DEFINITION

It is defined as the use of artificial

ventilation with external heart

compression to establish blood

circulation to the vital organs ie. Brain,

heart, kidney and lungs.

INDICATION

i) Cardiac causes

ii) Pulmonary causes

iii) Respiratory arrest causes

Cardiac causes

•Myocardial infarction

•Heart failure

•Dysrrhythmia

•Coronary artery spasm

•Cardiac tamponade

•Hypotension

•Hypothermia

Pulmonary causes

•Respiratory failure, secondary to respiratory

depression

•Airway obstruction (anoxia)

•Impaired gas exchange, in acute respiratory

distress.

•Impaired ventilation, such as pneumothorax.

•Pulmonary embolus

•Electrolyte imbalance

•Hyperkalemia

•Hypomagnesemia

•Retention of CO2

•Carbon monoxide and other type of poisoning.

Respiratory arrest causes

•Drowning

•Stroke

•Heart attack

•Drug over dose

•Suffocation

•Accident/injury

•Head trauma

•Neuro muscular paralysis

•Spinal injuries

•Post-operative cervical laminectomy

SIGNS AND SYMPTOMS OF CARDIAC

ARREST

The three cardinal signs of cardiac arrest are

Apnea,Absence of carotid and femoral pulse and

dilated pupils.

i. Apnea

ii. Absence of carotid and femoral pulse

iii) Dilated pupil

iv) Cyanosis

v) Unconsciousness

vi) Fits

SEQUENCE OF CARDIO-PULMONARY

RESCESCITATION

C - Circulation

B - Breathing

A - Airway

PULMONARY ASSESSMENT

Because of an emergency no time is cost to initiate

cardio pulmonary resuscitation procedures. The success

of the cardio pulmonary resuscitation depends on the

speed with which basic life supporting measures are

presence of cardio pulmonary arrest in the patient

making the three cardinal signs and symptoms such as

•Apnea

•Absence of carotid and femoral pulse

•Dilated pupils

PURPOSES

•To initiate breathing

•To restore blood circulation

•Restore – cardio pulmonary functioning

•Prevent irreversible brain damage form Anoxia.

PREPARATION OF EQUIPMENT

•Oxygen administration sets

•IV infusions sets and cut down set

•Ambu bag and mark devices.

•Endotracheal tubes of different sizes.

•Oropharyngeal and nasal airway

•Laryngeal scope of different sizes.

•Tracheotomy sets

•Suction apparatus

•Cardiac monitor and defibrillator

•Mechanical respiratory aids.

•Emergency drugs such as epinephrine, sodium bi

carbonate, cardiac and respiratory stimulants etc.

•Clear rag pieces or gauze pieces in containers.

PREPARATION OF THE PATIENT AND

ENVIRONMENT

The patient may be shifted to a hard surface or a

hard board is placed under the patient’s thorax.

Remove or push aside the clothing which covered

the patient’s chest to observe the chest for cardiac

beats and respiration.

Place patient flat on his back with out any pillows.

This position helps to maintain the airway and to give

external cardiac compression

Hyper extended the head and neck.

External cardiac massage and artificial ventilation

must be started with in 4-6 mts following cardiac

asset or irreversible brain damage will occurs as a

result of oxygen deprivation and lack of circulation.

GENERAL INSTRUCTION

a)Cardio pulmonary resuscitation techniques are used

in persons whose, respirations and circulation of blood

have suddenly and unexpectedly stopped.

b)The CPR must be initiate with in 3-4 minutes in

order to prevent permanent brain damage.

c)Strike the centre of the chest sharply with the side of

the clenched fist twice.

d)Call for assistance.

e)Trace the last rib, and follow the rib to the notch

where the ribs meet the sternum. Then place the heel

of the other hand on the lower part of the sternum

above 1- above the palpating hand

GENERAL INSTRUCTION

a)Clear the airway of false teeth, vomitus, food

materials etc.

b)Initiate ventilation & external cardiac massage

without wasting time.

c)To prevent the tongue falling back and obstructing

the airway, tilt the head and neck into a hyper

extended position.

d)The artificial breathing and cardiac massage should

correspond to the normal respiration and pulse rate.

e)Watch for the complications that may occur during

the CPR.

f)Discontinue the procedure only when you are sure

that his respirations and circulation are reestablished

Look for,constriction of pupilschange in feeling of pulse regular, rhythm and good volumethe systemic blood pressure return to normal.There is improved co lour of skin.The respiratory movements are taking place rhythmically.

STEPS RATIONALE

TO MAINTAIN CIRCULATIONBegin external cardiac compression immediately

Position the patient on his back on a flat, firm surface.

Kneel along one side of the patient’s chest. If the patient is on a bed or on a table. It is often necessary to kneel on the bed or table at the side of the patient.

Tissue hypoxia will cause irreversible brain damage if an adequate circulation is not restored within 3 -4 mts.

If bed is sagging it is difficult to evaluate the amount of sternal pressure existed during each compression.

To use the pressure effectively.

STEPS RATIONALE

Place the heel of open hand on the lower third of the sternum of above the xiphoid process. Place the heel of the other hand on the top of the first hand, keep the fingers elevated from the chest wall or they may be kept interlocked.

Straighten arms by locking elbows. Lean forward until your shoulders are directly over your hands, depress patient’s sternum1 ½ to 2 inches with each compression.

Using the heel of the hand exerts pressure only on the sternum. Pressure elsewhere can create with fracture.

Locking the elbows and straightening the back adds pressure of chest compression.

STEPS RATIONALE

Release pressure on the sternum quickly and completely taking care not to change the position of your hands, nor to move them off the chest wall.

Rhythmically continue cardiac compression a rate of 100 per minute. For young children and infants the rate of compression is 80-100mt.

Periodically assess the vital signs.

Each compression on squeezes blood out of the heart and relaxation period allows time for the heart to fill with blood before the next compression.

Improvement of color and return of spontaneous movement of the chest are the only observation possible to note by one rescuer.

STEPS RATIONALE

BREATHING: MOUTH TO MOUTH BREATHINGMaintain the position of the head as discussed.

Pinch the patient’s nostrils closed. Using an index finger and thumb of the hand near the patients face. Take a deep breath. Place your widely opened mouth over the patient’s mouth over the patient’s mouth and blow forcefully enough to make the patient’s chest rise. Turn the face towards the patient’s chest to observe its expansion.

Keep the airway clear.

Closing the nostrils with fingers and enclosing the patient’s mouth into the rescue’s mouth ensures air tight seal.

STEPS RATIONALE

After each inflation move your mouth away from the patient’s mouth.

Repeat inflation 12 to 15 times per minute at the rate of one inflation every three to five seconds. Until the patient breaths spontaneously. In children, less volume of air is introduced but they are given about 20 or 30 times per minute.

To allow air to escape when the patient exhales and for you to inhale.

The inflation of the lungs should. Correspond to the normal respiration.

STEPS RATIONALE

MAINTAINING THE AIRWAYClear the airway of obvious foreign matter eg. Vomitus, secretion etc.

Hyper extended the head and neck of the patient by lifting it backward as for as possible.

Pull the victim’s jaw forward by placing the finger behind the angle of jaw and is lifted forwarded until the teeth on the upper jaw and the lower are approximated.

Clearing of airway obstruction may restore the spontaneous respiration and circulation.

Prevents the tongue falling.

Helps to keep airway open and prevents falling back of the tongue.

STEPS RATIONALE

With the above steps. If breathing is restored, placed an oro-pharyngeal airway. If breathing is not restore start artificial ventilation.

Placing an oro pharyngeal airway helps to keep the airway patent. It also prevents biting of tongue

AFTER CARE OF THE PATIENT

•Skilled after care of the patient who has suffered

cardiac arrest is crucial for survival. The patient

should be continually watched by skilled person

over a period of 48-72 hours.

•If the patient is not in the intensive care unit shift

him to the ICU for constant observation and

expert care.

•Give oxygen continuously for 48 hour following

resuscitation are depressed for some time after

the cardiac arrest.

•Frequently checking the victim’s head and jaw

position because his tongue may fall back and

obstruct the airway.

•Assess the patient’s respiration by nothing the

rhythm, rate and depth of respiration.

•Check the colour of the skin. Persisting cyanosis

indicates adequate oxygenation of blood.

•Watch for the signs of restored circulation and

respiration.

•contraction of pupils

•improved colour

•change in the quality of pulse

•normal breathing pattern

•return of systemic blood pressure

check temperature every hour

watch for convulsion.

Insert entotracheal tube, if not already in

place. This maintains the airway patient.

Insert foly’s catheter. Write output is one of

the measures of the cardio-vascular status.

Start I.V infusion to administer enough fluid.

Blood gas and PH determinations are done to

detect metabolic acidosis.

Record the procedure on the nurses record

with date and time.

MEDICATIONS USED IN CPR

i. Vasopressors

Adrenaline or epinephrine enhances cerebral and myocardial

blood flow by preventing arterial collapse. The dose is 1mg every

3-5 minutes.

In children 10Mg/Kg or 0.1ml/kg of in 10000 solution.

ii. Anti arrhythmic agents

Lignocaine is of undoubted value in treatment of ventricular

tachycardia (vt) and its ability to prevent (VF) has also been

demonstrated.

Dose: 1 – 1.5mg/kg bolus

ii) The other drugs such as amiodorone, procainamide, sotalol and

flecainide. The amiodorone is a complex drug with effects on

sodium, potassium and calcium channel as well as alpha, betas

blocking properties. It is useful in treatment of both AF & VF.

Dose: 150mg diluted in 20ml of 5% dextrose given over 10min,

followed by infusion 1mg/min for to hours then 0.5mg/ml.

iii) Others

a. Sodium-bicarbonate (NaHCO3):

Whenever possible, bicarbonate therapy should be guided by the

bicarbonate concentration or calculated base deficit obtained from blood

gas analysis.

b. Calcium (Ca++): (Calcium gluconate)

Usually has no role unless patient present with calcium channel blocker

toxicity or if there is evidence of hypocalcaemia or hyperkalemia.

Dose: 0.5ml/kg

c)Magnesium (Mg++)

It is indicated only if hypokalemia or hypomagnesaemia.

Dose of magnesium sulfate: 1-2 gm/ diluted in 100ml of 5% dextrose

gain over 30-60mints followed by an infusion of 0.5 – 1.0gm/hour.

d) Atropine

It enhances automaticity and conduction of both sinoatrial and

atrioventricular node and is most effective in haemodynamically

significant bradycardia.

Dose: 1.0mg IV repeated 3-5 minutes if required.

For brady cardia, 10mg/kg repeated every 3-5mints.

Step Procedure

Prepare the patient Assemble a laryngoscope, ET

Tubes, stylet, suctioning

equipment and a bag value mark.

Determine which medications

will be used and prepare them for

administration. Begin cardiac and

O2 saturation monitoring.

STEPS PROCEDURE

Provide cervical spine immobilization or indicated.

Provide 100% oxygen.

Pre-medicate if appropriate.

Push (IV) sedative

Paralyze

Prevent cervical spine damage in trauma patients.

Pre oxygenate using a bag-value mark.

Lidocaine 1 to 1.5 mg/kg IV should be sued if there is concern about increased intracranial pressure. Atropine 0.02mg/kg IV should be used in children. Edomidate 0.2 to 0.6mg/kg IV. Thiopental 3-5mg/kg IV. Fentanyl 3-5mg/kg c midazolam.

Succinyl choline 1-5 to 2mg/kg IV or propofol 3-5mg/kg IV cricoids pressure should be applied to prevent regurgitation.

Pressure is applied to the cricoids

Pass the tube

Placement is confirmed.

Post intubation plan is made

After 40 seconds of cricoid pressure intubate the patient. This procedure should be accomplished with 30 seconds. Visualize tube placement. Look for the rise and fall of the patient’s chest. Auscultate for lung sounds bilaterally. Check oxygen saturation 98-100% perform a chest x-ray to check tube placement.

Secure the ET stube inflate the cuff. Continuously assess O2 saturation.

Determine ventilation setting. Assess whether the patient should remain paralyzed and sedated.

FAILURE OF CARDIO-PULMONARY

RESUSCITATION CAUSED BY

•Massive myocardial infarction

•cardiac tampon

•Enlarged heart with incompetent values.

•Obstructed airway.

•Severely decreased / damaged lungs.

•Pulmonary embolism

•Chest deformity

•Fracture of ribcage.

FAULTY TECHNIQUE OF CPR RESULT IN

1.In adequate airway opening.

2.Placement of patient on soft yielding

surface.

3.In adequate chest compression

4.Improper seal around the patient’s

mouth.

5.Improper or on adequate drug therapy

6.Prolonged interruption.

SIGNS OF SUCCESSFUL CPR

•Perceptive lung expansion

•Palpable pulse

•The pupil will react to light or will appear

normal.

•Normal heart rate will be return.

•A spontaneous gasp or breathing will

occur.

•Move body parts, colour may improve from

cyanosis.

NURSING INTERVENTION

In effective airway clearance related to airway

obstruction secondary to aspiration or obstruction

with foreign matter.

Risk for aspiration secondary to

unconsciousness.

Risk for fall related to unconsciousness

Fatigue related to impaired blood circulation

secondary to cardiac arrest

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