SEMINAR ON

Amy Lalringhluani
1st yr Msc N (Paediatric Nursing)
SRIHER, Chennai
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
 Abbreviations & Terminologies
1. CPR : Cardiopulmonary 5. ACLS: Advanced
resuscitation Cardiac Life Support
2. AHA: American Heart 6. IHCA: In-hospital
Association cardiac arrest
3. BLS: Basic life Support 7. OHCA: Out of
4. AED: Automated hospital cardiac
external defibrillator arrest
 Abbreviations & Terminologies
8. Ventilation: The exchange of air between the lungs
and the atmosphere so that oxygen can be exchanged
in the alveoli
9. Ventricular fibrillation: Abnormal and irregular heart
rhythm in which there are rapid uncoordinated
fluttering contractions of the ventricles.
 Abbreviations & Terminologies
10. Ventricular tachycardia: Occurrence of 3 or more
premature ventricular complexes (PVC) in a row, at
a rate exceeding 100bpm
 Abbreviations & Terminologies
12. Asystole and Pulseless electrical Activity (PEA):
a) Asystole: A complete absence of demonstrable
electrical and mechanical cardiac activity
b) PEA: ECG rhythms without sufficient mechanical
contraction of the heart to produce a palpable pulse
or measurable blood pressure.
THE HEART
 Overview Of Cardiovascular System
• Consists of heart, blood and
blood vessels
• Transport blood to lungs
• Delivers CO2 and picks up O2
• Transport O2 and nutrients to all
parts of the body
• Helps regulate body
temperature
• Helps maintain body fluid
balance
Circulation of blood through the heart
 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
 Indications

Cardiac Arrest Respiratory Arrest

• Ventricular fibrillation • Drowning
• Ventricular • Stroke
tachycardia(pulseless) • Foreign body in throat
• Asystole • Smoke inhalation
• Pulseless electrical activity • Drug overdose
(PEA) • Suffocation
 Signs & Symptoms of
Cardiac & Respiratory Arrest:

1. Cardinal signs
─ Apnea
─ Absent carotid and femoral pulse
─ Dilated pupils
2. Agonal breathing(heavy, noisy, gasping breathing)
3. Cyanosis
4. Unconsciousness
5. Fits
 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
 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
 Contraindications
1. When the victim is
biologically dead and rigor
mortis has set in
2. “Do not Resuscitate(DNR) “
order is in effect
3. Properly executed living
will requests that CPR is
not to be initiated
Adult Chain of Survival
 Sequence of CPR
1. 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
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

4. Start CPR
CIRCULATION
AIRWAY
Airway Maneuver Video
 BREATHING
(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

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.
2. Bag-to-Mask Technique
 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.
 Antero-Lateral Anterior pad on the
right infraclavicular chest and
lateral pad lateral to left chest at
the level of nipple in midaxillary
line
 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
 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.
 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.
USE OF AED
 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
BLS/CPR for infants (0-12 months)
Pulse:
• Brachial artery
Compression technique:
• Two finger method ( 1 rescuer)
• Thumb method ( 2 rescuer)
Compression depth:
• 1/3rd 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
Infant Compression techniques
 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.
 AED for Infants
Pad placement: Energy:
● 2 joules/kg for the first
attempt
● 4 joules/kg for the
subsequent attempts
 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
Recovery Position Steps
BLS VIDEO
 Definition
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. 

ACLS includes: Breathing

 Circulation by cardiac massage

 Airway management by equipments

 Breathing by advanced techniques

 Defibrillation by manual defibrillator

 Drugs.
The ACLS Survey (A-B-C-D)
H’s and T’s of ACLS ( Reversible causes of Cardiac
Arrest
H’s and T’s of ACLS ( Reversible causes of Cardiac
Arrest
 Advanced Airway Adjuncts

Endotracheal tube
► Inserted 5 – 6 cm beyond the vocal
cords

► Advantages: Ensures proper lung

ventilation. No gastric inflation. No
regurgitation or aspiration of gastric
contents.
► Disadvantages: Requires insertion
by highly skilled personnel.
Laryngeal mask (LMA)

► Available in a variety of pediatric

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

a) Mono-phasic waveform
• Energy delivered in one direction through the patient's heart
b) Biphasic waveform
• Energy delivered in both direction through the patient's heart

Voltage:
Biphasic – 120J to 200J
Monophasic – 360J
Resuscitation And
Life Support
Medications
► Adrenaline:
- MOA: Given as a 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 3rd 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 3rd shock.
► 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.
► 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 NaHCO3 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.
► 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).
 The complication of CPR
Complication of Compression: Complication of artificial
ventilation:
• Fractures of ribs, sternum or
spine • Gastric distention
• Laceration of lungs or liver or • Regurgitation
other abdominal organs • aspiration
• Pulmonary or cerebral fat
embolism  These complications are
• Laceration or rupture of heart more likely to occur when
• Herniation of the heart ventilation pressure
through the pericardium exceeded the opening
• cardiac tamponade pressure of the lower
• Hemothorax or pneumothorax esophageal sphincter 
 The complication of CPR
Complication of defibrillation: Late complication:
• Pulmonary edema
• Skin burns (common) • Gastrointestinal hemorrhage
• Skeletal muscle injury or • Pneumonia
thoracic vertebral fractures • Recurrent cardiopulmonary
(uncommon) arrest.
• Myocardial injury and • Anoxic brain injury can occur
• Post-defibrillation in a resuscitated victim who
dysrhythmias (high-energy suffered prolonged hypoxia
shocks) .It is the most common cause
• Electrocution of bystanders of death in resuscitated
or rescuer patients
Nursing Responsibilities

Team leader
Airway nurse
Compression
Nurse
Cardiopulmonary
 General Principles for Resuscitation in
Patients with Suspected and Confirmed
COVID-19

1. Reduce provider exposure to covid-19

2. Prioritize oxygenation and ventilation
strategies with lower aerosolization
risk
3. Consider the appropriateness of
starting and continuing resuscitation
Adjustments to CPR algorithms in patients with suspected
or confirmed COVID-19
NURSING THEORY APPLICATION
 APPLICATION
Assessment Nursing Diagnosis Intervention

Universal self requisite: ― Ineffective breathing pattern r/t Wholly compensatory

a) Maintenance of sufficient air cardiovascular and respiratory • Compression
• Patient not breathing or assault • Airway
gasping ― Risk for injury(neurological) r/t • Breathing
• Monitor airway and breathing poor perfusion to the brain
b) Prevention of hazard tissues
• Monitor saturation, breathing,
airway, LOC
• Assess contributing factors

Health deviation requisite: ― Decreased cardiac output r/t Wholly compensatory

• Assess pulse inability of heart pump blood • Compression
• Check for bleeding adequately • Airway
• Monitor fluid status • Breathing
• Fluid replacement

Therapeutic self care demand & ― Self care deficit r/t cardiac Wholly compensatory
Self care deficit arrest • Provide all self care needs
• Patient unconscious and unable ― Anxiety (of relatives) r/t • Provide nutritional needs
to perform any form of self care potential loss of loved one • Provide hygienic needs
Supportive-educative
• Spiritual, psychological support
JOURNAL ABSTRACT
“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
Preprint :June 16, 2020
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
 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, 2nd edition, Lippincott Williams Wilkins
• 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_amon
g_different_class_groups%27
• https://
www.researchgate.net/publication/342219155_Study_of_pre-hospital_care_of_O
ut_of_Hospital_Cardiac_Arrest_victims_and_their_outcome_in_a_tertiary_care_h
ospital_in_India_Pre-hospital_Cardiac_Arrest_REsuscitation_Pre-CARE_study