CPR CARDIO PULMONARY RESUSCITATION

1. BY ARUSHI NEGI
M.Sc. Nursing Ist year

2. INTRODUCTION:
• Resuscitation includes all measures that are applied to
the patients who have stopped breathing suddenly and
unexpectedly due to either respiratory or cardiac failure.
• Emergency Cardiac Care includes all responses
necessary to deal with sudden and often life-threatening
events affecting the cardiovascular, cerebrovascular, and
pulmonary systems.
• CODE BLUE

3. DEFINITON:
• Cardio-pulmonary resuscitation includes those
techniques which are used to revive circulation and
breathing in patients whose respiration and circulation of
blood have suddenly and unexpectedly stopped.

5. BLS
• Basic Life Support.
• It involves a variety of life-saving skills and techniques,
like CPR , a combination of chest compressions and rescue
breaths and pulse checks.
• Also involves using Automatic External Defibrillators and
bag valve masks.
• BLS is performed mostly by healthcare professionals but
also first responders like police officers and firefighters.

6. Immediate rec
ognition of
sudden
cardiac arrest
(SCA)
Activation of
the
emergency
response
system
Cardiopulmon
ary
resuscitation (
CPR)
Defibrillati
on
Fundament
al aspects
of BLS
includes

7. INDICATIONS :
• Cardiac arrest refers to a sudden state of apnoea and
circulatory failure
CARDIAC
ARREST:
• The respiratory and cardio-vascular systems are
interdependent.
• Conversely, the ventilation of the lungs fail soon after the
heart stops. This is because the respiratory centre in the
medulla oblongata can not function without the
continuous supply of oxygen that is normally transported
to it by the cardiovascular system.
CARDIO-
RESPIRATORY
FAILURE

8. Causes of Cardiac Arrest
5 H's
Hypoxia,
Hypovole
mia,
Hydrogen
ions
(acidosis),
Hyper/Hypo
-kalemia,
Hypothermi
a;
5 T's
Tension
pneumothora
x,
Tamponade
-cardiac,
Toxins,
Thrombosis
-coronary
(MI),
Thrombosis
-pulmonary
(PE).

9. Signs and Symptoms of Cardiac Arrest
• Apnoea
• Absence of Carotid and Femoral Pulse
• Dilated Pupils
• Cyanosis
• Unconsciousness
• Fit (grand mal seizure)

10. CONTRA - INDICATIONS OF CPR :
The patient has a valid DNAR order.
The patients has signs of irreversible death: rigor mortis,
decapitation or dependent lividity
Vital functions have deteriorated despite maximal therapy ,
e.g- progressive septic or cardiogenic shock
Confirmed gestation <23 weeks or birth weight <400g,
anencephaly.

11. CHAIN OF SURVIVAL (BLS)

12. CARDIO-PULMONARY RESUSCITATION

13. BLS ALOGRITHM

14. STEPS OF BLS :
Ensure the safety of patient and self .Move the
patient only if necessary.
Assess the response of the person by tapping
his/her shoulder and asking loudly,”are you okay?”
Call for help.
Assess the carotid pulse , not more than 10 sec.

15. PROCEDURE
(A) To maintain circulation
• Position the patient on his back on a flat, firm surface.
• Kneel along one side of the patient's chest.
To locate the lower part of the sternum, follow the following steps:
• Place the heel of one hand on the lower third of the sternum about 4
cm from the tip of the xyphoid process.
• Place the heel of other hand on the top of the first hand. Fingers
may be kept interlocked.
• Using the heel of the hand exert pressure only on the sternum.
Pressure elsewhere can create rib fracture if excessive force is used.

17. • To provide effective chest compressions, push hard and
push fast a rate of at least 100 compressions per minute
with least 2 inches/5 cm depth.
• Rescuers should allow complete recoil of the chest after
each compression, to allow the heart to fill completely
before the next compression (ROSC).
• Compression-ventilation ratio of 30:2 is recommended .
• Approx in 1 minute 120 compressions and 8-10 breaths
are delivered.
• Only after 5 cycles , the rescuers should switch.

18. • Assess for a return of the carotid pulse.
• Resume CPR within 7 seconds if the carotid pulse is
absent.
• Reassess the pulse every few minutes.
• If the carotid pulse is present check for spontaneous
breathing for 3-5 seconds.
• If the client is breathing stop cardiopulmonary
resuscitation but continue monitoring. If breathing is
absent continue artificial breathing and keep monitoring
pulse.
• Periodically assess the vital signs.

19. (B) To maintain the airway clear
HEAD - TILT CHIN LIFT
JAW THRUST
Clear the airway of obvious foreign matter,
Use head tilt–chin lift maneuver to open
the airway of a victim with no evidence of
head or neck trauma.
In case of cervical spine injury, open the
airway using a jaw thrust without head
extension

20. • Hyper extend the head and neck of the patient to
prevent the tongue falling back and obstructing the
airway.
• If breathing is restored, place an oro-pharyngeal
airway which also prevents biting of the tongue,
should the patient develops a fit.
• If breathing is not restored start artificial ventilation.

21. (C) TO INITIATE BREATHING
Pinch the patient's
nostrils closed,
using index finger
and thumb of the
hand near the
patient's face
ensuring air-tight
seal.
Take a deep
breath, place your
widely opened
mouth over the
patient's mouth
and blow forcefully
enough to make
the patient's chest
rise.
Turn the face
towards the
patient's chest to
observe its
expansion
ensuring
ventilation of the
lungs

22. METHODS:
Mouth-to-Mouth Rescue
Breathing
Mouth-to–Barrier Device
Breathing
Mouth-to-Nose and Mouth-
to-Stoma Ventilation

23. Ventilation With Bag and Mask
The Bag-Mask Device
• Inlet valve
• Pressure relief valve that
can be bypassed
• Oxygen reservoir
• Non - rebreathing outlet
valve

24. Ventilation With an Advanced Airway
• Ventilations are delivered
at the rate of 1 breath
about every 6 to 8
seconds
• Which will deliver
approximately 8 to 10
breaths per minute.

25. (D) Defibrillation With an AED
• Defibrillation is a treatment for life-threatening cardiac
dysrhythmias, specifically ventricular fibrillation (VF)
and non-perfusing ventricular tachycardia (VT).
• A defibrillator delivers a dose of electric current (often
called a counter-shock) to the heart.

26. Defibrillation Sequence
• Turn the machine on.
• Bare the chest. Dry it off , If excessive hair, shave it off.
• Place one pad on the patient’s upper right chest above
the nipple.
• Place the other pad on the patient’s lower left ribs below
the armpit.

27. Resuscitation electrodes placement

28. • Follow AED prompts.
• Stand Clear. Do not touch the patient while the AED analyzes.
• If the AED says, “Shock advised, charging…,” shout, “Clear”
, make sure no one is touching the patient.
• Push the shock button when the AED tells you to
• Biphasic - (150-200 J ), monophasic - 360J
• If no shock is advised, give CPR if the patient is not moving
and not breathing.
• As soon as the shock has been delivered, give 30 chest
compressions followed by 2 breaths.
• The AED will reanalyze every 2 minutes and prompt for a
shock if needed.

29. When to give shock ?
• Ventricular fibrillation is a type of abnormal heart rhythm
(arrhythmia). Disorganized heart signals cause the ventricles to twitch
uselessly. As a result, the heart doesn't pump blood to the rest of the
body.
• Symptoms
Chest pain, tachycardia , Dizziness, Nausea ,Shortness of breath
• Causes
Problem in the heart's electrical properties or by a disruption of the normal
blood supply to the heart muscle.
Sometimes, the cause of ventricular fibrillation is unknown.

30. Ventricular tachycardia
• It is a heart rhythm disorder (arrhythmia) caused by abnormal electrical
signals in ventricles.
Symptoms
• Dizziness
• Shortness of breath
• Lightheadedness
• Feeling as if your heart is racing (palpitations)
• Chest pain (angina)

32. • Carry out cardio-pulmonary resuscitation until one of the
following occurs:
a)Client regains a satisfactory pulse
• Constriction of pupils.
• The systemic blood pressure is returned to normal.
• There is improved colour of the skin.
• The respiratory movements are taking place rhythmically
b)The client is declared dead by the doctor

34. ACLS
• ACLS stands for Advanced Cardiovascular Life Support.
• It involves healthcare professionals interpreting a patient’s
heart rhythm . Based on this heart rhythm, decisions are made
regarding treatment options.
• ACLS providers must have the skills and knowledge to place
advanced airways and insert an IV (Intravenous) or IO
(Intraosseous) line for the administration of fluids and
medications.
• BLS is component of ACLS.

35. CHAIN OF SURVIVAL
• Recognition of early warning
signs
• Activation of the EMS system
• Basic CPR
• Management of the airway and
ventilation
• Defibrillation
• Intravenous administration of
medications

36. Commonly Used Medications in ACLS.
Adenosine.
Amiodarone.
Atropine.
Dopamine.
Epinephrine.
Lidocaine.

37. EPINEPHRINE
• Increase myocardial and cerebral blood flow during CPR.
• The recommended dose of epinephrine is 1.0 mg (10ml of
a 1:10,000) solution administered IV every 3 to 5 minutes
during resuscitation.
ATROPINE
• Increases heart rate and conduction through the AV node.
• DOSE - Bolus 1.0 mg IV. Repeat at 3 - 5 minute intervals,
not to exceed approximately 3mg
•

38. • AMIODARONE
• Prolongs the recovery period of cardiac cells after they have
carried an impulse and effects sodium, potassium, and calcium
channels.
• DOSE - VF/VT-Cardiac arrest: 300mg IV, may repeat 150mg in
3 - 5min
Infusion: 900mg/500mL (1.8mg/mL) / Infuse @ 1mg/min
(33mL/hr) x 6hrs then 0.5mg/min (17mL/hr)
• Max combined daily dose 2.2grams in any 24 hour period

39. LIDOCAINE
• Depresses ventricular irritability and automaticity and
increases fibrillation threshold
Dosage:
• VF & Pulseless VT = 1.0 - 1.5mg/kg. Repeat at half dose
if necessary. Max: 3mg/kg
Infusion:
• Maintenance Infusion: Mix 2gm/500mL D5W (4mg/mL)
• Infuse @ 1 - 4mg/min (15 - 60 mL/hr)

41. NURSE'S RESPONSIBILITY
1.Preliminary
Assessment
Because of an emergency no
time is lost to initiate cardio
pulmonary resuscitation
procedures. Call loudly for
help as soon as you confirm or
have strong suspicion of
respiratory or cardiac failure.
2.Preparation
of the
Equipment
No equipment is absolutely
necessary for effective
performance of cardio-
pulmonary resuscitation.
But the few equipments may
be helpful if they are at hand.
They may be kept ready
where they are easily
available round the clock e.g..
in the intensive care unit.

42. Equipments:
1.Oxygen administration sets.
2.IV infusion sets and cut down sets.
3.Ambu bag and mask devices.
4. Endotracheal tubes of different sizes.
5. Oropharyngeal and nasal airways.
6. Laryngoscope of different sizes.
7. Tracheostomy sets.
8. Suction apparatus.
9. Cardiac monitor and defibrillator.
10. Mechanical respiratory aids.
11. Emergency drugs such as epinephrine, atropine, isopril, calcium
gluconate, sodium bicarbonate, lidocaine, Lasix, decadron, glucose 10%,
5%, respiratory stimulants like aminophylline, doxapram
12. Clean rag pieces or gauze pieces in
containers.
13. Syringes and needles
14. B.P. apparatus
15. Light sources

43. Preparation of the Patient and the Environment
No time is lost in explaining the procedure to the patient or his relatives. If someone is
free she may explain to the relatives why the patient is receiving such treatment.
The patient may be shifted to a hard surface or a hard board placed under the patient's
thorax.
Remove or push aside clothing which covered the patient's chest to observe the chest
cardiac beats and respirations.
Place the patient flat on his back without any pillows. This position helps to maintain the
airway to give external cardiac compressions.
Remove the tight clothing around the neck and chest.

44. AFTER CARE OF THE PATIENT
1.The patient
should be
continually
watched by
skilled persons
over a period of
48 to 72 hours.
2.Shift him to
the ICU for
constant
observation
and expert
care.
3.Give oxygen
continuously for 48
hours following
resuscitation. This is
necessary because
respirations are
depressed for some
time after the
cardiac arrest.
4.Frequently
check the victim's
head and jaw
positions
because his
tongue may fall
back and obstruct
the airway.
5.Assess the
patient's
respirations by
noting the
rhythm, rate
and depth of
respiration.

45. 6.Check the colour of the skin. Persisting cyanosis indicates
inadequate oxygenation of blood.
7.Watch for the signs of restored circulation and respiration.
They are :
(a) Contraction of pupils.
(b) Improved colour.
(c) Change in the quality of pulse.
(d) Free movements of the chest wall and no retraction of
muscles over the intercostal space.
(e) Return of systemic blood pressure.
(f) Struggling movements.

46. 8.Temperature is taken every hour. A high temperature usually
indicates cerebral damage or cerebral oedema.
9.Watch for convulsions. It may occur due to brain damage or
acidosis.
10.Insert endotracheal tube, if not already in place. This
maintains an airway an open airway for the unconscious patient
who can not clean secretions by coughing.
11.Insert Foley's catheter. Urine output is one of the measures of
the cardiovascular status .
12.Start I.V. infusions to administer enough fluids in the patient.
13.Blood gas and pH determinations are done to detect
metabolic acidosis.

47. 14.Watch for the complications that might have occurred duringthe procedure:
(a) Damage neck to the cervical spine due to hyperextension of the neck.
(b) Fracture of the rib and xiphoid process.
(c) Haemopericardium, pneumothorax, haemorrhage etc.
(d) Gastric distension with air.
15.Record the procedure on the nurse's record with date and time. Record the following:
(a) Time the victim was discovered.
(b) Type of arrest (respiratory or cardiac both).
(c) Any complications developed during the CPR.
(d) Time at which spontaneous respiration and pulse returned.
(e) Time at which CPR started and discontinued.
(f) Vital signs when the CPR team left the patient

48. VIDEO ON BLS AND ACLS:
BLS - https://youtu.be/fkFjT5-g2CA
ACLS - https://youtu.be/dGMSxrT3VL4

49. SUMMARY
• Through this we learnt about cardio pulmonary resuscitation,
BLS,ACLS, cardiac arrest, cardio- respiartory failure,
contraindications , chain survival of bls , steps , the procedure,
chest compressions, airway, breathing through various
equipments, defibrillator, ventriculary fibrillation and
ventricular tachycardia, ACLS chain survival, common drug
used, nurses responsibility and after care .

50. CONCLUSION
The critical lifesaving steps of are:
Immediate Recognition and Activation of the emergency response system,
Early CPR, Rapid Defibrillation ,Hospitalization,Post care.
When an adult suddenly collapses, whoever is nearby should activate the
emergency system and begin chest compressions (regardless of training).
Chest compressions should be delivered by pushing hard and fast in the
center of the chest (ie, chest compressions should be of adequate rate and
depth). Rescuers should allow complete chest recoil after each
compression and minimize interruptions in chest compressions.

51. BIBLIOGRAPHY
• Nancy Sr., Principles and practices of nursing Senior nursing
procedures, volume 2 , fourth edition, 2005, N.R. Publishing
house ,pg no 236-248.
• https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONA
HA.110.970939