CARDIO PULMONARY RESUSCITATION (CPR)

INTRODUCTION :- Cardio pulmonary resuscitation ( CPR ) is a technique of basic life

support for oxygenation the brain and heart untill appropriate definitive medical
treatment can restore normal heart and ventilatoroy action cardio pulmonary
resuscitation techniques are used to artificial maintain both circulation and ventilation in
persons suffering from cardiac arrest. It involve

External cardiac massage ( mannual heart compression).

Artificial ventilation by either mouth to mouth, mouth to nose or mouth to airway

techniquse.

Managemnet of foreign body or airway obstruction cricothyroidotomy may be necessary to

open the airway before CPR can be performed.

DEFINITION :-

According to T.N.A.I. :-

Resuscitation is a method which includes all measures that are applied to revive patients
who have stopped breathing suddenly and unaspectedlly due to either respiratory or
cardiac failure.

According to I Clement :-

Artificial ventilation accompained by cardiac massage to facillitate normal breathing and

heart action in the event of cardiac arrest.

PURPOSES OF CPR :-

1. To maintain an open and clear airway.

2. To maintain breathing by artificial ventilation.
3. To maintain blood circulation by external cardiac massage.
4. To save life of the patient.
5. To provide basic life support till medical and advanced life support arrives.

INDICATIONS FOR CPR :-

1. Cardiac arrest :-

Ventricular fibrillation

Ventricular tachycardia
A systole

Pulse less electrical activity.

2. Respiratory arrest :-

Drowning

Stroke

Foreign body in throat

Smoke inhalation

Drug overdose

Electrocution or injury by lighting

Suffocation

Accident injury

Epiglottis paralysis.

SIGN AND SYMPTOMS :-

1. Sudden loss of consciousness.

2. Absence of carotid pulse.
3. Cessation of respiration no chest wall movement.
4. Dilatation of pupils.
5. Marked cyanosis (later).

The three cardinal signs of cardiac arrest are:-

1. Apnea
2. Absence of carotid and femoral pulse
3. Dilated pupils
4. Cyanosis unconsciousness.

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 person 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 stage of an
incurable illness an in persons whose heartbeat 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
the lungs and external cardiac massage.
c. Coll for help.
4. The cardio pulmonary resuscitation must be initated within three to four minutes in
order to prevent permanent brain damage.
a. Strik the center of the chest sharply with the side of the cleanched first twice.
b. Coll for assistance.
c. Clear the airway of false teeth, vomitus 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 patient is moved to a hard surface.
b. When endotracheal intubation is being carried out (maximum time allowed for
these two procedure is 15 seconds.)
6. Before CPR is airway is clear. It make be obstructed due to many reasons so keep
the patients neck hyperextended after confirming that be is having any cervical
injury.

THE PRECARDIAL THUMP :-

1. Use of ‘precordial thump’ is effectivene in case of witnessed cardiac arrest

precordial thump is a blow, which is delivered to the lower half of the patients
sternum with the fleshy part of the fist from 8- 12 inches above the patients chest.
This blow generates a small current of electricity which shocks the myocardium and
stimulates cardiac beating and circulation. To be effective it must be done within a
minute of cardiac arrest. If delayed it may precipitative ventricular fibrillations.
2. Cardiac compressions helps to stimulate the circulation. Locate correctly the lower
half of the sternum when cardiac compressions are used.
3. If hands are placed too high- callar bone may be fractured.
4. If hands are placed too low liver may be damaged.
SIGHT FOR CARDIAC COMPRESSION :-

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

1 ½ inch above the palpating hands. The palpating hand is then placed on the top of the
hand, which is resting on the sternum. Both hands should be parallel.

Keep finger 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 copmpression to ventilation is 5:1 ie. 5 cardiac compression is given at
the rate of 60 per minute.

Ventilations are given between the cardiac compression without interrupting or sloving the
rate of compression. Thus 60 cardiac compression and 2 ventilations per minutes are
achieved.

The ratio, is 5:1 when there are two rescueres. When there is only one resurer, interrupt
compression afterevery 15 compressions to give two quick deep lung inflations.

This results in a cardiac compressions to the ventilation ratio of 15 :2

PREPRATION OF THE PATIENT AND THE ENVIRONMENT :-

1. No time is last in explaining the procedure to the patient or his relatives.

2. If someone is free, can explain in simple lunguage to the relatives and ask them to
leave the room to lessen distractions and to provide more space to the resscure to
work.
3. The patient may be shifted to a hard surface or a hard board is placed under his
thorax.
4. Remove or push a side the clothing which covered the patients chest to observe for
cardiac beats and respirations.
5. Place the patients back on his back with out any pillows. This position helps in
maintaining airways and giving external cardiac compression.
6. Tight clothing around the neck and chest should be removed.
7. Ensure fresh air in the room by opening windows and doors.
8. External cardiac massage must be started within four to size minutes following
cardiac arrest or irreversible brain damage will occur as a result of oxygen
deprivation and lack of circulation.
PREPARATION OF ARTICLES :-

Equipment :- A tray containing the following articles.

1. Endotracheal tubes of various sizes (7, 7.5,8 ).

2. An ambu bag with mask
3. a. stillet (in a plastic cover)
b.megal’s forcep (in a plastic cover)

4. A suction tube or catheter

5. a. laryngoscopy with different sizes blades.

b. nasal airway

c. oral airway

d. a bowel with gauze pieces

e. lubricating jelly

6. Adhesive tape with scissors

7. Local anaesthetic (drug spray)

8. Gloves in cover

9. A kidney tray

10. A paper bag

11. Masks of various sizes

12. Local anarsthetic drugs (xylocaine 2% and 4%)

13. disposable syringes with needles

14. An intravenous (IV) set and a cut down set.

Others:-

a. oxygen inhalation (central supply )

b. suction point ( central supply)
c. defibrillator.

A tray containing emergency drugs:-

1. inj. Adrenaline
 2. Inj. Atropin
3. Inj. Digoxine
4. Inj. Sodium bicarbonate
5. Inj. Dopamine
6. Inj. Efcorlin
7. Inj. Decadron
8. Inj. Avil
9. syringes with needles, nannula on cotton pad.
10. Inj. Calcium gluconate
11. Inj. Lasix
12. Inj. Calmpose
13. Inj. Isoptin
14. Inj. Aminophyllin
15. Inj. 20 % dextrose
16. Inj. Deriphyeline
17. Gloves in cover.

PROCEDURE :-

NURSING ACTION RATIONALE

Determine the unresponsiveness :- This will prevent injury from attempted

1. Tap or gently shake the patient while resuscitation of a person who has not suffered
shouting “ are you ok?” a cardiac or respiratory arrest.
2. Determine pulselessness check for carotid Carotid pulse may persist when peripheral
pulse on one side for not more than 5 pulse are not palpable.
seconds.
3. Call for help in hospital set up. Alerts other trained personnel.

Sequence of CPR :-
A. Circulation :-
1. Position the arrest under- Neath victim’s The arrest board provides a firm surface
chest (when arrest board is not available, allowing for compression of the heart.
place victim on firm, flat surface)
2. Kneel at victim’s side. Allows performance of chest compression and
rescue breathing with efficiency.
3. Using index finger of the hand locate the Proper hand positioning ensures maximum
lower rib margin and more the fingers up compression of the heart and prevents injury to
to where the ribs connect to the sternum. liver and rib.
Place the middle finger of this hand on the
notch and index finger next to it. Place the
 heel of the opposite hand next to the index
finger on the sternum. Ensure that the
long – axis of the heel of hand is parallel to
the long – axis of the sternum. Remove the
first hand from the totch and place on top
of the hand that is on the sternum. Extend
or interlace the fingers, do not allow them
to tough the chest. Keep the arm straight
with shoulders directly over the hands on
the sternum and lack elbows.

4. Compress the adult chest at least 2 inches

(5cm) at the rate of at least 100 per
minute.

5. Release the chest compression completely Release of external chest compression allows
and allow the chest to return to its normal blood flow in to the heart. Removing hands
position after each compression. The time from the chest will result in more time required
allowed for release should be equal to the to located the exact point for chest
time required for compression. Do not lift compression.
hands off chest.

6. Do so compression and then performing Rescue breathing and chest compressions

two ventilations revaluate the patient should be combined.
after four cycles. ( use the mneumonic 1
and 2 and 3……….to keep rhythm and
timing ).

7. For cpr performed by one or two rescuers,

the compression rate is 100/min. the
compression ventilation ratio is 30:2.
B. Airway :-
1. Open the victim’s airway by using one of
the following maneuvers:
a. Head tilt chin lift maneuver :Place one This supports the jaw and helps tilt head back.
hand on victims forehead and apply firm This maneuver should not be performed for
backward pressure with the palm to till victims of suspected head and neck injuries.
the head back. Then place the fingers of
the other hand under the body part of the
lower jaw near the chin and lift up to bring
the jaw forward.
b. Jaw thrust maneuver :- Grasp the angles of Jaw thrust technique without head tilt is the
the patient’s lower jaw and lift with both safest methods for opening the airway in the
hands, one on each side, displacing the presence of suspected neck injury. Keep airway
mandible forward. Place on airway if patient occluding the nostrils and forming a
available. seal over the patients mouth will prevent air
 leakage and provide full inflation of the lungs.
Excessive air volume and rapid respiratory
flow rates can create pharyngeal pressure that
is greater than esophageal opening pressure.
This will allows air into the stomach resulting
in gastric distension and increased risk of
vomiting.
C. Breathing :-
1. Occlude nostrils with thumb and index
finger of the hand on forehead that is
tilting the head back from a tight seal over
the patients mouth or place an
appropriate respiratoroy arrest device
(ambubag and mask ) and give two full
breaths of appproximately 0.5 to 2
seconds allowing time for both inspiration
and expiration.
2. Observe for rise and fall of the chest.

WHEN TO STOP CPR :-

Guidelines for termination of resuscitation are :

1. Return of spontaneous circulation.

2. Arrival of arrest team or medical help.
3. If the rescuer becomes exhausted.
4. When death is confirmed.

ALGORITHM FOR BASIC LIFE SUPPORT :-

Verify scene safety.

 Victims is unresponsive. Shout for nearby help. Provide rescue breathing :- 1 breath
Activate emergency response system via mobile every 5-6 seconds, or about 10-12
device (if appropriate). Get AED( automated breaths/min.
external defibrillator) and emergency equipment
(or send someone to do so).  Activate emergency response
system (if not already done) after 2
Normal breathing, has pulse No normal breathing, minutes.
 Continue rescue breathing: check
has pulse
pulse about every 2 minutes. If no
pulse, begin CPR (go to CPR box).
Look for no breathing or only gasping and
Monitor until check pulse (simultaneously ). Is pulse  If possible opioid overdose,
emergency definitely felt within 10 seconds? administer naloxone if available
responders per protocol.
arrive.

No breathing or only gasping, By this time in all scenarios, Emergency response system or

No pulse backup is activated, and AED and Emergency

a equipment are retrieved or some one is retrieving

CPR : begin cycles of 30

compressions and 2 breaths. Use
AED as soon as it is available.

AED arrives.

Check rhythm.
Shockable rhythm?
Yes shockable No, non shockable

Give 1 shock. Resume CPR Resume CPR immediately for

immediately for about 2 about 2 min (until prompted by
minutes (until prompted by AED to allow rhythm check).
AED to allow rhythm check). Continue until ALS providers
Continue until ALS providers take over or victim starts to
take over or victim startADVANCE
to LIFE SUPPORT (ALS)
move.
move.
INTRODUCTION :-

Advanced Life Support (ALS) is a set of life-saving protocols and skills that extend Basic
Life Support to further support the circulation and provide an open airway and adequat
ventilation (breathing)

These include:

 Tracheal intubation
 Rapid sequence induction
 Cardiac monitoring
 Cardiac defibrillation
 Transcutaneous pacing
 Intravenous cannulation (IV)
 Intraosseous (IO) access and intraosseous infusion
 Surgical cricothyrotomy
 Needle cricothyrotomy
 Needle decompression of tension pneumothorax
 Advanced medication administration through parenteral and enteral routes (IV, IO,
PO, PR, ET, SL, topical, and transdermal)
 Advanced Cardiac Life Support (ACLS)
 Pediatric Advanced Life Support (PALS) or Pediatric Education for Pre-Hospital
Providers (PEPP)
 Pre-Hospital Trauma Life Support (PHTLS), Basic Trauma Life Support (BTLS) or
International Trauma Life Support (ITLS)

2010 changes in ALS :-

ALS is a treatment consensus for cardiopulmonary resuscitation in cardiac arrest and

related medical problems, as agreed in Europe by the European Resuscitation Council, most
recently in 2010.

2010 revisions include:

 greater emphasis on continuous (uninterrupted) chest compression

 less emphasis on airway and breathing
 promotion of the intraosseous infusion of drugs and fluids if IV access not readily
available
 further demotion of the precordial thump
 ongoing simplification
 expanded role for post-arrest hypothermia and emphasis on post-arrest normo-
glycaemial maintenance.

ALS algorithms :-
ALS assumes that basic life support (bag-mask administration of oxygen and chest
compressions) are administered.

The main algorithm of ALS, which is invoked when actual cardiac arrest has been
established, relies on the monitoring of the electrical activity of the heart on a cardiac
monitor. Depending on the type of cardiac arrhythmia, defibrillation is applied, and
medication is administered. Oxygen is administered and endotracheal intubation may be
attempted to secure the airway. At regular intervals, the effect of the treatment on the heart
rhythm, as well as the presence of cardiac output, is assessed.

Medication that may be administered may include adrenaline (epinephrine), amiodarone,

atropine, bicarbonate, calcium, potassium and magnesium. Saline or colloids may be
administered to increase the circulating volume.

While CPR is given (either manually, or through automated equipment such as AutoPulse),
members of the team consider eight forms of potentially reversible causes for cardiac
arrest, commonly abbreviated as "6Hs & 5Ts" according to 2005/2010 AHA Advanced
Cardiac Life Support (ACLS).[1][2][3][4] Note these reversible causes are usually taught and
remembered as 4Hs and 4Ts[5]—including hypoglycaemia and acidosis with
hyper/hypokalaemia and 'metabolic causes' and omitting trauma from the T's as this is
redundant with hypovolaemia—this simplification aids recall during resuscitation.
INDICATION :-

 Hypoxia: low oxygen levels in the blood

 Hypovolemia: low amount of circulating blood, either absolutely due to blood loss or
relatively due to vasodilation
 Hyperkalemia or hypokalemia: disturbances in the level of potassium in the blood,
and related disturbances of calcium or magnesium levels.
 Hypothermia/Hyperthermia: body temperature not maintained
  Hydrogen ions (Acidosis)
 Hypoglycemia: Low blood glucose levels
 Tension pneumothorax: increased pressure in the thoracic cavity, leading to
decreased venous return to the heart
 Tamponade: fluid or blood in the pericardium, compressing the heart
 Toxic and/or therapeutic: chemicals, whether medication or poisoning
 Thromboembolism and related mechanical obstruction (blockage of the blood
vessels to the lungs or the heart by a blood clot or other material)
 Other conditions

ALS also covers various conditions related to cardiac arrest, such as cardiac arrhythmias
(atrial fibrillation, ventricular tachycardia), poisoning and effectively all conditions that
may lead to cardiac arrest if untreated, apart from the truly surgical emergencies (which
are covered by Advanced Trauma Life Support).

Who performs ALS:-

Many healthcare providers are trained to administer some form of ALS.

In out-of-hospital settings trained emergency medical technicians, paramedics or medics

typically provide this level of care. Canadian paramedics may be certified in either ALS
(Advance Care Paramedic-ACP) or in Basic Life Support (Primary Care Paramedic-PCP)
(see paramedics in Canada). Emergency medical technicians (EMTs) are often skilled in
ALS, although they may employ slightly modified version of the Medical algorithm. In the
United States, Paramedic level services are referred to as Advanced Life Support (ALS).
Services staffed by basic EMTs are referred to as Basic Life Support (BLS). Services staffed
by Advanced Emergency Medical Technicians can be called Limited Advanced Life Support
(LALS) Intermediate Life Support (ILS), or simply Advanced Life Support (ALS), depending
on the State. In the Republic of Ireland, Advanced Life Support (ALS) is provided by an
Advanced paramedic. Advanced Paramedic (AP) is the highest clinical level (level 6) in pre-
hospital care in the Republic of Ireland based on the standards set down by PHECC, the
Irish regulatory body for pre-hospital care and ambulance services. This terminology
extends beyond emergency cardiac care to describe all capabilities of the providers.

In hospitals, ALS is usually given by a team of doctors and nurses, with some clinical
paramedics practicing in certain systems. Cardiac arrest teams, or "Code Teams" in the
USA, generally include doctors and senior nurses from various specialties such as
emergency medicine, anesthetics, general or internal medicine.