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

INDEX
S.No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Contents Objective Introduction Definition Purpose of CPR Indications for CPR Cardio-Respiratory Failure Cardiac Arrest Sign and Symptom of cardiac arrest General Instruction for Effective CPR Sight for Cardiac compression Preparation of Article Steps of Procedure Precaution Specific Medical Therapy Post Resuscitation Complication Post Resuscitation Measures and Management Summary Bibliography Page No. 1 1 2 3 3 4-5 6-8 9-10 11-13 14-15 16-17 18-23 24-25 26-27 28 Nursing 28-30 30 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

 2)

Hypotension

CO2 Retention Reactions to anaesthesia Depression from anaesthesia. Coronary occulusion. Acute myocardial infarction. Inadequate ventilation of lungs. Anoxia due to airway obstruction. 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 Adams 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 patients 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 patients sternum with

the fleshy part of the first from with the fleshy part of the first from 8-12 inches above the patients 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 1-1 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. 2. 3. 4. 5. 6. 7. No time is lost in explaining the procedure to the patient or his relatives. The patient may be shifted to a hard surface or a hard board is placed under his thorax. Remove or push aside the clothing, which covered the patients chest to observe for cardiac beats and respirations. Place the patients back on his back with any pillow. This position helps in maintaining airways and giving external cardiac compressions. Tight clothing around the neck and chest should be removed. Ensure fresh air in the room by opening windows and doors. 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. 2. 3. 4. 5. Endofraechead tubes of various sizes (7, 7.5,8). An ambu bag with mask a) Stillent (in a plastic cover) b) Megals forceps (in a plastic cover) A section tube or catheter. a) Laryagoscope with different sizes of blodes. b) Nasal Airway. c) Oral Airway. d) A bowl with gauze pieces. e) Lubricating Jelly.

6. 7. 8. 9. 10. 11. 12. 13.

Adhesive type with scissors. Local Anaestetic (Drug) Spray. Gloves in cover. A kidney fray. A paper bag. Masks for various sizes. Disposable syringes with needles. Intravenous (I/V) set and a cut down set.

OTHERS
a) b) c) A 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Oxygen Inhalation (Central Supply) Suction point (Central Supply) Defibrillator. Tray containing emergency drugs. Injection Adrenaline. Injection Atropin Injection Digoxine. Injection Sodium Bicarbonate. Injection Dopamine Injection Gycolin. Injection Decadron. Injection Aviv Injection Calcium Gluconate. Injection Lasix. Injection Aminophyline Injection Isoptin. Injection Compose. Injection 20% Dextrose. Injection Deriphydine. Syringes with needles.

17. 18.

Cannulas on cotton pad. Gloves in cover.

STEPS OF PROCEDURE
1. 2. 3. 4. 5. Determine unresponsiveness observe for spontaneous respiration, palpate carotid pulse, and ask the victim. Are You Ok? Call for help. Patient supine on a firm, flat surface or use a board. Kneel at the patients side. Open the patients airway. a) Place one hand on the patients 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) c) d) 7) For Ambu loage resuscitation use a proper size face mask and apply it over the patients mouth. For artificial respiration with an ambu bag in an adult, compress the bag fully for two breath. For ambu bag resuscitation in a child use two small compressions of the bag. 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) 9)

Suction any secretions from the airway. If suction is unavailable, turn the patients head one side. 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) c) d) Fingers are removed up the ribcage to notch where ribs meet the lower sternum in the center of the lower part of the chest. 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. 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 patients sternum. - compress chest 3-5 cms. (1-2 inches) a) b) c) Compress chest 80-100 times/min. perform 15 external compressions with one and two and three and ------- to 15 Ventilate lungs with two slow rescuer breath. 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 infants head just under the infra mammary line where it intersect sternum. 3) Using two or three fingers compress 1.3-2.5cm ( -1 inches) at least 100 times/ mt.

4) At the end of every fifth compression allow a pause for ventilation (1 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 rescuers other hand maintains the childs head position. b. Compress sternum with one hand 2.5-3.8 cm (1-1) 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 Measures Performed with equipment Airway Backward tilt of the head. equipment Suction Endo-trachial intubation.

1) Basic Life A) support control

Supine

aligned

position

stable side position. Lung inflation attempts. Triple airway maneuver

Tracheostomy

(jaw thrust, open mouth) Manual cleaving of the mouth and throat.


B)

Back

blows

manual

thrusts. Breathing Mouth to mouth ventilation

Manual ventilation without

bag with

mask or

support

mechanical direct

C) Circulation Manual 2)

chest

compression

ventilation. Open chest

support Pulse checking Advanced D) Drugs and fluids. E) Electrocardio graphy F) Fibrillation

cardiac compressions. I/V line E.C.G. monitoring defibrillation

life support

treatment 3) Prolonged G) Gauging life support H) I) care Human mentation. Intensive

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 patients 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 patients 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. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Medication Oxygen Morphine sulfate Lidocaine Atropine sulfate Isoproterenol hydrochloride Epinephrine hydrochloride Norepinephrine Dopamine hydrochloride Dobutamine hydrochloride Debutamime hydrochloride Calcium gluconate Digitadis preparations Indication Hypexemia Pain of acute MI Ventricular tachicardta and fibrillation Sinus brady cardia Brodycardia CPR (increase myocardiacl and CNS blood flow Severe hypotension and low peripheral

resistance Severe hypotension Heart failure Hyperkalemia Hypocaucemia Atrial flutter atrial fibrillation Heart failure or unstable angina

13. 14.

Nitroglycerin Sodium Bicarbonate

Severe and base imbalance 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 foleys 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 nurses 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.

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3)

Luckmann Joan, Karen Creason, Sorenson, Medical Surgical Nursing, 3 rd Edition W.B. Saunders Company Philodelphia, London P.P. Lippincott, Medical Surgical Nursing, 8th Edition Philadelphia New York. P.P. 287-288.

4)

5) Brunner & Suddharths, 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. 477488. 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 & Suddharths. Text book of Medical And Surgical Nursing, Lippincott Williams & Wilkins. P.P. 810812. 10)Luckmann Joan & Karen Creason Sorenson. Medical Surgical Nursing Third Edition, W.B. Saunders Company. P.P. 921-926.