cardiopulmonary _ resuscitation. pptx

cardiopulmonary_resuscitation.pptx
For under graduate students

1. Cardiopulmonary Resuscitation CPR for Nurses Dr/ Mohamed Elgariah Assistant lecturer CTS Dep. TUH

2. What does CPR stand for? C = Cardio (heart) P = Pulmonary (lungs) R = Resuscitation (recover) Oxygen is the basic requirement for breathing and every Living cell in the body

3. Definition of CPR : it is an emergency life saving 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 ( ACLS )? It is life support with the use of special equipment ( eg . Airway, endotracheal tube, defibrillator).

4. ANATOMY AND PHYSIOLOGY:

5. Definition of Cardiac arrest : It is loss of cardiac function, breathing and loss of consciousness. Diagnosis of cardiac arrest (TRIAD ): Loss of consciousness . Loss of apical & central pulsations (carotid, femoral). Apnea .

6. Types (forms) of cardiac arrest : Asystole ( Isoelectric line ). Ventricular fibrillation ( VF ). Pulseless Ventricular tachycardia ( VT ). PEA : pulseless electrical activity.

7. Causes of cardiac arrest (6 H & 4 T ): H ypoxia. H ypotension. H ypothermia. H ypoglycemia. Acidosis ( H + ). H ypokalemia (electrolyte disturbance). Cardiac T amponade. T ension pneumothorax. T hromboembolism ( pulmonary , coronary ). T oxicity (eg. digoxin, local anesthetics, TCA, insecticides).

8. Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

9. APPROACH SAFELY! WATCH OBSERVE Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

10. CHECK RESPONSE Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

11. Shake shoulders gently Ask “Are you all right?” If he responds Leave as you find him. Find out what is wrong. Reassess regularly. CHECK RESPONSE

12. SHOUT FOR HELP Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

13. OPEN AIRWAY Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

14. OPEN AIRWAY Head tilt and chin lift - lay rescuers - non-healthcare rescuers No need for finger sweep unless solid material can be seen in the airway

15. OPEN AIRWAY Head tilt, chin lift + jaw thrust

16. CHECK BREATHING Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

17. CHECK BREATHING Look, listen and feel for NORMAL breathing Do not confuse agonal breathing with NORMAL breathing

18. Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

19. 30 CHEST COMPRESSIONS Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

20. Place the heel of one hand in the centre of the chest Place other hand on top Interlock fingers Compress the chest Rate 100 min -1 Depth 4-5 cm (1.5 to 2 inch) Equal compression : relaxation When possible change CPR operator every 2 min CHEST COMPRESSIONS

21. RESCUE BREATHS Approach safely Check response Shout for help Open airway Check breathing Call code blue team 30 chest compressions 2 rescue breaths

22. RESCUE BREATHS Pinch the nose Take a normal breath Place lips over mouth Blow until the chest rises Take about 1 second Allow chest to fall Repeat

23. CONTINUE CPR 30 2

24. Life support includes A B C A = Airway (and cervical spines) B = Breathing C = Circulation

25. A = Airway

26. 2) Jaw thrust :

27. 3) Finger sweep : Sweep out foreign body in the mouth by index finger ( in unconscious pt only. This is NOT advised in a conscious or convulsing patient).

28. 4) Heimlich manoeuvre : if the pt is conscious or the foreign body cannot be removed by a finger 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 his can be done by a series of blows on the back and chest thrusts.

29. (B) Advanced techniques for airway 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.

30. 2) Oropharyngeal airway 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).

31. 5) Endotracheal tube ► Advantages : Ensures proper lung ventilation. No gastric inflation. No regurgitation or aspiration of gastric contents. ► Disadvantages : Requires insertion by highly skilled personnel.

32. 6) Combitube ► Advantages : Easy to use. Does not require highly skilled personnel (can be used by paramedics).

33. B = Breathing

34. (A) Basic techniques include: 1) Mouth to mouth breathing : with the airway held open, pinch the nostrils closed, take a deep breath and seal your lips over he patients mouth. Blow steadily into the patients mouth watching the chest rise as if the patient was taking a deep breath.

35. 2) Mouth to nose breathing : seal the mouth shut and breathe steadily though the nose. 3) Mouth to mouth and nose : is used in infants and small children.

36. Expired air = 16% O 2 Ambu Bag ( room air ) = 21% O 2 Ambu bag + O 2 (10-15L) = 45% O 2 Ambu Bag + O 2 + Reservoir bag = 85% O 2

37. C = Circulation (A) Chest compressions (BLS & ACLS). (B) IV access (ACLS). (C) Defibrillation (ACLS).

38. (A) Chest compressions (cardiac 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 pulsations. Technique of chest 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. ( AVOID xiphisternal junction → fracture & injury).

39. The other hand is placed over the hand on the sternum. Shoulders should be positioned directly over the hands with the elbows locked straight and arms extended. Sternum must be depressed 4-5 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.

40. Chest compressions in infants (0-12 months)

41. Complications of chest 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). Usually AVOIDABLE by performing the technique correctly.

42. ► Chest compressions must be continued for 2 minutes before reassessment of cardiac rhythm. ► (2 minutes = equivalent to 5 cycles 30:2). ► 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.

43. (B) IV access 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.

44. Also in cases of difficult venous access intraosseous drug and fluid administration can be performed.

45. Ventricular Tachycardia (VT) shockable Broad bizarre-shaped complexes. Rapid rate: 120 -250/min. Regular. Precordial thump : Rapid treatment of a witnessed and monitored VF/VT cardiac arrest.

46. Ventricular fibrillation (VF) shockable Bizarre irregular waveform. No recognizable QRS complexes. Random frequency and amplitude. Coarse / fine. Exclude artifact : movement electrical interference

47. Asystole ( non- shockable ) Check that all leads are attached . Adrenaline 1 mg IV every 4 mins (2 cycles) (until a shockable rhythm is achieved).

48. PEA: Pulseless Electrical Activity non- shockable Exclude / treat reversible causes. Adrenaline 1 mg IV every 4 mins (2 cycles) (until a shockable rhythm is reached).

49. Drugs used in CPR ► 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 3 rd 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 3 rd shock . - If unavailable give lidocaine 100 mg IV (1-1.5 mg/kg).

50. ► Vasopressin (ADH): 40 IU single dose once. ► Magnesium : - Dose : 2 g IV. - Given : 1- VF / VT with hypomagnesemia. 2- Torsade de pointes. 3- Digoxin toxicity. ► Calcium : Dose : 10 ml of 10% Calcium chloride IV. Indications : PEA caused by: hyperkalemia, hypocalcemia, hypermagnesemia, and overdose of calcium channel blockers. Do NOT give calcium solutions and NaHCO 3 simultaneously by the same route.

51. ► IV Fluids : Infuse fluids rapidly if hypovolemia is suspected. 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. Dextrose is indicated only if there is documented hypoglycemia . ► Thrombolytics : Fibrinolytic therapy is considered when cardiac arrest is caused by proven or suspected acute pulmonary embolism . If a 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: steptokinase).

52. Sodium bicarbonate : ► Used in : 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 CO 2 load: 2- Inhibits release of O 2 to tissues. 3- Impairs myocardial contractility. 4- Causes hypernatremia. 5- Adrenaline works better in acidic medium.

53. Atropine : Its routine use in PEA and asystole is not beneficial and has become obsolete . Indicated in: sinus bradycardia or AV block causing hemodynamic instability. Dose : 0.5 mg IV . Repeated up to a maximum of 3 mg ( full atropinization ).

54. Managing the Cardiac Arrest Team ► During cardiac arrest the team leader 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.

55. DEFIBRILLATION: GENERAL CONCEPT Immediate defibrillation if witnessed arrest and automated external defibrillation available compressions before defibrillation if unwitnessed or arrival at the scene >4-5 minutes. One shock followed by immediate CPR ( beginning with chest compression)

56. KEY POINTS TO REMEMBER WHILE DEFIBRILLATING Use a conducting agent between the skins the paddles such as saline pads or electrode paste. This decreases the electrical impedance and helps to prevent burns. The paddles are placed on the chest wall one the sternal paddle is placed to the right of the sternum, 2’nd intercostals space just below the clavicle. The apex paddle is placed on the left 6’Th intercostals space mid axillary line. Switch on the defibrillator.

57. ASP Medical Clinic/ sept 2012 58 CAB VS ABC???

58. NURSING MANAGEMENT Maintains 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 Inserts gastric tube and/or facilitates gastric decompression post intubation as required. Assists with ongoing management of airway patency and adequate ventilation

59. Supports less experienced staff by coaching/guidance e.g. drug preparation If a shockable rhythm is present (VF/VT) ensure manual defibrillator 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 medications administered (including time)

60. NURSING TEAM LEADER (USUALLY SENIOR WARD NURSE)   Identifies self as Nursing Team Leader, responsible for co-coordinating and directing emergent nursing care of the patient. Checks appropriate emergency call has been placed Starts timer as soon as the Emergency trolley arrives. Delegates available staff to roles appropriate to their level of practice: Airway, Compression, Monitor & Medications and Runner to collect or remove extra equipment, supplies, labs etc. Establishes the patient’s weight and delegates someone to print out an Emergency Drug Worksheet (Icon on desktop of clinical computers).

61. Cont ……. Ensures that the patient is placed on CPR back board. Reassigns nursing staff once the PICU nurse and additional staff arrive as required. Ensure someone is assigned to support family members. Documents initial and ongoing vital signs and cardiac rhythm, medication administration, procedures and patient’s response to interventions on the ACH/Starship Resuscitation record (CR8545). Monitors the time interval between adrenaline administration and prompts the Team Leader when 4 minutes has passed since last dose administered. Completes, including a brief summation of presenting events and signs the ACH/Starship Resuscitation record (CR8545). Ensures the outside copy of the CR8545 form is placed on the Charge Nurse desk and the inside copy is placed in the clinical record.  

62. AIRWAY NURSE (USUALLY THE PATIENTS NURSE OR THE NURSE WHO FINDS THE PATIENT) Summons help and initiates CPR as required until initial assistance arrives and then assumes responsibility for airway management. Maintains airway patency with use of airway adjuncts as required (suction, high flow oxygen, via Hudson mask, blob mask with O2 or bag valve mask ventilation).

63. Cont…….. This role becomes the responsibility of the PICU nurse on their arrival. Assist with intubation and securing of ETT Inserts gastric tube and/or facilitates gastric decompression post intubation as required. Assists with ongoing management of airway patency and adequate ventilation Supports less experienced staff by coaching/guidance e.g. drug preparation

64. COMPRESSION NURSE If CPR in progress, assume responsibility for cardiac compressions (this includes ensuring that staff doing compressions are changed at regular intervals (e.g. every 2 minutes) to avoid fatigue resulting in inadequate compressions being delivered) Assess pulses (including pulse volume) and capillary refill as required

65. During CPR During CPR Ensure high-quality CPR: rate, depth, recoil Plan actions before interrupting CPR Give oxygen Consider advanced airway and capnography Continuous chest compressions when advanced airway in place Vascular access (intravenous, intraosseous) Give adrenaline every 3-5 min Correct reversible causes

66. When is CPR not of benefit? • Knowledge of the probability of success with CPR could be used to determine its futility. University of Washington School of Medicine •CPR has been shown to be have a 0% probability of success in the following clinical circumstances: •Septic shock •Acute stroke •Metastatic cancer •Severe pneumonia •In other clinical situations, survival from CPR is extremely limited: •Hypotension (2% survival) •Renal failure (3%) •AIDS (2%) •Homebound lifestyle (4%) •Age greater than 70 (4% survival to discharge from hospital)