, provide rescue breathing (12 to 20 bpm) without chest compressions

Chest Compressions
Push hard: push with sufficient force to depress the chest approximately one third to one half the anteriorposterior diameter of the chest.

Push fast: push at a rate of approximately 100 compressions per minute. Release completely to allow the chest to fully recoil. Minimize interruptions in chest compressions. Compress the lower half of the sternum but do not compress over the xiphoid.

TECHNIQUES
Two thumbencircling hands technique Recommended for healthcare providers when 2 rescuers are present. Encircle the infants chest with both hands; spread your fingers around the thorax, and place your thumbs together over the lower half of the sternum. Forcefully compress the sternum with your thumbs as you squeeze the thorax with your fingers for counter pressure.

TECHNIQUES
Two finger technique : Lone rescuers should compress the sternum with 2 fingers placed just below the intermammary line. Most important is that the chest be compressed about one third to one half the anterior-posterior depth of the chest.

Coordinate Chest Compressions and Breathing

One rescuer - 30:2 For 2-rescuer 15:2


With as short a pause in chest compressions as possible. The 15:2 ratio for 2 rescuers is applicable in children up to the start of puberty.

Compression-Only CPR
If a rescuer is unwilling or unable to provide ventilations, chest compressions alone are better than no resuscitation at all. Ventilation may not be essential in the first minutes of VF cardiac arrest during which periodic gasps and passive chest recoil may provide some ventilation if the airway is open. It is not true for most cardiac arrests in infants and children, who are more likely to be asphyxial cardiac arrest.

Advanced cardiovascular life support (ACLS)

1.

Pulse less arrest

2. CPR 3. Oxygen when available 4. Attach monitor/defibrillator when available

2. Check rhythm Shockable rhythm ? Shockable 3. VF/VT

4. Give 1 shock Resume CPR Give 5 cycles of CPR

5. Check rhythm Shockable rhythm ? 6

Continue CPR Give 1 shock Resume CPR immediately Epinephrine 1 mg IV/IO Repeat every 3-5 min 1 dose vasopressin 40 U to replace first or second dose of epinephrine Give 5 cycles CPR

No

12. If asystole go to 10 If electric activity, check pulse No pulse go to 10 If pulse present, begin post resuscitation

7. Check rhythm Shockable rhythm ?

Continue CPR Give 1 shock Resume CPR immediately Consider anti arrhythmics Amiodarone 300 mg then 150 mg once or lidocaine 1-1.5 mg/kg then 0.5-0.75 mg/kg Mg 1-2 g IV/IO torsades de pointes After 5 cycles CPR go to 5.

Shockable

2. Check rhythm Shockable rhythm ?

9. Asystole

10. Resume CPR for 5 cycles . Epinephrine 1 mg IV Vasopressin 40 U IV Atropine I mg IV Repeat 3-5 min

11.Check rhythm Shockable rhythm ? Go to 12 If Not shockable Go to 4 If Shockable

Defibrillation
Early defibrillation is critical to survival from sudden cardiac arrest (SCA) for several reasons:  The most frequent initial rhythm in witnessed SCA is ventricular fibrillation.  The treatment for VF is electrical defibrillation  The probability of successful defibrillation diminishes rapidly over time  VF tends to deteriorate to asystole within a few minutes.

TYPES OF DEFIBRILLATORS
Manual external defibrillator Manual internal defibrillator Automated external defibrillator (AED) Semi-automated external defibrillators Implantable Cardioverter-defibrillator (ICD)

CARE AFTER DEFIBRILLATION

Clinician assesses ECG and pulse after defibrillation immediately. If first counter shock is unsuccessful, immediate defibrillation must be performed according to type of defibrillator used (monophasic/biphasic). Defibrillator may be applied up to three times for persistent V Fib. Or Pulse less VT. CPR should be continued if defibrillations have not been successful.

Successful response Cessation of fibrillation, restoration of sinus rhythm and palpation of a regular pulse. After successful response assess vital signs, neurological status and ECG.

Medications for Arrest Rhythms

Medications for Arrest Rhythms : VF and Pulse less VT 1. Epinephrine : Alpha-adrenergic effects of epinephrine can increase coronary and cerebral perfusion pressure during CPR. Dosage :1-mg dose IV/IO every 3 to 5 minutes during adult cardiac arrest If IV/IO access is delayed give ET route 2 -2.5 mg. Higher doses may be indicated to treat specific problems, such as beta blocker or calcium channel blocker overdose.

2. Vasopressin : Nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction. Vasopressin 40 U IV/IO may replace either the first or second dose of epinephrine in the treatment of pulse less arrest. 3. Antiarrhythmics : Amiodarone It affects sodium, potassium, and calcium channels as well as alpha and beta adrenergic blocking properties. Dosage : initial dose of 300 mg IV/IO followed by one dose of 150 mg IV/IO.

Lidocaine : Should be considered an alternative treatment to amiodarone. Dosage :initial dose is 1 to 1.5 mg/kg IV. If VF/pulse less VT persists, additional doses of 0.5 to 0.75 mg/kg IV push may be administered at 5- to 10-minute intervals, to a maximum dose of 3 mg/kg.

Magnesium : It can effectively terminate torsades de pointes. Dosage :  VF/pulse less VT cardiac arrest with TOP - 1 to 2 g diluted in 10 ml D5WIV/IO push, typically over 5 to 20 minutes. Torsades with pulses - 1 to 2 g is mixed in 50 to 100 ml of D5W and given as a loading dose.

Asystole and Pulseless Electrical Activity 1. Vasopressors 2. Atropine : Atropine sulphate reverses cholinergic-mediated decreases in heart rate, systemic vascular resistance, and BP. Dosage :1 mg IV, repeated every 3 to 5 minutes (maximum total of 3 doses or 3 mg) if asystole persists. 3. Anti arrhythmics : Amiodarone

Transcutaneous Pacing : Transcutaneous pacing is non invasive and should be used For patients with high degree block (Mobitz type II second Degree or third degree) Use analgesic and sedative for pain control. Initiate immediately: If there is no response to atropine. If there atropine unlikely to be effective. If patient is severely symptomatic.

Procedure
Explain procedure to the patient. Clip excess hair from chest. Ensure skin is dry. Apply anterior electrode to chest at the fourth intercostal space to the left of the sternum. Apply posterior electrode to pts back in the area of left scapula. Connect pacing electrode to transcutaneous pacemaker.

Set the pacemaker mode, Hr and output. Turn unit on and check for the effectiveness.

TERMINATION OF RESUSCITATION
If an organized rhythm and pulse have not returned. Resuscitation can be stopped if successful ET intubation, successful IV access, suitable basic CPR and all rhythm appropriate medications has been done.

DOCUMENTATION
    

Procedure rhythm. Total time CPR performed. Times and voltage of shocks delivered, if any. Post defibrillator rhythm. Name, times of administration and doses of medications. Other hemodynamic data available before, during and after defibrillation.

COMPLICATIONS
Spinal cord Injury Fracture rib Internal organ damage Vomiting Risk for aspiration Specific problems due to Defibrillation Damage to myocardium Chest burns Electrocution of the by-standers

Post Resuscitation Care

Cardiovascular system
Restore normal blood volume and control mean arterial pressure blockers to control hypertension Colloids Inotropic agents Atropine Transcutaneous pacing. Pulmonary artery catheterization if needed

Respiratory system
Maintain FiO2 of 1.0 for first few hours Later reduce to 0.5 with PEEP, if no spontaneous efforts. Moderate hyperventilation to reduce ICP for a short period

Cerebrovascular system
Maintain normal BP and cerebral blood flow Maintain tissue oxygenation Correct acidosis Control convulsions Reduce cerebral edema and ICP Avoid hyperglycemia Induce moderate hypothermia

Nursing Management

Immediate care after CPR

LOC and GCS scoring ECG Temperature (core and peripheral) Arterial BP CVP Urine output ABG value FiO2

InvestigationsChest X ray Complete blood count Blood glucose Clotting screen Plasma, urea and electrolytes Hb and Haematocrit

Post procedure care

POST PROCEDURE CARE

Patient is shifted to intensive care unit. Nsg. Diagnosis : risk for altered respiratory pattern r/t disease condition. Assess respiratory rate. Auscultate breath sounds. Fowlers position if difficulty. Monitor pulse oximetry and ABG analysis. Report any abnormality. Continuous monitoring for the first half hr. of defibrillation.

Nursing Diagnosis: decreased cardiac output r/t cardiac

arrest, dysrhythmia. Assess vitals signs, CVP, urinary output and peripheral pulses. Assess heart rate and rhythm (ECG). Oxygen administration as hypoxia can lead to further dysrhytmias. Administer drugs, antidysrhythmic medication as ordered. Administer fluid therapy as ordered. Prepare for pacemaker therapy, if required.

Nursing Diagnosis: risk for complication r/t pacemaker. Observe for pacemaker spike with subsequent capture. Assess mode, heart rate and rhythm, BP, LOC. Assess patients anxiety levels and pain. Administer pain medication. Transvenous pacingCheck for the positioning of extremity used. Check the peripheral pulses below the pacemaker insertion.

Nursing Diagnosis: altered tissue perfusion r/t to decreased cardiac output. Note the color and temperature of the skin. Assess hemodynamic pressures hrly. Monitor peripheral pulses q4h. Monitor urine out put q4h. Monitor lactate levels. Provide warm environment.

Nursing Diagnosis: risk for fluid electrolyte imbalance r/t altered physiology. Monitor intake and output. Administer fluid and diuretics. Monitor electrolytes daily and replace as ordered. Monitor BUN, creatinine and urine electrolytes daily.

Nsg. Diagnosis : risk for complications r/t disease process, procedure performed and defibrillation. Interventions: Assess level of consciousness. Reorient the time, place and person. Assess vital signs and ECG continuously. Initiate IV antidysrhythmics therapy. Administer IV fluid to correct fluid electrolyte imbalances

Monitor lactate levels. Correct lactic acidosis. Maintain blood glucose within normal range using insulin. Assess for burns and treat the injury. Document neurological, respiratory and cardiovascular status before and after the defibrillation.

Summary
CPR- definition Chain of survival Adult basic life support Pediatric basic life support Advance life support Nursing management

References
Circulation, Journal of American Heart Association, American heart association 2005;112;35-46. Joyce MB, Medical Surgical Nursing, sixth edition, Sunders company, Page : 1560-1568. Patricia GM, Critical Care Nursing, Eighth edition, Lippincott William and Wilkins, Page : 368-372. www.google.com

Thank you