Rathish Rajan, 22nd batch MSc Nursing

INTRODUCTION India is home to 60 percent of heart disease

patients worldwide.

1.2 billion People in India are suffering from Heart disease.

Kerala is placed third in the country with high number of unnatural deaths reported owing to cardiac arrest

ORIGIN OF THE CONCEPT OF CPR

The first city to teach and promote resuscitation was Amsterdam in Europe

In August 1767, a few wealthy citizens formed the “society for recovery of drowned persons” and provided mouth to mouth ventilation, head low position and warming techniques

In 1954, Dr. James Elam together with Dr. Peter Safar (anesthetists) demonstrated CPR for the first time

In 1957,Dr. Peter Safar wrote the book ‘ABC of resuscitation’

In 1970’s CPR was promoted as a technique for the public

ORIGIN OF THE CONCEPT OF CPR Dr. Peter Safar created the guidelines for community wide

emergency medical service and he found the “ INTERNATIONAL RESUSCITATION RESEARCH CENTER[IRRC]

1979 Advanced Cardiovascular Life Support (ACLS) is developed 1983 AHA convened a national conference on pediatric

resuscitation to develop CPR and ECC Guidelines for pediatric and neonatal patients

1988 AHA introduces first pediatric courses, pediatric BLS, pediatric ALS and neonatal resuscitation, cosponsored with The American Academy of Pediatrics (AAP)

1992 International Committee on Resuscitation (ILCOR) founded;1999 First task force on first aid was appointed; First International Conference on Guidelines for CPR and ECC

ORIGIN OF THE CONCEPT OF CPR 2005 The 2005 International Consensus on

ECC and CPR Science with Treatment Recommendations (CoSTR) Conference produces the 2005 American Heart Association Guidelines for CPR & ECC.

2008 The AHA releases a statement about Hands-Only™ CPR

2010 The 2010 International Consensus on ECC and CPR Science with Treatment Recommendations (CoSTR) Conference produces the 2010 American Heart Association Guidelines for CPR & ECC; 50th Anniversary of CPR

CPR DEFINITION “Cardiopulmonary resuscitation (CPR) is a procedure

to support and maintain breathing & circulation for an infant, child, or adult who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest)”.

“It is a combination of chest compression and ventilation provided to act in cardiac arrest”

CARDIAC ARREST Cardiac arrest is the cessation of

normal circulation of the blood due to failure of the heart to contract effectively.

Medical personnel can refer to an unexpected cardiac arrest as a sudden cardiac arrest or SCA.

Shockable and non-shockable

H’s and T’s Hs

Hypovolemia - A lack of blood volume

Hypoxia - A lack of oxygen

Hydrogen ions (Acidosis) - An abnormal pH in the body

Hyperkalemia or Hypokalemia - Both excess and inadequate potassium can be life-threatening.

Hypothermia - A low core body temperature

Hypoglycemia or Hyperglycemia - Low or high blood glucose

Ts

Tablets or Toxins

Cardiac Tamponade - Fluid building around the heart

Tension pneumothorax - A collapsed lung

Thrombosis (Myocardial infarction) - Heart attack

Thrombo-embolism (Pulmonary embolism) - A blood clot in the lung

Trauma

2010 AHA GUIDELINES FOR CPR

Change in CPR sequence

No look ,listen and feel

Emphasis on high quality CPR

Rate 100/min

Depth= 2inches/5cm

Allow complete chest recoil

Use team approach

Begin chest compression if pulse is not felt within 10 sec

The routine use of cricoid pressure is not recommended as it may block ventilation

Manual defibrillation is preferred to an automated external defibrillator[AED]

KEY PRINCIPLES OF CPR [CHAIN OF SURVIVAL]

STEPS IN RESUSCITATION (DRS C-A-B-D ) Check for Danger

Check for Response

‘S’ has been added for Send for help

‘C’ directs rescuers to perform 30 Compressions to patients who are unresponsive and not breathing normally, followed by 2 rescue breaths.

‘A’ directs rescuers to open the Airway

‘B’ directs rescuers to check Breathing but no need to deliver rescue breaths

‘D’ directs rescuers to attach an AED as soon as it is available and follow prompts.

BLOOD FLOW MECHANISM DURING CPR Cardiac pump theory

Thoracic pump theory

CPR PRACTICE Single rescuer

Two rescuer

Team of experts

SINGLE RESCUER ADULT CPR

Assessment and scene safety

Activate emergency response system and get an AED

Check pulse

Begin cycles of 30 compressions and 2 breaths

METHODS TO OPEN THE AIRWAY Head –tilt –chin –lift method

Jaw thrust method

Breathing techniques Mouth to mouth breathing

Mouth to mask breathing

Bag-mask breathing

TWO RESCUER ADULT CPR

Rescuer -1 At the victim’s side Perform chest compressions Give 30 compressions(count loud) Allow complete chest recoil Rescuer 2 At the victim’s head Open airway Head-tilt chin- lift Jaw thrust Give 2 breaths, watch for chest rise Switch duties after every 5 cycles

DEFIBRILLATION VF and Pulseless VT

Automated external defibrillator [AED]

TYPES

Mono phasic- recommended energy level is 360 J

Biphasic- recommended energy level is 200 J

SPECIAL SITUATIONS CPR in children from 1 year of age to puberty Steps The sequence is similar to that of adult CPR Assess response. If not sure, assume that the child is not breathing Activate the emergency response system and get an AED Check pulse[carotid or femoral pulse] Start 30 compressions May use 1 or 2 hands Rate :100/min Depth: 2 inches(5cm or 1/3rd chest depth) Give 2 rescue breaths Cover the child’s mouth with your mouth and pinch the nose with

fingers

In case of two rescuer, ratio is 15:2

After 5 cycles get an AED

Choose correct size AED pads. If using standard pads, make sure they do not touch or overlap.

CPR for infantsPEDIATRIC CHAIN OF SURVIVAL Prevention of arrest

Early high quality bystander CPR

Rapid activation of emergency response system

Effective advanced life support

Integrated post cardiac arrest care

Steps Assess response: rub or tap soles or feet or shoulder or

chest; don’t hurt the baby.

Shout for help!!

Activate emergency response system and get an AED

Check pulse

Brachial pulse is checked [5-10 sec]

If pulse present, give 1 breath every 3 sec

Do compressions if pulse is less than 60/min or no pulse

Recheck pulse every 2 min

CHEST COMPRESSIONSTechnique Single rescuer Two rescuer

Rate 100/min 100/min

Ratio 30:2 15:2

Depth 1.5 inches[4cm] 1.5 inches[4cm]

Compression technique Place infant on a firm flat

surface

Place two fingers in the center

of the chest just below the

nipple line

Push hard and fast

Allow chest recoiling, minimize

interruptions

Two thumb encircling hands

technique

With your hands, encircle the

chest and place thumbs on the

lower half of the breast bone

Depress the breast bone

Deliver compressions

Switch roles every 2 minutes

Open airway and provide breathsMouth to mouth and

nose

Mouth to mouth

Most preferred

Make an air tight seal

with your mouth and

nose

Blow 2 breaths, make

sure that chest is rising

Pinch victim’s nose

tightly with thumb and

fore finger

Make a mouth to mouth

seal

Provide 2 breaths, make

sure chest is rising

Use AED Infant pads must be used

2-4 joules/kg

Recheck pulse and start compressions immediately if needed

CPR with advanced airway When advanced airway [laryngeal mask airway, supra-

glottic or endo-tracheal tube] is in place, rescuers must not pause chest-compressions in order to provide breaths. Give one breaths every 6-8 sec ie. 8-10 breaths/min. Endo-tracheal tube remains the gold standard for air way maintenance in CPR

SUMMARY OF STEPS OF CPR FOR ADULTS, CHILDREN AND INFANTS

In pregnancy During pregnancy when a woman is lying on her back

the uterus may compress the inferior vena cava and thus decrease venous return. It is recommended for this reason that the uterus be pushed to the persons left and if this is not effective either roll the person 30°s or consider emergency cesarean section.

POST RESUSCITATION CARE Adequate oxygenation

Provide side lying position[recovery]

Continuous monitoring

Life saving drugs

Induced hypothermia for 24 hrs with cold IV fluids (32-34 degree Celsius)

Maintenance of cerebral perfusion

Seizure treatment and supportive care

Stable vital signs

Maintain blood oxygen levels and blood chemistry

Blood sugar maintenance

LONG TERM MANAGEMENT Thrombolysis Coronary angiography PCI’s Artificial pacemaker Implantable cardioverted defibrillator(ICD) CABG Mechanical ventilation Catheter ablation therapy Medications to stabilize the heart function, blood

chemistry and seizures Heart transplantation if needed Rehabilitation

ALTERNATIVE CPR TECHNIQUES Interposed abdominal compression CPR(IAC)

High frequency (rapid manual) CPR

Vest CPR

Chest compression only CPR

Prone CPR(reverse CPR)

Precordial thump

Invasive CPR

DEVICES TO SUPPORT CIRCULATION IABP

Ventricular assistive devices

SIGNS OF SUCCESSFUL CPR Lung expansion

Pupil will react to light / will appear normal

Normal heart beat will return

A spontaneous gasp/breathing will occur

May move legs / arms and color may improve.

COMPLICATIONS Faulty techniques of CPR can result in

local blunt trauma

bruising or fracture of the sternum or ribs

Compression at the xiphoid process causes laceration of liver.

Cardiac tamponade

Pneumothorax

Hemopericardium

Lung laceration

LEGAL AND ETHICAL CONSIDERATIONS CPR can be given without fear of any legal actions

The lay rescuers should not be afraid of any harm if the patient dies after the CPR attempt.

Avoid CPR in conditions where there is DO NOT ATTEMPT RESUSCITATION(DNAR OR DNR) order, because we have to respect patient’s wish

Withhold CPR in case of DNR order of physician

WHEN TO STOP CPR? Victim starts to move

AED arrives

Trained helpers arrive

When you become too exhausted

Signs of death become apparent

NURSE’S ROLE IN CPR Nurses play a key role in the management of victims in

hospitals. Often they are the first on the scene of an arrest-initiating CPR as well as summoning advanced life support team

All nurses are expected to manage a collapse situation Skilled clinical assessment and recognition of the

prodromes of collapse may decrease the incidence of in-hospital cardiac arrests.

Nurses must be aware of the CPR procedure and must update it.

Nurse must be able to provide defibrillation Nurses must take initiation in educating common people

about CPR

NURSING DIAGNOSIS AND INTERVENTION Ineffective tissue perfusion r/t decreased cardiac output as

evidenced by absence of pulse.

Goal

Will demonstrate adequate tissue perfusion as evidenced by presence of pulse.

Nursing interventions:

Provide a safe environment and asses response

Monitor carotid and peripheral pulse

Activate the emergency team and provide CPR

Provide rapid defibrillation if needed

Provide post-resuscitation care

Impaired gas exchange r/t ventilation perfusion mismatch as evidenced by absence of breathing

Goal

Maintains effective gas exchange as evidenced by return of normal breathing pattern, visible chest rise

Nursing interventions:

Reassess breathing pattern

Provide resuscitation and rescue breaths

Administer oxygen

Assess vital signs and record

Monitor for arrhythmias

Obtain ABG values

Administer medications

Risk for potential complication like rib fracture related to CPR

Goal

Remains free from rib fracture, injury as evidenced by good outcome

Nursing interventions:

Place the victim in a safe environment

Provide CPR effectively using the correct procedure

Place hands properly on the chest

Do not apply vigorous force

Assess for any complication

Provide appropriate management for any complication

POST CPR NURSING DIAGNOSIS Activity intolerance r/t fatigue secondary to cardiac

insufficiency/compromised cardiac function as evidenced by weakness

Imbalanced nutrition less than body requirement r/t npo status, decreased intake, anorexia secondary to disease condition

Risk for dysarrythmias r/t decreased cardiac output

Anxiety related to prognosis and fear of death

Deficient knowledge regarding long term management of disease condition