CARDIOPULMONARY RESUSCITATION

 INTRODUCTION-
Cardiopulmonary resuscitation is an emergency medical
procedure for a victim of cardiac arrest or, in some circumstances, respiratory
arrest. CPR is performed in hospitals or in the community by lay person or by
emergency response professionals. CPR is the basic life-saving skill that is
utilized in the event of cardiac, respiratory or cardiopulmonary arrest to
maintain tissue oxygenation.
The essential treatment procedure has been established as a standardized
guideline. It involves-
 External cardiac massage [manual chest compression]
 Management of foreign body or airway obstruction, cricothyroidotomy
may be necessary to open the airway before CPR can be performed.

 DEFINITION-
 According to American Heart Association (AHA), “Cardiopulmonary
resuscitation is an emergency lifesaving procedure performed when the
heart stops beating. Immediate CPR can double or triple chance of
survival after cardiac arrest.
 According to Angela Morrow RN- CPR is a procedure used when a
patient’s heart stops beating and breathing stop. It can involve
compressions of the chest or electrical shocks along with rescue
breathing.
 CPR is a technique, of basic life support for the purpose of oxygenation
to the heart, lungs and brain until and unless the appropriate medical
treatment can come and restore the normal cardiopulmonary function.

 PURPOSE OF CPR
 To maintain an open and clear airway.
 To maintain breathing by artificial ventilation.
 To save life of the patient.
 To provide basic life support till medical & advanced life support arrives.
 To maintain blood circulation by external cardiac massage.
  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

 INDICATIONS FOR CPR.

 Cardiac Arrest-
o Ventricular fibrillation
o Ventricular tachycardia
o Asystole
o Pulseless electrical activity
 Respiratory Arrest – It can be due to
o Drowning
o Stroke
o Foreign body in threat
o Smoke inhalation
o Drug overdose
o Injury by lightening or electrocution
o Suffocation
o Accident [Head injury, chest injury, abdominal & spinal injury).
o Coma
o epiglottis paralysis
 Cardio-respiratory failure
The respiratory and cardiovascular system are
interdependent. Heart consumes more Oxygen per minute than any other
organ in the body because it is constantly beating. Consequently, when
lung’s stop working, the heart fail occurs. Conversely, the ventilation of
the lungs fails soon after the heart stop, it occurs because the respiratory
centre medulla oblongata cannot functions with at the continuous supply
of oxygen which is normally transported by the cardiovascular system.
 PHYSIOLOGY OF CPR-
The air we breathe in travels to our lungs where oxygen is picked up
by our blood and then pumped by the heart to our tissue and organs. When a
person experiences cardiac arrest – whether due to heart failure in adults and the
elderly or an injury such as near drowning, or severe trauma in a child. The
heart good from a normal beat to an arrhythmic pattern called ventricular
fibrillation, and eventually ceases to beat altogether. This prevents oxygen from
circulating throughout the body, rapidly killing cells and tissue. In essence,
Cardio (heart) Pulmonary (lung) Resuscitation (revive, revitalize) serve as an
artificial heartbeat and an artificial respirator if it started within 4 minutes of
cardiac arrest and defibrillation is provided within 10 minutes, a person has a
40% chance of survival. The medical term for the condition in which a person’s
heart has stopped is Cardiac arrest.
Cardiac arrest may be defined the abrupt cessation of
cardiac function. The heart may be in one of the two states during arrest, either
asystole or fibrillation.
Three cardinal signs of cardiac arrest are
 apnoea
 absence of carotid and femoral pulse
 Dilated pupils
For the last 50 years CPR has consisted of the combination of
artificial blood circulation with artificial respiration, i.e., chest
compression and lung ventilation. However, in march 2008, the American
Heart Association and the European Resuscitation Council, in a reversal
of policy, endorsed the effectiveness of chest compressions alone without
artificial respiration for adult victim who collapse suddenly in cardiac
arrest.
 PRINCIPLES OF CPR
 To recognize early
 To restore effective circulation and ventilation
 To prevent irreversible cerebral damage to anoxia.
 To restore quality of life.
 PRECORDIAL-THUMP-
Use of precordial thump is effective in witnessed
cardiac arrest. Precordial thump is a blow, which is derived to the half of the
patient’s sternum with the fleshy part of the fist from 8-12 inches, above the
patient’s 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 with in a minute of cardiac arrest. If delayed it may precipitate
ventricular fibrillation.
 MAIN STAGES OF RESUSCITATION –
  C[Circulation] – restore the circulation by external cardiac massage
 A[Airway]- ensure open airway by the falling back of tongue trachea,
intubation, if possible
 B [Breathing] start artificial ventilation of lungs.
 D [Differentiation diagnosis, Drugs, Defibrillation) Quickly perform
differential diagnosis of cardiac arrest, use medication and electric
defibrillation in case of ventricular fibrillation
 GOLDEN HOURS
The Golden Hours is the first hour after the trauma. If proper and timely first
aid is given, road accident victims survive. Prompt action may also reduce the
severity of the injuries. It is said the four minutes are crucial.
Refer to the period of time immediately following Good Samarital law,
launched 2015, by the Ministry of Road Transport and Highways and Supreme
court gave these guidelines the force of Law in 2016-
 Protection from ant. Legal complications to anyone who comes forward
to help a road accident victim.
 Good Samaritans can choose to file a police complaint without disclosing
their names.
 Before CPR is attempted in a patient, make sure that the airway is clear,

 GUIDELINES-
In 2005, new CPR guidelines were published by the International Liason
Committee on Resuscitation (ILCOR), agreed at the 2005 International
Consensus Conference on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science. The primary goal of these changes was to
simplify CPR for lay rescuers and healthcare providers alike, to maximize the
potential for early resuscitation. The important changes for 2005 were-
 A universal compression-ventilation ratio (30:2) recommended for all
single rescuers of infant, child and adult victims (excluding newborns).
The primary difference between the age group is that with adults the
rescuer uses two hands for the chest compressions, while with children it
is only one, and with infants only two fingers (index and middle finger)
 The removal of the emphasis on lay rescuers assessing for pulse or signs
of circulation for an unresponsive adult victim, instead taking the absence
of normal breathing as the key indicator for commencing CPR.
  The removal of the protocol in which lay rescuers provide rescue
breathing without chest compression for an adult victim, with all cases
such as there being subject to CPR. Research has shown that lay
personnel cannot accurately detect a pulse is about 40% of cases and
cannot accurately discern absence pulse in about 10%. The pulse check
step has been removed from the CPR procedure completely for lay person
and de-emphasised for healthcare professionals.

 CPR IN ADULTS-
According to American Heart Association guidelines
for adult CPR is performed on any person over the age of 8 years. The
recommended method for performing CPR changed yearly In 2010, the
AHA made a change in recommended CPR process of victim of cardiac
arrest studies showed compression only CPR (no mouth-to-mouth) is as
effective as traditional approach.
 PURPOSES
a) Restore cardiopulmonary functioning
b) Prevent irreversible brain damage from anoxia.
Part 1: Taking Vitals
a. Checking the scene for immediate danger-
Without putting yourself in danger
and the victim while performing CPR to someone unconscious, make
sure to move to safe area for the safety of the victim.
 keeps the victim comfortable.
 The best way to move the victim is by placing a blanket or coat
underneath their bag and dragging it.

b. Assess the victim’s consciousness-

Gently tap his or her shoulder and ask
“Are you ok? In loud, clear voice. If he or she responds then CPR is not
required. Basic first aid and other required measures to be done and
assess the need to contact emergency services.
If victim do not respond, continue the following steps.

c. Send for help

 The more people are required for these steps, but for life saving can
be done alone, send someone to call for Emergency Medical
Services (EMS).
  To contact for emergency service call 108 in India.
 Give the location and notify him/her that you are going to perform
CPR.
 If you are alone get off the phone and start compressions. If
someone with you make them to stay on the line while you are
doing the CPR on the victim.

d. Do not check the pulse

 Unless you are a trained medical professional don’t spend too
much time for looking pulse when doing compression.
 Check for carotid pulse for 10 seconds.

e. Check for breathing

 Make sure that the airway is not blocked. If the mouth is closed,
press with the thumb and forefinger on both cheeks at the end of
the teeth and the look inside.
 Remove any visible obstacles that is in your reach but never push
your fingers inside too far.
 Put your ear close to the victim’s nose and mouth and listen for
slight breathing.
 If victim is coughing or breathing normally do not perform CPR.

Part II: Administering CPR

a. Place the victim on his/her back-
 Make the victim lying as flat as possible, this will prevent injury while
doing chest compression. Tilt the head back by using the palm against
the forehead and push against their chin.
 Place the heel of one hand on the victim’s breast bone, 2 fingers-widths
above the meeting area of the lower ribs, exactly between the nipples.
 Place your second hand, palms – down interlock the fingers of the
second hand between the fist.
 Position your body directly over your hands so that your arms are
straight and somewhat rigid. Don’t flex the arms to push but sort of lock
your elbows, and use your upper body strength to push.
 Perform 30 chest compression. Press down by about 2 inches (5 cm). Do
the compressions in a relatively fast rhythm or at roughly 100
beats/minutes.

Part III. 3 Continuing the process until help arrives

a. Minimize pause in chest compression that occurs when changing
provides or preparing for shock.
Attempt to limit interruptions to less than 10 seconds.
b. Make sure the airway is open:
 Place your hand on victim’s forehead & two fingers on their chin
and tilt the head back to open the airway.
 If the suspect has neck injury, pull the jaw forward rather than
lifting the chin. If jaw thrust fails to open the airway do a careful
head tilt and chin lift.
 If there are no signs of life, place a breathing barrier (if available)
over the victim mouth.

c.
I. Give two rescue breath (optional):
The American Heart Association on longer consider rescue breath
necessary for CPR, as the chest impression are more important.
The trained people in CPR can give two rescue breath after 30
 chest compressions. If never done CPR than only stick with chest
compression.
 Keeping airway open, take fingers that were on the forehead and
pinch the victim’s nose closed. Make a seal with your mouth over
the victim’s mouth and breathe out for about one second. Make
sure the air goes in the lungs and not the stomach.
 If the breath goes in the slight chest rise can be seen and also feel
it. Give a second rescue breath.
 If the breath does not go in, reposition the head & try again. If it
doesn’t go in again then there must be any choking. Do abdominal
thrust (the Heimlich maneuver) to remove the obstruction.

II. Repeat the cycle of 30 chest compression:

 If doing rescue breath, keep doing a cycle of 30 chest compressions and
then 2 rescue breath, repeat 30 compressions and 2 more breathe.
 CPR to be done for 2 minutes [5 cycles of compressions to breath) before
spend time for signs of life.

III. Continue CPR until someone takes over, emergency personnel

arrive, you are too exhausted to continue, an automated external
defibrillator (AED) is available for immediate use, or signs of life
return.
Part IV: • Using an AED
a) Use an AED (Automated External Defibrillator]
 If an AED is available in the immediate area, use it soon as possible to
jump start the victim’s heart.
 Make sure there are no puddles, or standing water is the immediate area.
b) Town one the AED-
It should have voice prompts that tell you what to do
c) Fully expose the victim’s chest.
 Remove any metal necklace or underwire bras. C heck for any body
piercings, er evidence that the victim has a pacemaker or implantable
cardioverter defibrillator (should be indicated by a medical bracelet) to
avoid shocking to close to those spots.
 Make sure the chest area is absolutely dry and the victim is not in a
puddle.
 If person have a lot of chest hairs, then, if possible, have to shave. Some
of AED kits have razor for this purpose
d) Attach the sticking pads with electrodes to the victim’s chest,
 Follow the instructions on the AED for implanted placement, move the
pad at least 1inch [2.5cms] away from any mental piercings’ device.
 Make sure no one is touching the person, when shock is applied.
e) Press analyses on the AED machine.
 If shock is needed for the victim the machine will notify, make sure
nobody should touch the victim during shock
f) Resume CPR-
Without removing the pads from victim, resume CPR for
another 5 cycles before
 If not alone, start high quality CPR at a compression-to-breath ratio of
15:2
 Every 2 minutes check, pulse, check rhythm and switch compressors.
 In infants, high quality CPR and changing rescuer every 2 minutes
improves a victim’s chance of survival.
g) Attach AED as soon as possible available for child, if shockable rhythm,
defibrillation and immediately start CPR
 MEDICATIONS USED IN CPR
 Epinephrine-
Epinephrine also called as adrenalin increases systemic
vascular resistance and blood pressure, improves coronary cerebral
perfusion and myocardial contractility.
It is given to patients in cardiac arrest, especially caused by
asystole or pulseless electrical activity and may be given if caused by
ventricular tachycardia or ventricular fibrillation.
It is administered by IV push or through Endotracheal tube.
Avoid adding to IV lives that contain alkaline solution.
Part: PUTTING THE PATIENT IN RECOVERY
a. Position the patient ONLY after the victim has been stabilized and is
breathing on his/her own.
b. Flex and raise one knee joint, push the victim’s hand that’s on the
opposite side from the raised knee, partially under the hip with the
straight leg. Roll the victim onto the side with straight leg and position
the free hand to the opposite shoulder.
The raised knee / bent leg is on top onto the abdomen
and help stop the body from rolling over.
c. Use the rolling position to help the victim to breath more easily. This
position keeps saliva [spit] from accumulating in the back of the mouth or
throat and helps the tongue to hang to the side without it falling into the
back of the mouth and obstructing the airway.

 TERMINATION OF CPR
CPR is stopped as result of numbers of circumstances –
 The typical restoration of spontaneous respiration and circulation.
 Complete rescuer exhaustion or medical decision.
 Sign of restored ventilation and circulation include [struggling
movement, improved color, return of stronger pulse and return of
systemic blood pressure).

 POTENTIAL HAZARDS OR COMPLICATIONS OF CPR

 sternal or rib fracture
 Injury to the heart and the Great vessel
 Organ lacerations
 Aspiration of stomach contents.

 TYPES OF CPR DECISIONS

 Full code: -
It allows CPR drugs but no CPR
 No code or do not resuscitate (DNR)-
DNR or do not resuscitate is a type of advance directive a
document that instructs medical personnel that you don’t wish to receive,
 CPR if the heart or breathing stops. DNR order once complete should be
added to the medical record. The decisions about end-of-life care should
be made early in the case process which allow medical personnel to
serve well.

 POST RESUSCITATION MEASURES

 Skilled after care is essential for the patient who has suffered an arrest,
 Continuous observation must be ensured by a skilled person for 48 to 72
hours.
 If the patient is not in the intensive care unit shift him there for constant
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 as high temperature usually indicates cerebral
damage or cerebral edema.
 Blood gas and Ph determination are done to detect metabolic acidosis,
which may have developed, owing to poor oxygenation.
 A chest x-ray film is obtained by portable equipment as ribs often are
accidently fractur during cardiac massage.
 Invert ÉT tube if not placed to maintain an open airway for the
unconscious patient who cannot clear secretion by coughing.
 Give continuous oxygen for 48 hours, following resuscitation by an ET
tube or mask required. It is required because sometimes respiration is
depressed after arrest.
 Nasogastric intubation and aspiration of stomach content are necessary
for the patient with full stomach to prevent vomiting and aspiration of
vomitus to lungs.
 Insert foley’s catheter as urine output is one of the measures of
cardiovascular status. Report if urine output is less than 30ml/hr
 Start IV infusion to administer enough fluid is the patient.
 Maintain all record and report of the patient.
 NURSING RESPONSIBILITY
 Maintain airway patency with use of airway adjuncts as required
suction, high flow oxygen with O2, or bag valve mask ventilation
 Assist with intubation and securing of ETT.
 Insert gastric tube and/or facilitate gastric decompression post
intubation as required
 Assist with ongoing management of airway patency and adequate
ventilation.
 If a shockable rhythm is present (VT/VT) ensure manual defibrillation
pads are applied and connected.
 If CPR is in progress, prepare and independently double check and
label 3 doses of adrenaline.
 Prepare and administer IV fluids
 Document medication administered (including time)

 MODIFIED EARLY WARNING SYSTEM (MEWS)

The Modified Early Warning
System (MEWS) is a tool designed to identify patients with declining
conditions. It has been shown to be superior to clinical judgement for this
purpose. It was originally designed for nurses but can be used by any
healthcare professional with adequate training.

Actions to prevent patient deterioration: Depending on the total MEWS,

the nurse should consider the following actions to prevent deterioration:
Verify that all components have been entered so you know your score is
accurate.

 Normal = MEWS 0 to 1: No additional action steps/interventions

required by the nurse.

 LOW= MEWS 2 to 3: Nurse reviews patient’s condition and discusses

findings with provider during rounds. MEWS of 3 nurse considers
increasing patient vital signs monitoring and MEWS to 2-hour intervals.
If patient remains with MEWS of 3 for three consecutive readings, nurse
considers reviewing patient assessment with facilitator.
 MEDIUM= MEWS 4 to 6: Nurse reviews patient’s condition with
facilitator and considers discussing findings with provider during rounds
versus more immediate provider notification. Nurse considers increasing
patient vital signs monitoring and MEWS to 1-hour intervals.

 HIGH = MEWS 7 to 8: Nurse reviews patient’s condition with facilitator

and/or nursing colleagues. Nurse considers immediate provider
notification. Nurse considers activating Rapid Response. Nurse considers
increasing patient vital signs monitoring (including oximetry) to every
15-30 minutes or more frequently until patient’s vital signs and/or MEWS
stabilize and/or patient transferred to a higher level of care.

 Critical = MEWS> 8: This potentially constitutes a clinical emergency.

Nurse reviews patient’s condition with facilitator and/or nursing
colleagues. Rapid Response strongly recommended. Immediate provider
communication strongly recommended. Nurse considers close (every 5-
10 minute) vital signs monitoring (including oximetry) until patient’s
vital signs and/or MEWS stabilize and/or patient transferred to a higher
level of care.

 Additional Considerations when assessing clinical deterioration include:

o Communication and collaboration with providers

o Calling a Rapid Response

o Code Blue
 BIBLIOGRAPHY

 Basheer S., Khan S. (2013). Advanced Nursing Practice. Ed 1st. Emmess.

New Delhi. 297-301.
 Brar N., Rawat H. (2015). Textbook of Advance Nursing Practice. Ed 1st.
Jaypee Brothers. New Delhi. 496-500.
 Jacob A., Tarachand J. (2010). Clinical Nursing Procedure: The Art of
Nursing Practice. 2nd ed. Jaypee Brothers. New Delhi. 387-390.
 Smelter S., Bare B. (2004). Medical Surgical Nursing. 10th ed. Lippincott
Raven.US. 810-812.

Internet-
 https://www.med.upenn.edu/uphscovid19education/assets/user-
content/documents/curricula/lgh-nursing-to-inpatient/modified-
early-warning-system-(mews).pdf
