Cardiopulmonary 1

Resuscitation(CPR
)
BY

ADAMU ABDULLAHI
HARUNA.(R N)
STUDENT NURSE ANAESTHETIST SCHOOL OF POST
BASIC NURSING PROGRAMMES

A.B.U.T.H ZARIA.
 2
American Heart Association (AHA)
Guidelines for CPR & Emergency
Cardiovascular Care
UPDATED NOVEMBER 2017

Highlights of the 2017 AmericAn heArt

AssociAtion focused updAtes on Adult And pediAtric
BAsic life support And cArdiopulmonAry
resuscitAtion QuAlity These highlights summarize
the key issues and changes in the adult and pediatric
basic life support (BLS) 2017 focused updates to the
American Heart Association (AHA) guidelines for
cardiopulmonary resuscitation (CPR) and emergency
cardiovascular care (ECC).
3
Definition of Cardiac arrest:
4
It is loss of cardiac function,
breathing and loss of
consciousness.
Diagnosis of cardiac arrest (TRIAD):

1) Loss of consciousness.
2) Loss of apical & central
pulsations (carotid,
femoral).
3) Apnea.
 5
Types (forms) of cardiac
arrest:

1) Asystole (Isoelectric
line).

2) Ventricular fibrillation
(VF).

3) Pulseless Ventricular
tachycardia (VT).

4) PEA: pulseless electrical

activity.
Causes of cardiac arrest (6 H 6
& 4 T):
1) Hypoxia.
2) Hypotension. 1) Cardiac
Tamponade.
3) Hypothermia.
2) Tension
4) Hypoglycemia.
pneumothorax.
5) Acidosis (H+).
3) Thromboembol
6) Hypokalemia ism
(electrolyte (pulmonary,
disturbance). coronary).
4) Toxicity (eg.
digoxin, local
anesthetics,
insecticides).
 7

Definition of CPR: it is an emergency

medical procedure for a victim of cardiac
arrest or respiratory arrest.
What is basic life support (BLS)?
It is life support without the use of
special equipment.
What is Advanced Life Support (ALS)?
It is life support with the use of special
equipment (eg. Airway, endotracheal tube,
defibrillator).
BLS-SSS > LLFT 8
Basic Life Support (BLS) 9
► 3 steps before the initiation of resuscitation for
management of a collapsed patient:
1) Ensure your own Safety.
2) Check the level of responsiveness by gently Shaking
the patient and Shouting: “are you alright?”
3) Shout for help.

► Then check for carotid pulsations.

► Apnea (cessation of respiration) is confirmed by:

1) Look: to see chest wall movement.Seesaw
(paradoxical) movement of the chest wall
indicates airway obstruction.
2) Listen: to breath sounds from the mouth.
3) Feel: air flow.
For at least 10 seconds
10
 11

There are 4
cornerstones for optimising the
outcome following cardiac arrest:
 Early recognition & call for help: to prevent
cardiac arrest.
 Early CPR (with minimal interruptions): to
buy time.
 Early defibrillation: to restart the heart.
 Post resuscitation care: to restore quality of
life & minimize neurological insult.
Golden Hour
12
► Refers to the period of time immediately
following trauma during which
approximately ~ 50% of deaths occur.
► The causes of death are usually
preventable provided that adequate
resuscitation, diagnosis and surgical
intervention are provided. (Eg. tension
pneumothorax, cardiac tamponade).
Life support includes 13
A B C – C A B.

C= Circulation
A Airway (and cervical
=

spines)

B = Breathing
 14

C = Circulation
 (A) Chest compressions (BLS & ALS).
 (B) IV access (ALS).
 (C) Defibrillation (ALS).
(1) Chest compressions (cardiac 15
massage):
The human brain cannot survive more than
3 minutes with lack of circulation. So chest
compressions must be started immediately
for any patient with absent central
Technique of chest
pulsations.
compressions:
Pt must be placed on a hard
surface (wooden board).
The palm of one hand is placed
in the concavity of the lower half
of the sternum 2 fingers above
the xiphoid process.
 The other hand is placed over the
hand on the sternum.
16
 Shoulders should be positioned
directly over the hands with the
elbows locked straight and arms
extended.
 Sternum must be depressed 5-6 cm
in adults, and 2-4 cm in children, 1-2
cm in infants
 Must be performed at a rate
of 100-120/min
During CPR the ratio of chest
compressions to ventilation
should be as follows:

Single rescuer = 30:2
 In the presence of 2 rescuers chest
compressions must not be
interrupted for ventilation.
Chest compressions in infants 17
(0-12 months)
Complications of chest 18
compressions:
Fractured ribs (MOST commonly).
Pneumothorax.

Sternal fracture.
Anterior mediastinal hemmorrhage.
Injury to abdominal viscera (eg. liver
laceration or rupture).
Pulmonary complications (contusion).
Rarely injury to the heart and great
vessels (eg. myocardial contusion) (very
rarely).
NOTE: Usually AVOIDABLE by performing
the technique correctly.
Assessment of the adequacy of 19
chest compressions:
Systolic BP: 60-80 mmHg
Diastolic BP: > 40 mmHg
Capnography: End-tidal (expired
CO2): successful CPR is indicated by
expired CO2 > 20 mmHg.
 20
GOLDEN RULES:
Ensure high quality chest compressions:
rate, depth, recoil.
Plan actions before interrupting CPR.
MINIMIZE interruption of chest
compressions.
Early defibrillation of shockable rhythm.
 (2) IV ACCESS 21
 A pre-existing central venous
line is ideal in CPR, but if it is
not present it will be time-
consuming. Drug
administration must be
followed by 10 ml IV fluid
bolus.
 Peripheral IV line is
associated with significant
delay between drug
administration and delivery to
the heart, since peripheral
blood flow is drastically
reduced during resuscitation.
So drug administration must
be followed by 20 ml IV fluid
bolus in adults and elevation
of the limb to ensure delivery
to the central circulation.
(3) Defibrillation: Adult ALS 22
algorithm
Ventricular Tachycardia (VT) 23
(shockable)
 Broad bizarre-
shaped complexes.
 Rapid rate: up
to150/min.
 Regular.
 Precordial thump:
Rapid treatment of a
witnessed and
monitored VF/VT
cardiac arrest.

11/06/24 05:39 AM
 Ventricular fibrillation (VF) 24
(shockable)
Bizarre irregular
waveform.
 Rate up to 250b/min
 No recognizable
QRS complexes.
 Random frequency
and amplitude.
 Coarse / fine.
 Exclude:
artifact:
movement
electrical
interference
Asystole (non- 25
shockable)
Check that all leads are attached.

 Adrenaline 1 mg IV every 4 mins (2 cycles)

(until a shockable rhythm is achieved).
PEA: Pulseless Electrical Activity
non-shockable 26

 Exclude / treat reversible causes.

 Adrenaline 1 mg IV every 4 mins (2
cycles) (until a shockable rhythm is
reached).
(3) 27
Defibrillation
 Position of Paddles:
 One paddle is placed in
the right infraclavicular
region, while the other
is placed in the left 5th-
6th intercostal space
anterior axillary line.
 Alternatively antero-
posterior position may
be used: one paddle is
placed in the left
infrascapular region
while the other is
placed in the left 5th-
6th intercostal space
anterior axillary line.
 Precautions:
Make sure the paddles have conducting gel on them:
(Why??) 28
1- The electricity will not be properly transmitted to
the chest wall without it.
2- Even with the gel these paddles will often cause
a second-degree skin burn.
Make sure that you have cleared the bed: make sure
that no one is in contact with the bed.> electrocution
Hold the paddles down firmly
Chest compressions must be continued for 2 minutes
after DC shock before reassessment of cardiac rhythm.

Complications of defibrillation: skin

burn, injury to myocardium and elevation of cardiac
enzymes, electrocution of person in contact with the
bed.
Drugs used in CPR 29
► Adrenaline:
 - Given as a vasopressor α-1 effect (not as an inotrope).
 - Dose: 1 mg (0.01 mg/kg) IV every 4 minutes (alternating
cycles) while continuing CPR.
Given:
 1) Immediately in non-shockable rhythm (non-VT/VF).
 2) In VF or VT given after the 3rd shock.
 -Repeated: in alternate cycles (every 4 minutes).
 -Once adrenaline → ALWAYS adrenaline.
► Amiodarone:
 - Dose: 300 mg IV bolus (5 mg/kg).
 - Given: in shockable rhythm after the 3rd shock.
 - If unavailable give lidocaine 100 mg IV (1-1.5 mg/kg).
 Vasopressin (ADH): 40 IU single dose 30
once.
► Magnesium:
 - Dose: 2 g IV.
Given:
1- VF / VT with hypomagnesemia.
2- Digoxin toxicity.
► Calcium:
Dose: 10 ml of 10% Calcium chloride IV.
Indications:PEA caused by: hyperkalemia,
hypocalcemia, hypermagnesemia, and
overdose of calcium channel blockers.
DoNOT give calcium solutions and
NaHCO3 simultaneously by the same route.
► IV Fluids:
Infuse fluids rapidly if hypovolemia is suspected. 31
Use normal saline (0.9% NaCl) or Ringer’s solution.
Avoid dextrose which is redistributed away from the
intravascular space rapidly and causes hyperglycemia
which may worsen neurological outcome after cardiac
arrest.
Dextroseis indicated only if there is documented
hypoglycemia.

► Thrombolytics:
Fibrinolytic
therapy is considered when cardiac arrest is
caused by proven or suspected acute pulmonary embolism.
Ifa fibrinolytic drug is used in these circumstances
consider performing CPR for at least 60-90 minutes before
termination of resuscitation attempts.
Eg: Alteplase, tenecteplase (old generation:
streptokinase)
Sodium bicarbonate:
► Used in:
32
 1- Severe metabolic acidosis (pH < 7.1)
 2- Life-threatening hyperkalemia.
 3- Tricyclic antidepressant overdose.
► Dose: (half correction)
 1/2 Base Deficit × 1/3 Body weight.
Avoid its routine use due to its complications:
1- Increases CO2 load:
2- Inhibits release of O2 to tissues.
3- Impairs myocardial contractility.
4- Causes hypernatremia.
5- Adrenaline works better in acidic medium.
 33
Atropine:

Itsroutine use in PEA and asystole is not

beneficial and has become obsolete.

Indicatedin: sinus bradycardia or AV block

causing hemodynamic instability.

Dose: 0.5 mg IV. Repeated up to a maximum of 3

mg (full atropinization).
 34

A = Airway
Airway
35
►Loss of consciousness often results in airway obstruction
due to loss of tone in the muscles of the airway and falling
back of the tongue.
►(A) Basic techniques for airway patency:
1) Head tilt, chin lift: one hand is placed on the
forehead and the other on the chin the head is tilted
upwards to cause anterior displacement of the
tongue.
2) Jaw thrust: 36
3) Finger sweep: Sweep out foreign body
37
in the mouth by index finger (in
unconscious pt only. This is NOT advised in a
conscious or convulsing patient).
4) Heimlich manoeuvre: if the pt is conscious or the
foreign body cannot be removed by a finger 38
sweep. It is done while the pt is standing up or
lying down. This is a subdiaphragmatic abdominal
thrust that elevates the diaphragm expelling a
blast of air from the lungs that displaces the
foreign body. In infants this can be done by a
series of blows on he back and chest thrusts.
(B) Advanced techniques for airway
39
patency:
1) Face Mask

Signs of successful seal and ventilation include:

 - Foggy mask.
 - Rising chest.

Advantages: Easy. Does not require skilled personnel

(paramedics).

Disadvantages: Stomach inflation. Not protective

against regurgitation & aspiration of gastric
contents.
2) Oropharyngeal airway 40

Advantages: Easy. Does not require highly skilled

personnel (can be used by paramedics).
Disadvantages: Not protective against regurgitation
& aspiration of gastric contents. Poorly tolerated by
conscious pts (gag).
3) Nasopharyngeal airway 41

► Lubricated and inserted throught the nose.

► Better tolerated in conscious patients.
► Contraindicated: in anti-coagulated patients and fractured skull
base.
► Disadvantages: Not protective against regurgitation &
aspiration of gastric contents.
4) Laryngeal mask (LMA) 42
► Available in a variety of pediatric and
adult sizes.
► Advantages: Easy. Does not require
highly skilled personnel (can be
used by paramedics).
► Disadvantages: Stomach inflation.
Not protective against
regurgitation & aspiration of
gastric contents.
5) Endotracheal tube 43

► Advantages: Ensures proper lung ventilation. No

gastric inflation. No regurgitation or aspiration of
gastric contents.
► Disadvantages: Requires insertion by highly
skilled personnel.
 6) Combitube 44

► Advantages: Easy to use. Does not require highly skilled

personnel (can be used by paramedics).
7) Cricothyrotomy (Surgical 45
Airway)
 It is done either by a
commercially available
cannula in a specialized
cricothyrotomy set or a
large bore IV cannula 12-14
gauge.
 Is done in case of difficult
endotracheal intubation.
 Nu-trake canula is specially
designed to allow
ventilation by a self-
inflating bag (AMBU)
 An IV canula needs a
special connection to a
high pressure source to
generate sufficient gas flow
(trans-tracheal jet
ventilation)
8) Tracheostomy (Surgical 46
Airway)
 47

B = Breathing
(A) Basic techniques include:
48

1) Mouth to mouth breathing: with the

airway held open, pinch the nostrils closed,
take a deep breath and seal your lips over
the patients mouth. Blow steadily into the
patients mouth watching the chest rise as if
the patient was taking a deep breath.
2) Mouth to nose breathing: seal the 49
mouth shut and breathe steadily through the
nose.
3) Mouth to mouth and nose: is used in
infants and small children.
 ►Expired air contains 16% O2 so supplemental 100%
O2 should be used as soon as possible. 50
►Successful breathing is achieved by delivery of a tidal
volume of 800-1200 ml in adults at a rate of 10-12
breaths/min in adults.
(B) Advanced techniques include:
►1) Self-inflating resuscitation bag (Ambu
bag):
 When used without a source of O 2 (room air)
gives 21% O2.
 When connected to a source of O 2 (10-15
L/min) gives 45% O2.
 If a reservoir bag is added it can give up to
85% O2.
►2) Mechanical ventilator in OR or in ICU
 Expired air = 16%
O2 51

 Ambu Bag (room

air) = 21% O2

 Ambu bag + O2 (10-

15L) = 45% O2

 AmbuBag + O2 +
Reservoir bag =
85% O2
MANAGING THE CARDIAC ARREST TEAM
► DURING CARDIAC ARREST THE TEAM LEADER 52
SHOULD ALLOCATE AND ASSIGN THE VARIOUS
ROLES AND TASKS TO THE TEAM MEMBERS.
ASSIGN ONE PERSON FOR EACH OF THE
FOLLOWING ROLES:
AIRWAY MANAGEMENT & VENTILATION (EG.BAG &
MASK. INTUBATION).
CHEST COMPRESSIONS.
IV DRUG ADMINISTRATION.
DEFIBRILLATION (DC SHOCK).
TIMING AND DOCUMENTATION.

► THE PERSON RESPONSIBLE FOR THE AIRWAY MAY

TAKE TURNS WITH THE PERSON RESPONSIBLE
FOR CHEST COMPRESSIONS IN ORDER TO
DIMINISH FATIGUE & EXHAUSTION.
► IT IS ALSO THE RESPONSIBILITY OF THE TEAM
LEADER TO USE THE 2-MINUTE PERIODS OF
CHEST COMPRESSIONS TO PLAN TASKS, GIVE
ORDERS AND ELIMINATE & EXCLUDE/ CORRECT
THE REVERSIBLE CAUSES OF CARDIAC ARREST.
WITH THESE. SUCCESS IS ASSURED, OTHERWISE………
 TAKE HOME MESSAGES (12
 Points) 53
Make sure the environment is safe for rescuers and victim. Check for
responsiveness
 Commence CPR, if No breathing or only gasping (ie, no normal breathing)
 Breathing and pulse check can be performed simultaneously in less than 10
seconds
 1 or 2 rescuers 30:2 Adult only
 1 rescuer 30:2 and 2 or more rescuers 15:2 for paediatrics
 Continuous compressions at a rate of 100-120/min
 Give 1 breath every 6 seconds (10 breaths/min)
 At least 2 inches (5 cm) Adult.
 At least one third AP diameter of chest, About 2 inches (5 cm) for children
 At least one third AP diameter of chest, About 1½ inches (4 cm) Infant
excluding neonate.
 Allow full recoil of chest after each compression ABD do not lean on the chest
after each compression
 Limit interruptions in chest compressions to less than 10 seconds
 54
EOD