CPR- Cardio Pulmonary Resusciatation (Pediatrics)

COMPILED BY: ASHISH H. ROY

1. Pediatric Cardiopulmonary Resuscitation Compiled By :- Mr. Ashish H. Roy B.Sc Nursing,S.G.P.G.I.M.S Lucknow (NURSING TUTOR)

2. CPR When cardiac arrest occurs, the heart stops pumping blood.  CPR can support a small amount of blood flow to the heart and brain to “buy time” until normal heart function is restored. 

3. WHY CPR??? Rapid and effective bystander CPR is associated with successful return of spontaneous circulation and neurologically intact survival in children. Respiratory arrest: > 70% survival rate Ventricular fibrillation: 30% survival rate But only 2% to 10% of all children who develop out-of-hospital cardiac arrest survive, and most are neurologically devastated.

4. Pediatric CPR Pediatric basic life support (BLS) Pediatric advanced cardiovascular life support (ACLS) Prolonged life support

5. Basic Life Support Airway Breathing Circulation

6. Most Important Intervention Adequate oxygenation, ventilation

7. 2005 American Heart Association, PBLS Algorithm No response, send someone to call resuscitation team Open airway, check breathing If not breathing, give two breaths that makes chest rise One rescuer: 30 C & 2 B Two rescuer: 15 C & 2 B Child < 1 year: continue CPR Child > 1 year: Use AED after 5 cycles of CPR If no response, check for definite pulse within 10 sec. Give one breath q 3 sec Child > 1 year: Check rhythm Resume CPR, check rhythm q 5 cycles, continue until ALS provider take over or victim start to move Give 1 shock Resume CPR immediately for 5 cycles No Yes Non shockable Shockable

8. 2005 American Heart Association, PBLS Algorithm 100

9. Chain of survival 102, 1099

10. Check the response If the child is  unresponsive  and is not   moving, shout for help   and start CPR. If you are alone, continue   CPR for 5 cycles (about   2 minutes). One cycle of CPR for the   lone rescuer is 30 compressions and 2 breaths

11. Airway Head-tilt/chin-lift method Big tongue; Forward jaw displacement critical Avoid extreme hyperextension With possible neck injury, jaw thrust

12. Look in the mouth Do a jaw lift and look in the mouth. If you see food or a foreign object , follow up with a finger sweep Never do a blind finger sweep.

13. Airway position Head-tilt/chin-lift method Jaw thrust maneuer

14. Check breathing Look-Listen-Feel for 10 sec. Limit to volume causing chest rise Pedi BVM’s should not have pop-off valves BVM-get good seal with no leaking Use E-C method for BVM

15. Look listen & feel

16. Give rescue breaths Pinch the victim's nose shut.  Place your mouth over the mouth of the victim.  Create a good tight air seal with your mouth over the mouth of the victim and give 2 slow, gentle breaths. Breathe in only enough air to make the victim's chest to rise up a little bit

17. Methods Mouth-to-Mouth Rescue Breathing Mouth-to–Barrier Device Breathing Mouth-to-Nose and Mouth-to-Stoma Ventilation Ventilation With Bag and Mask Ventilation With an advanced Airway

18. E C-E position for BVM

19. Breathing Ensure proper head-tilt chin lift and provide breaths with bag Ventilate infants and children every 3 seconds Ventilate older children every 5 seconds Ensure adequate chest rise with breaths If using BVM, obtain adequate seal-use EC grip If via ET: 1 breath / 6-8 seconds

20. CHILD-Airway obstruction

21. Circulation Feel for pulse: Infants: check brachial Children: check carotid Feel for pulse on side closest to you Check for pulse for 10 seconds 90% of pediatric cardiac arrest is bradycardia, PEA, or asystole

22. Circulation If despite oxygenation and ventilation the pulse is 60 bpm and there are signs of poor perfusion (i.e. pallor, cyanosis), begin chest compressions. If the pulse is 60 bpm but the infant or child is not breathing, provide rescue breathing (12 to 20 bpm) without chest compressions .

23. Circulation Infant chest compressions 2 fingers 1 finger width below nipple line 1/2 - 1 inches At least 100/minute

24. Circulation Child chest compressions One hand Lower half of sternum 1 - 1.5 inches 100/minute

25. Breathing & circulation Chest compressions: 30:2 one responder, with two responders 15:2 Ensure adequate chest recoil after compression

26. Best Sign of Effective Ventilation Chest Rise

27. Best Sign of Effective Circulation Pulse with Each Compression

28. Circulation-children Chest compressions: 30:2 with one responder, 15:2 with two Use one hand Compress on lower half of sternum Ensure adequate chest recoil after compression

29. Circulation-older children For older/adult size children 30:2 ratio, even with 2 responders Use 2 hands Ensure adequate chest recoil after compressions

30. Oxygen Therapy Use highest possible FiO 2 No risk in short term 100% O 2 Humidify if possible Avoids plugging airways, adjuncts

31. AEDs

32.  Termination of Resuscitative Efforts Unfortunately there are no reliable predictors of outcome during   resuscitation to guide when to terminate resuscitative efforts.   Prolonged efforts should be made for infants and children with   recurring or refractory VF or VT, drug toxicity, or primary   hypothermic insult.

33. Summary of PBLS

34. CPR/Rescue Breathing Adult and Older Child Child (1-14 years ) Infant (<1 year ) Activating EMS – Lone Rescuer Check responsiveness Activate EMS First Hypoxic Arrest : Call after 2 min. of CPR Call after 2 min. of CPR Sudden, witnessed arrest: Activate First Call after 2 min. of CPR Sudden, witnessed arrest: Activate First Open airway (Head tilt-chin lift or jaw thrust) Head tilt-chin lift (If trauma is present, use jaw thrust) Head tilt-chin lift (If trauma is present, use jaw thrust) Head tilt-chin lift (If trauma is present, use jaw thrust) Breathing 2 effective breaths at 1 sec/breath 2 effective breaths at 1 sec/breath 2 effective breaths at 1 sec/breath 1 breath / 5-6 seconds If via ET: 1 breath / 6-8 seconds 1 breath / 3-5 seconds If via ET: 1 breath / 6-8 seconds 1 breath / 3-5 seconds If via ET: 1 breath / 6-8 seconds

35. Adequate Breathing If not adequate: Provide Rescue Breathing If no breathing: Provide Rescue Breathing If no breathing: Provide Rescue Breathing Foreign-body airway obstruction (CHOKING) Abdominal thrusts Unresponsive: CPR & NO Blind finger sweeps Abdominal thrusts Unresponsive: CPR & NO Blind finger sweeps Back blows and chest thrusts Unresponsive: CPR & NO Blind finger sweeps Pulse Check: Check X 10 seconds or less Carotid Carotid or Femoral Brachial or Femoral When to Provide Compressions? Pulse Absent HR < 60 with signs of poor perfusion HR < 60 with signs of poor perfusion Compression landmarks Center of chest, between nipples Center of chest, between nipples Just below nipple line Compression method Push Hard & Fast, allow chest recoil 2 Hands: Heel of one hand, other hand on top. 1 Hand or 2 Hands: Use heel of hand(s) 1-rescuer: 2 fingers 2-rescuers: 2 thumbs-encircling hands Umbilical

36. Compression depth 1 ½ to 2 in (4 to 5 cm) 1/3 to ½ the depth of the chest 1/3 to ½ the depth of the chest Compression rate 100/min 100/min 100/min Compression-ventilation ratio 30:2 (1 or 2 rescuers) 1-rescuer: 30:2 2-rescuers: 15:2 1-rescuer: 30:2 2-rescuers: 15:2 AED Perform 2 min. or 5 cycles of CPR immediately after shock(s) delivered. Use Adult pads only. In Hospital: Apply immediately. Out-of-Hospital: 2 min. CPR first. 1-8 years: use child pads. If Child pads not available, use Adult pads Not recommended

37. Complications of CPR Spinal cord Injury Internal organ damage Vomiting Risk for aspiration Gastric distension Punctured lungs, lacerated liver, fractured ribs and sternum--caused by chest compressions Disease transmission, including herpes, HIV, Hepatitis, Mononucleosis, Influenza, Staph infection, and TB--due to inadequate or no protective mask .

38. Immediate care after CPR LOC and GCS scoring ECG Temperature (core and peripheral)  Arterial BP  CVP  Urine output  ABG value  FiO2

39. Post CPR Investigations Chest X ray Complete blood count Blood glucose Clotting screening Plasma, urea and electrolytes Hb and Haematocrit 

40. Nursing care after resuscitation

41. Nursing CARE Nursing. Diagnosis : r isk for altered respiratory pattern r/t disease condition . Interventions: Assess respiratory rate. Auscultate breath sounds. Recovery/ Fowler’s position if difficulty. Monitor pulse oximetry and ABG analysis. Report any abnormality. Continuous monitoring for the first half hr. of defibrillation.

42. Nursing Diagnosis: decreased cardiac output r/t cardiac arrest, dysrhythmia . Interventions: Assess vitals signs, CVP, urinary output and peripheral pulses. Assess heart rate and rhythm (ECG). Oxygen administration as hypoxia can lead to further dysrhytmias . Administer drugs, antidysrhythmic medication as ordered. Administer fluid therapy as ordered. Prepare for pacemaker therapy, if required.

43. Nursing Diagnosis: altered tissue perfusion r/t to decreased cardiac output. Interventions: Note the color and temperature of the skin. Assess hemodynamic pressures hrly . Monitor peripheral pulses q4h. Monitor urine out put q4h. Monitor lactate levels. Provide warm environment.

44. Nursing Diagnosis: r isk for fluid electrolyte imbalance r/t altered physiology. Interventions: Monitor intake and output. Administer fluid and diuretics. Monitor electrolytes daily and replace as ordered. Monitor BUN, creatinine and urine electrolytes daily.

45. Nsg. Diagnosis : Risk for complications r/t disease process, procedure performed and defibrillation. Interventions: Assess level of consciousness. Reorient the time, place and person. Assess vital signs and ECG continuously. Initiate IV antidysrhythmics therapy. Administer IV fluid to correct fluid electrolyte imbalances

46. Monitor lactate levels. Correct lactic acidosis. Maintain blood glucose within normal range using insulin. Assess for burns and treat the injury. Document neurological, respiratory and cardiovascular status before and after the defibrillation.

47. Nsg. Diagnosis : Altered family process r/t fear about unknown outcome. Interventions : Prepare patient and family and explain what is expected. Clarify any misconceptions. Provide adequate rest to the patient. Encourage to ask questions related to equipments, monitoring, treatment.

48.  Family Presence During Resuscitation Family members with no medical background   report that being at the side of a loved one and saying goodbye   during the final moments of life is comforting and helps   in their adjustment, have less anxiety and depression and   more constructive grieving behavior. Members of the resuscitation   team must be sensitive to the presence of family members, and   one person should be assigned to comfort, answer questions,   and discuss the needs of the family

49. Summary CPR Airway Breathing Circulation/compression AEDs Complications Post resuscitation care Nursing management Sustain efforts until PALS can be initiated

50. References American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation. 2005;112:IV-156 – IV-166 (available from in internet) http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-166) Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective.  J Emerg Nurs .  1992; 18: 104–106.[Medline] [Order article via Infotrieve ]  Meyers TA, Eichhorn DJ, Guzzetta CE. Do families want to be present during CPR? A retrospective survey.  J Emerg Nurs .  1998; 24: 400–405.[ CrossRef ][Medline] [Order article via Infotrieve ] Offord RJ. Should relatives of patients with cardiac arrest be invited to be present during cardiopulmonary resuscitation?  Intensive Crit Care Nurs .  1998; 14: 288–293

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