CPR SEMINAR PPT.pptx

CPR

1. SEMINAR ON Amy Lalringhluani 1 st yr Msc N (Paediatric Nursing) SRIHER, Chennai

2. Introduction Cardiac or respiratory arrest can occur at any time to individuals of any age as a result of an accident or a disease process. Cardiopulmonary resuscitation (CPR) is an emergency medical procedure for a victim of cardiac arrest and in some circumstances, respiratory arrest. CPR can provide oxygenation to the victim’s brain and the heart, dramatically increasing his/her chance of survival. If properly instructed, almost anyone can learn and perform CPR

3. Abbreviations & Terminologies CPR : Cardiopulmonary resuscitation AHA: American Heart Association BLS: Basic life Support AED: Automated external defibrillator ACLS: Advanced Cardiac Life Support IHCA: In-hospital cardiac arrest OHCA: Out of hospital cardiac arrest

4. Abbreviations & Terminologies Ventilation: The exchange of air between the lungs and the atmosphere so that oxygen can be exchanged in the alveoli Ventricular fibrillation: Abnormal and irregular heart rhythm in which there are rapid uncoordinated fluttering contractions of the ventricles.

5. Abbreviations & Terminologies Asystole and Pulseless electrical Activity (PEA): Asystole: A complete absence of demonstrable electrical and mechanical cardiac activity PEA: ECG rhythms without sufficient mechanical contraction of the heart to produce a palpable pulse or measurable blood pressure.

6. THE HEART

7. Overview Of Cardiovascular System Consists of heart, blood and blood vessels Transport blood to lungs Delivers CO 2 and picks up O 2 Transport O 2 and nutrients to all parts of the body Helps regulate body temperature Helps maintain body fluid balance

8. Circulation of blood through the heart

9. Definition: CPR is a technique of basic life support, consisting of a series of steps used to establish artificial ventilation and circulation in an individual who is not breathing and has no pulse

10. Cardiac Arrest Ventricular fibrillation Ventricular tachycardia(pulseless) Asystole Pulseless electrical activity (PEA) Respiratory Arrest Drowning Stroke Foreign body in throat Smoke inhalation Drug overdose Suffocation Indications

11. Signs & Symptoms of Cardiac & Respiratory Arrest: Cardinal signs Apnea Absent carotid and femoral pulse Dilated pupils Agonal breathing(heavy, noisy, gasping breathing) Cyanosis Unconsciousness Fits

12. Purpose To maintain blood circulation To maintain open and clear airway To maintain artificial breathing To provide basic life support till medical and advanced life support arrives

13. CPR Time - line CPR initiated within 4 mins -- > 40% survival chance 0 to 4 mins: Brain damage unlikely 4 to 6 minutes: Brain damage possible 6 to 10 mins: Brain damage probable Over 10 minutes: Probable brain death Timely CPR provides 10 to 20% normal blood flow to heart 20 to 30% normal blood flow to brain

14. Contraindications When the victim is biologically dead and rigor mortis has set in “Do not Resuscitate(DNR) “ order is in effect Properly executed living will requests that CPR is not to be initiated

15. Adult Chain of Survival

16. Determination of safe scene Ensure safe scene for rescuer and victim Move victim to safety 2. Assessment of victim Tap or gently shake victim Talk loudly to victim Agonal breathing in not counted as breathing Sequence of CPR

17. 3. Determination of pulselessness and activation of emergency response Check for carotid pulse Feel for not more than 10 seconds Call for help while assessing for pulse and breathing

18. 4. Start CPR

19. CIRCULATION

20. AIRWAY

21. Airway Maneuver Video

22. BREATHING 1. Mouth-to-Mask Technique Kneel at patient’s head and open airway. Place the mask on the patient’s face. Take a deep breath and breathe into the patient for 1 second. Remove your mouth and watch for patient’s chest to fall. (a) Mouth-to-Mouth Technique Maintain a head tilt-chin lift position to open the airway. Pinch the casualty’s nose with your thumb and index finger to prevent air from escaping. Seal your lips around the casualty’s mouth. Give 2 short breaths quickly, one after the other. Observe the chest rise with each breath. Release the nostrils after each breath. The duration for each breath is 1 second (b) Mouth-to-Barrier Technique

23. 2. Bag-to-Mask Technique

24. USE OF AED (AUTOMATED EXTERNAL DEFIBRILLATOR) Turn on the AED Expose the person’s chest and wipe the bare chest dry with a small towel or gauze pads . Anterior pad on right upper sternum just below clavicle Apex pad below left nipple in anterior axillary line over apex of heart Let the AED analyze the heart rhythm . Advise all responders and bystanders to “stand clear ” After delivering the shock or if no shock is advised, continue CPR with the pads remaining on the person Continue to follow the prompts of the AED

25. AED Precautions Do not use alcohol to wipe the person’s chest dry. ALCOHOL IS FLAMMABLE . Do not use an AED pads designed for an adult on a child 8 years or younger or 55 pounds unless pediatric AED pads are not available . Do not use pediatric AED pads on an Adult. Does not provide enough level of energy . Do not touch the person while the AED is analyzing . Before shocking a person with an AED, make sure that no one is touching or is in contact with the person .

26. Do not touch the person while the device is defibrillating. Do not defibrillate someone when around flammable or combustible materials. Do not use an AED in a moving vehicle. The person should not be in a pool or puddle of water when operating an AED Do not use an AED on a person wearing a nitroglycerine patch or medical patch on the chest. Do not use a mobile phone or radio within 6 feet of the AED.

27. USE OF AED

28. BLS/CPR for children (1-8yrs) Pulse: Carotid or femoral pulse Compression technique: One handed compression Two handed compression Compression depth: Half of anteroposterior diameter 2 inch (5cm) depth Compression Ventilation ratio: 30:2 (1 rescuer) 15:2 (2 rescuers) Breath/Ventilation: 2 full breaths Lasting for one second each

29. BLS/CPR for infants (0-12 months) Pulse: Brachial artery Compression technique: Two finger method ( 1 rescuer) Thumb method ( 2 rescuer) Compression depth: 1/3 rd of anteroposterior diameter 1.5 inch (approx 4cm) depth Compression Ventilation ratio: 30:2 (1 rescuer) 15:2 (2 rescuers) Breath/Ventilation: 2 full breaths( gently) Lasting for one second each

30. Infant Compression techniques

31. Infant mouth to mouth/nose rescue breaths Open the airway using a head tilt lifting of chin. Do not tilt the head too far back. Cover the baby's mouth and nose with your mouth Give 2 small gentle puffs. Each breath should be 1 second long. You should see the baby's chest rise with each breath.

32. AED for Infants Pad placement: E nergy: 2 joules/kg for the first attempt 4 joules/kg for the subsequent attempts

33. Recovery Position All casualties who are unconscious and breathing normally must go into the recovery position regardless of their injuries. Important Points Head must have full head tilt Face should be angled towards the floor Spinal Injuries – Use the spinal log roll if possible Pregnant women must be rolled on to their left side

34. Hand supporting the head Bent arm gives stability Bent leg prevents casualty from rolling forward Head tilted well back

35. BLS VIDEO

36. ACLS includes : Circulation by cardiac massage Airway management by equipments Breathing by advanced techniques Defibrillation by manual defibrillator Drugs. Breathing ACLS refers to a set of clinical interventions for the urgent treatment of cardiac arrest and other life-threatening medical emergencies, as well as the knowledge and skills to deploy those interventions.  Definition

37. The ACLS Survey (A-B-C-D)

38. H’s and T’s of ACLS ( Reversible causes of Cardiac Arrest

39. Advanced Airway Adjuncts Endotracheal tube ► Advantages : Ensures proper lung ventilation. No gastric inflation. No regurgitation or aspiration of gastric contents. ► Disadvantages : Requires insertion by highly skilled personnel . ► Inserted 5 – 6 cm beyond the vocal cords

40. Laryngeal mask (LMA) ► Advantages : Easy. Does not require highly skilled personnel (can be used by paramedics). ► Disadvantages : Stomach inflation. Not protective against regurgitation & aspiration of gastric contents.

41. Combitube/ Esophageal laryngeal tube Double lumen tube Distal tube enters esophagus and proximal tube enters the pharynx Cuff in esophagus inflated to prevent aspiration ► Advantages : Easy to use. Does not require highly skilled personnel (can be used by paramedics).

42. Defibrillation Definition: Defibrillation is a process in which an electronic device sends an electric shock to the heart to stop an extremely rapid, irregular heartbeat, and restore the normal heart rhythm. Defibrillation is a common treatment for life threatening cardiac dysrhythmias, ventricular fibrillation, and pulse less ventricular tachycardia. There are two general classes of waveforms: Mono-phasic waveform Energy delivered in one direction through the patient's heart Biphasic waveform Energy delivered in both direction through the patient's heart Voltage: Biphasic – 120J to 200J Monophasic – 360J

43. Resuscitation And Life Support Medications

44. ► Lidocaine : - MOA : Na channel blocker - Dose : 100 mg IV (1-1.5 mg/kg ). - Given : If Amiodarone is unavailable ► Magnesium : - Dose : 2 g IV. - Given : 1- VF / VT with hypomagnesemia. 2- Torsade de pointes( ventricular tachycardia in patients with a long QT interval) 3- Digoxin toxicity.

45. ► Adrenaline : - MOA : Given for its α -1 adrenergic receptor stimulation 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 ). ► Amiodarone : - MOA : Affects Na, K & Ca channels and has α & β adrenergic blocking properties - Dose : 300 mg IV bolus (5 mg/kg). - Given : in shockable rhythm after the 3 rd shock .

46. ► 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 as they may precipitate. ► 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 .

47. ► 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: streptokinase ). ► 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 ).

48. Complication of Compression: F ractures of ribs, sternum or spine Laceration of lungs or liver or other abdominal organs Pulmonary or cerebral fat embolism Laceration or rupture of heart Herniation of the heart through the pericardium cardiac tamponade Hemothorax or pneumothorax The complication of CPR Complication of artificial ventilation: Gastric distention Regurgitation aspiration These complications are more likely to occur when ventilation pressure exceeded the opening pressure of the lower esophageal sphincter  

49. The complication of CPR Complication of defibrillation: Skin burns (common) Skeletal muscle injury or thoracic vertebral fractures (uncommon) Myocardial injury and Post-defibrillation dysrhythmias (high-energy shocks) Electrocution of bystanders or rescuer Late complication: Pulmonary edema Gastrointestinal hemorrhage Pneumonia Recurrent cardiopulmonary arrest. Anoxic brain injury can occur in a resuscitated victim who suffered prolonged hypoxia .It is the most common cause of death in resuscitated patients

50. Nursing Responsibilities Team leader Airway nurse Compression Nurse

51. Cardiopulmonary

52. General Principles for Resuscitation in Patients with Suspected and Confirmed COVID-19 1. Reduce Provider Exposure to COVID-19 Rationale It is essential that providers protect themselves and their colleagues from unnecessary exposure. Exposed providers who contract COVID-19 further decrease the already strained workforce available to respond and have the potential to add additional strain if they become critically ill. 2. Prioritize Oxygenation and Ventilation Strategies With Lower Aerosolization Risk Rationale Although the procedure of intubation carries a high risk of aerosolization, if the patient is intubated with a cuffed endotracheal tube and connected to a ventilator with a high-efficiency particulate air (HEPA) filter in the path of exhaled gas and an inline suction catheter, the resulting closed circuit carries a lower risk of aerosolization than any other form of positive-pressure ventilation

53. 3. Consider the Appropriateness of Starting and Continuing Resuscitation Rationale CPR is a high-intensity team effort that diverts rescuer attention away from other patients . In the context of COVID-19, the risk to the clinical team is increased and resources can be profoundly more limited, particularly in regions that are experiencing a high burden of disease. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high and rises with increasing age and comorbidities, particularly cardiovascular disease . Therefore , it is reasonable to consider age, comorbidities, and severity of illness in determining the appropriateness of resuscitation and to balance the likelihood of success against the risk to rescuers and patients from whom resources are being diverted .

54. A djustments to CPR algorithms in patients with suspected or confirmed COVID-19

55. NURSING THEORY APPLICATION

56. Assessment Nursing Diagnosis Intervention Universal self requisite: Maintenance of sufficient air Patient not breathing or gasping Monitor airway and breathing Prevention of hazard Monitor saturation, breathing, airway, LOC Assess contributing factors Ineffective breathing pattern r/t cardiovascular and respiratory assault Risk for injury(neurological) r/t poor perfusion to the brain tissues Wholly compensatory Compression Airway Breathing Health deviation requisite: Assess pulse Check for bleeding Monitor fluid status Decreased cardiac output r/t inability of heart pump blood adequately Wholly compensatory Compression Airway Breathing Fluid replacement Therapeutic self care demand & Self care deficit Patient unconscious and unable to perform any form of self care Self care deficit r/t cardiac arrest Anxiety (of relatives) r/t potential loss of loved one Wholly compensatory Provide all self care needs Provide nutritional needs Provide hygienic needs Supportive-educative Spiritual, psychological support Application

57. JOURNAL ABSTRACT

58. “Study of pre-hospital care of Out of Hospital Cardiac Arrest victims in India and their outcome in a tertiary care hospital” Rachana Bhat, Prithvishree Ravindra, Ankit Kumar Sahu, Roshan Mathew, William Wilson P reprint :June 16, 2020

59. Hands‑only cardiopulmonary resuscitation training for schoolchildren : A comparison study among different class groups Roshan Mathew, Ankit Kumar Sahu, Nirmal Thakur, Aaditya Katyal, Sanjeev Bhoi, Praveen Aggarwal Turkish Journal of Emergency Medicine:07-10-2020

60. https:// www.slideshare.net/LanglenChanu/cardiopulmonary-resuscitation-67246062 https :// www.ahajournals.org/journal/circ https :// nhcps.com/course/acls-advanced-cardiac-life-support-certification-course/ https :// cpr.heart.org/en https://www.researchgate.net/publication/343224677_% 27Hands-only%27_CPR_training_for_school_children_A_comparison_study_among_different_class_groups%27 https:// www.researchgate.net/publication/342219155_Study_of_pre-hospital_care_of_Out_of_Hospital_Cardiac_Arrest_victims_and_their_outcome_in_a_tertiary_care_hospital_in_India_Pre-hospital_Cardiac_Arrest_REsuscitation_Pre-CARE_study Reference Karl Disque, ”BLS provider handbook”,2016, Sartori continum Publishing Karl Disque , ”ACLS provider handbook”,2016, Sartori continum Publishing Jacob Annamma, “Clinical Nursing Procedures: The art of Nursing Practice”, 4 th edition, Jaypee Publications Janice L. Hinkle, “Brunner and Suddarth’s Textbook of Medical Surgical Nursing”, 14th edition , Lippincott Williams Wilkins ACLS Review made incredibly Easy, 2 nd edition, Lippincott Williams Wilkins