CARDIO PULMONARY RESUSCITATION

DEFINITION

It is an emergency procedure, often employed after cardiac arrest, in which external cardiac
massage, artificial respiration and drugs are used to maintain the circulation of oxygenated blood
to the brain.

PURPOSE OF CPR

 To maintain an open and clear airway (A).

 To maintain breathing by artificial ventilation (B).

 To maintain circulation by external cardiac massage (C).

 To save life of the patient.

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

INDICATIONS OF CPR

 Cardiac Arrest:
 Ventricular fibrillation.
 Ventricular tachycardia.
 Asystole.
 Pulseless electrical activity.

 Respiratory Arrest :

This may be the result of the following :

 Drowning.
 Stroke.
 Foreign body in throat.
 Smoke inhalation.
 Drug overdose.
 Suffocation.
 Accident, injury.
 Coma.
 Epiglottis paralysis.
PRINCIPLES OF CPR :

 To restore effective circulation and ventilation.

 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

 CPR technique is used in person whose respiration and circulation of blood have
suddenly and unexpectedly stopped.

 There are no need of attempting CPR techniques in patients in the last stage of an
incurable illness and in persons whose heartbeat and respiration have been absent for
more than six minutes.

The immediate responsibilities of the resuscitator are :

 To recognize the signs of cardiac arrest.

 Protect the patient’s brain from anoxia by immediately starting artificial ventilation of the
lungs and external cardiac massage.

 Call for help.

 The cardio pulmonary resuscitation must be initiated within three to four minutes in order
to prevent brain damage.

 Strike the centre of the chest sharply with the side of the clenched first twice.

 Call for assistance.

 Clear the airway of the false teeth, vomitus food material etc.

 Initate ventilation and external cardiac massage without wasting time.

 The CPR techniques should not be discontinued for more than five seconds before
normal circulation and ventilation of lungs are established except.

 When the patient is moved to a hard surface.

 When endotracheal intubation is being carried out ( maximum time allowed for these two
procedures is 15 seconds )

 Before CPR is attempted in a patient, make sure that the airway is clear.
SITE FOR CARDIAC COMPRESSION

First of all trace the last rib and and follow the rib to the notch where the rib meet the sternum.
Then place the heel of the other hand on the lower part of the sternum about 1- 1.5 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.

 Keep fingers off the chest or interlocked.

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

 The artificial breathing and the cardiac massage should correspond to the normal
respiration and pulse rate.

 The ratio of cardiac compression to ventilation is 5: 1 that is 5 cardiac compressions to

one ventilation. Cardiac compression is given at the rate of 60 per minute.

 Ventilation is given between the cardiac compression without interrupting or slowing the
rate of compressions. Thus 60 cardiac compressions and 12 ventilations per minute are
achieved.

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

 When there is only one rescuer, interrupt compressions after every 15 compressions to
give two quick deep lung infiltrations. This results in a cardiac compression to the
ventilation ratio of 15:2.

PRECAUTIONS

 The patient should be placed on a hard surface.

 The body of the patient should be horizontal because the blood pressure generated is not
adequate to pump the blood upto the head.

 Assess properly and indicate CPR within three minutes of arrest.

 Do not interrupt CPR for more than seven seconds.

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

 Give compression only over sternum not on ribs.

 When you are giving cardiac compression, fingers should be in upward direction to
prevent rib fracture.
CPR TIME LINE :-

0-4 minutes : brain damage unlikely

4-6 minutes: brain damage possible.

6-10 minutes: brain damage probable.

Over 10 minutes: probable brain death

MAIN STAGES OF RESUSCITATION

Chest compressions

Chest compressions will be initiated sooner and ventilation only minimally delayed until
completion of the first cycle of chest compressions

A (Airway) - ensure open airway by preventing the falling back of tongue, tracheal intubation if
possible.

B (Breathing) – start artificial ventilation of lungs.

CPR GUIDELINES ACCO. TO AMERICAN HEART ASSOCIATION

 The 2010 CPR Guidelines rearranged the order of CPR steps.

 American Heart Association wants rescuers to practice C-A-B: chest compressions first,
then airway and breathing.

 You can hold your breath for a minute or two without having brain damage, victims of
cardiac arrest can go a minute or two (actually a lot longer than that) without taking a
breath.

 By starting chest compressions first, the victim only has to hold his breath an extra 18
seconds while blood gets flowing again.

 Chest compressions should be started immediately on anyone who is unresponsive and is

not breathing normally. Oxygen will be present in the lungs and bloodstream within the
first few minutes, so initiating chest compressions first will facilitate distribution of that
oxygen into the brain and heart sooner.

 The new guidelines also recommend that during CPR, rescuers increase the speed of
chest compressions to a rate of at least 100 times a minute. In addition, compressions
should be made more deeply into the chest, to a depth of at least 2 inches in adults and
children and 1.5 inches in infants.
CONTRAINDICATIONS :

 Do not resuscitate when a decision not to resuscitate has been noted in the chart.

 Patient on anticoagulant therapy.

 Any history of central nervous system damage.

 Severe uncontrolled hypertension.

 Recent trauma to head or cranium.

 Neoplasm with increased bleeding risk.

 Active peptic ulceration.

 Known history of ischemic stroke.

ASSESSMENT :-

 Determine that the client is unconscious. Shake the client and shout at him or her to
confirm if conscious rather than being asleep.

 Assessment for the presence of respiration.

 Assess carotid artery for pulse.

EQUIPMENTS :-

 A hard, flat surface.

 No additional equipment is necessary but in hospital setting, an emergency cart with

defibrillator and cardiac monitoring should be the bedside. Crash card usually contains :

 Airway equipment.

 Suction equipment.

 Intravenous equipment.

 Laboratory tubes and syringes.

 Pre packed medications for advanced life support.

PROCEDURE :-

One rescuer- adult, adolescent client

1. Assess the response by tapping or gently shaking client while shouting – Are u ok?

It prevents injury to a client who is not experiencing cardiac and respiratory arrest.

2. Call for helps or activate or activate the emergency medical system because the majority
of adults with sudden cardiac arrest in ventricular fibrillation.

3. Turn client on to the back while supporting head and neck. Place a cardiac board under
the back or place client on the floor.a firm surface is needed for adequate compression of
the heart beneath the sternum.

4. Position self: face the client on your knees parallel to the client, next to the head, to begin
to assess the airway and breathing status.

AIRWAY:
 If the client is conscious and unresponsive you need to make sure that his airway is clear
of any obstruction. Open the airway.
 The most commonly used methods is the head tilt /chin lift method. With the client lying
flat on his back, place your hand on his forehead and your other hand under the tip of the
chin.
 Use the modified jaw thrust if a neck injury is suspected. Place hands at the angles of the
lower jaw and lift, displacing the mandible forward while tilting the head backward.
 Assess for respiration. Place your ear over the client’s mouth and observe the chest for
rising with respiration. The breaths may be faint and shallow- look, listen and feel for
any signs of breathing for 3 to 5 seconds.

BREATHING:
 With the clients airway clear of any obstructions gently support his chin so as to keep it
lifted up and the head tilted back. Pinch his nose with your fingertips to prevent air from
escaping once you begin to ventilate.
 Form a seal over the client mouth using either your mouth or the appropriate respiratory
assist device.
 Take a deep breath and place your mouth over the clients. As you assist the person in
breathing, keep an eye on his chest. Try not to over- inflate the client lungs.
 Give two full breaths of 0.5 to 2 seconds. Between each breath allow the clients lungs to
relax place your ear near his mouth and listen for air to escape and watch the chest fall
the client exhales.
  In the events of serious mouth or jaw injury that prevents mouth to mouth ventilation,
mouth to nose ventilation may be used by tilting the head with one hand and using the
other hand to lift the jaw and close the mouth.
 If the client is breathing but still unresponsive turn on to side ( recovery position )
 Check the circulation.

CIRCULATION:
 In order to determine if the clients heart is beating, place two finger tips on his carotid
pulse, located in the depression between the windpipe and the neck muscles and apply
slight pressure for 5 to 10 seconds on the side next to which you are kneeling.
 If there is no pulse then the client’s heart is not beating and you will have to perform
chest compressions.
 Maintain position on knees parallel to sternum.
 Positions the hands for compression: using the hand nearest to the legs place middle
and index finger on the lower ridge or near ribs and move fingers up along ribs to the
costalsternal notch ( in the centre of the lower chest ).
 Place middle finger on this notch and the index finger next to the middle finger on the
lower end of the notch.
 Place the heel of the other hand along the lower half of the sternum, next to the index
finger.
 Remove first hand from the notch and place heel of that hand parallel over the hand
on the chest and interlock the fingers, keeping them off client’s chest.
 Keeping the hands on the sternum, extent the elbows, locking the elbows, with your
shoulders directly over the client chest.
 Using your body’s weight, compress the client’s chest.
 The depth of the compression should be approximately 1 and half to 2 inches at the
rate of 80 to 100 compressions per minute. 2 hands- 2 inches. If you feel or hear
cracking sounds, you may be pressing too hard. Do not stop your rescue efforts
damaged cartilage or cracked ribs are far less serious than a lost life. Simply apply
less pressure as you continue compression.

TWO HANDS TWO INCHES:

 The heel of the hand must completely release pressure between compressions, but it
should remain in contrast contact with the client’s skin to allow the heart to fill with
blood.
 Use the mnemonic one and two and three and to keep rhythm and timing.
 Finish the cycle by giving the client 2 breaths. This process should be performed four
times-30 compression and 2 breaths after which remember to check the client carotid
artery for pulse and any signs of consciousness.
TWO RESCUERS – ADULT, ADOLESCENT:-

1. When the second rescuer arrives the first rescuer stops CPR after completing two
ventilations and assesses for carotid pulse for 5 seconds.

2. The second rescuer moves into the chest compression position. Plus and deliver one
ventilation.

3. The second rescue begins chest compression while counting out loud. The compression
rate is 100 per minute.

4. The first rescuer gives two slow ventilations after 30 cardiac compressions. The first
rescuer also assesses carotid pulse during chest compressions to evaluate effectiveness.

5. If the second rescuer wishes to change the position, he or she states, change, one and two
and three and four and five.

6. The first rescuer delivers the ventilation then moves into the chest compression positions.

7. The second rescuer moves to the ventilator position and assesses for carotid pulse for 5
seconds.

CHILD CPR: According to the American heart associations guidelines child cpr is
administered to any victim under the age of 8. If the child is unresponsive and you are alone with
him, start rescue efforts immediately and perform CPR for at least 1to 2 minutes before dialing
9-1-1.

AIRWAY: A child breaths may be extremely faint and shallow- look, listen and feel for any
signs of breathing. If there is none tongue may be obstructing the airway and preventing the child
from breathing on his own. If the child is still not breathing after his airway has been cleared you
will have to assist him in breathing, look, listen, feels for breath.

BREATHING:- IF the child remains unresponsive and still not breathing on his own, pinch his
nose with your fingertips or cover his mouth and nose with your mouth creating a tight seal and
give two breaths.

CIRCULATION:- Check the child’s carotid artery for pulse by placing two fingertips and
applying slight pressure on his carotid artery for 5 to 10 seconds.

COMPRESSION: When performing chest compression on a child proper hand placement is

even more crucial than with adults. Place two fingers at the sternum and then put the heels of you
other hand directly on top of your fingers. The rule to remember is 1 hand 1 inch.
INFANT CPR :

According to generally accepted guidelines, infant CPR is administered to any victim under the
age of 12 months. Check the infant for responsive by patting his feet and gently tapping his chest
or shoulders. If he does not react immediately check his airway.

AIRWAY :- It is normal for an infant to take shallow and rapid breaths, so carefully look, listen
and feel for breathing. If you cannot detect any signs of breathing the tongue may be obstructing
the infant’s airway. When clearing an infant’s airway it’s important not to tilt the head too far
back. Infant airway is extremely narrow and overextending the neck may actually close off the
air passage.

SNIFFER’S POSITION:-

Breathing: cover the infant’s mouth and nose with your mouth creating a seal and give quick,
gentle puff from your cheeks. Let the victim exhale on his owns - watch his chest and listen and
feel for breathing. If does not breathe on his own again place your mouth over his mouth and
nose and give another small puff if the infant remains unresponsive. Immediately check his
circulation.

PUFF FROM THE CHEEKS:-

CIRCULATION:- An infant’s pulse is checked at the brachial artery, which is located inside of
upper arm, between the elbow and the shoulder. Place two fingers on the brachial artery applying
slight pressure for 3-5 seconds. If you do not feel a pulse within that time, then the infant’s heart
is not beating and will need to perform chest compressions.

BRACHIAL ARTERY:

COMPRESSIONS: Place three fingers in the center of infant’s chest with the top fingers on an
imaginary line between the infant’s nipples. Raise the top finger up and compress with the
bottom two fingers. The compression should be approximately to ½ the depth of the infant’s
chest.

Infant hand placement

Count aloud as you perform 5 cycles of 30 compressions are 2 breaths before checking the
infant for breathing and pulse. If there is no pulse, continue administering 30 compressions / 2
breaths until an ambulance arrives. If at any point the infant regains a pulse but still does not
breathe on his own, give him one rescue breath every 3 seconds.
DEFIBRILLATION

Immediate defibrillation if witnessed arrest and automated external defibrillator available

compressions before defibrillation if unwitnessed or arrival at the scene > 4-5 minutes. One
shock followed by immediate CPR.

IMPORTANCE OF EARLY DEFIBRILLATION

Most frequent arrest rhythm VF /VT.

Treatment is defibrillation

Successful conversion diminishes over time.

VF tends to deteriorate to asystole.

NOT USED FOR

Sinus rhythm

Bradycardia

A Systole

PEA.

DRUGS USED DURING CPR

Inj. Epinephrine

Inj. Atropine

Inj. Lidocaine

Inj. Magnesium sulphate

Inj. Dopamine

Inj. Sodium bicarbonate

Inj. Calcium chloride

Inj. Dobutamine.
SIGNS OF EFFECTIVE

RESUSCITATION

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

 Distinct carotid pulsation with each cardiac compression.

 Blinking upon stimulation of the eyelids.

 Breathing that begins spontaneously.

 Movement and struggling.

 Decreased cyanosis.

SIGNS OF INEFFECTIVE RESUSCITATION

 Incorrect resuscitative techniques.

 Heart is drained of its blood by haemorrhage or cardiac tamponade.

 Blood supply to the heart is obstructed by the presence of pulmonary embolus.

 Severe chronic lung disease has destroyed lungs capacity to oxygenate blood.

 Lungs are filled with vomitus as a rescue of aspiration during cardiac massage.

POST RESUSCITATION MEASURES

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

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

 If the patient is not in the intensive care unit shift him there for consent observation and
expert care.

 Monitor ECG, CVP and blood pressure.

 Check the oral cavity and jaw position as his tongue may fall and obstruct the airway.

 Temperature is taken every hour. A high temperature usually indicates cerebral damage
or cerebral edema.

 Blood gas and Ph determinations are done to detect metabolic acidosis.

 Amobarbital sodium is given intravenously in case of convulsions

 A chest X- ray film is obtained using portable equipment. Ribs often are accidentally
fractured during cardiac massage.

 Insert an endotracheal tube if not already in place. This maintains an open airway for the
unconscious patient.

 Give oxygen continuously for 48 hours following resus citation by an endotracheal tube
or mask.

 Insert foley’s catheter. Urine output is one of the measures of the cardiovascular status.

 Start IV infusion to administer enough fluids in the patient.

 Record the procedure on the nurse’s record with date and time.

 A nasogastric intubation and aspiration of contents of stomach are necessary for a patient
with a full stomach to prevent vomiting and aspiration of vomitus into lungs.
 BIBLIOGRAPHY

 Shabbeer.P. Basheer,S. Yassen khan “A concise text book of advanced nursing practice”
published by EMMESS medical publishers, edition 1st, page no. 297- 324.

 S. nancy “principles and practice in nursing” published by N.R brothers, edition 5th, page
no. 286- 292.

 Linda s. Williams paula d. Hopper “medical surgical nursing” published by F.A Davis
company, page no. 406- 412.

 Brunner & suddarth’s “A text book of medical surgical nursing” published by Lippincott
Williams& wilkins, edition 10th, page no; 810 -815.

 www.wikepedia.com