CARDIO-PULMONARY CARDIO-PULMONARY RESUSCITATIONRESUSCITATION

MR.SURENDRA SHARMAMR.SURENDRA SHARMA

ASSIST. PROFESSORASSIST. PROFESSOR

SWIFT INSTITUTE OF NURSINGSWIFT INSTITUTE OF NURSING

DefinitionDefinition

CPR stands for cardiopulmonary CPR stands for cardiopulmonary resuscitation. Cardio refers to the heart. resuscitation. Cardio refers to the heart. Pulmonary refers to the lungs. CPR is a Pulmonary refers to the lungs. CPR is a way to give oxygen and keep the heart way to give oxygen and keep the heart pumping when it has stopped beating. It is pumping when it has stopped beating. It is an emergency procedure that can save an emergency procedure that can save the life of an infant or child whose heart the life of an infant or child whose heart has stopped beating and who is not has stopped beating and who is not breathing. breathing.

Cardiopulmonary resuscitation (CPR) is Cardiopulmonary resuscitation (CPR) is the term used to describe the procedure in the term used to describe the procedure in which oxygen is manually delivered and which oxygen is manually delivered and heartbeat is manually restored in heartbeat is manually restored in individuals who have stopped breathing individuals who have stopped breathing and and/or have no heartbeat.and and/or have no heartbeat.

Reasons for ProcedureReasons for Procedure

CPR is administered when a child has stopped CPR is administered when a child has stopped breathing and has no discernible heartbeat. breathing and has no discernible heartbeat. Reasons for this include:Reasons for this include:

Serious head or back injury Serious head or back injury Choking Choking Drowning Drowning Multiple electrical shocks Multiple electrical shocks Severe infection Severe infection Severe allergic reactionSevere allergic reaction

CPR is a basic emergency procedure of CPR is a basic emergency procedure of artificial respiration and manual external artificial respiration and manual external cardiac massage.cardiac massage.

The ‘ABCs’ of cardiopulmonary The ‘ABCs’ of cardiopulmonary resuscitation are to establish an airway, resuscitation are to establish an airway, initiate, breathing and maintain circulation. initiate, breathing and maintain circulation. A defirillatory shock within 5 min of A defirillatory shock within 5 min of collapse outside the hospital and within 3 collapse outside the hospital and within 3 min in the hospital.min in the hospital.

PROCEDUREPROCEDUREFor effective CPR, the victim is placed on his or For effective CPR, the victim is placed on his or her back on a firm, flat surface, employing her back on a firm, flat surface, employing appropriate precautions.appropriate precautions.Because pediatric arrest is most commonly the Because pediatric arrest is most commonly the result of a respiratory arrest, maintaining result of a respiratory arrest, maintaining ventilation is a primary consideration.ventilation is a primary consideration.With loss of consciousness, the tongue which is With loss of consciousness, the tongue which is attached to the lower saw, relaxes and falls attached to the lower saw, relaxes and falls back, obstructing the air way.back, obstructing the air way. To open the airway, the head is positioned with To open the airway, the head is positioned with either the head tilt/chin lift or jaw thrust.either the head tilt/chin lift or jaw thrust.

Head tilt is accomplished by placing one Head tilt is accomplished by placing one hand on the victim’s forehead and hand on the victim’s forehead and applying firm, backward pressure with the applying firm, backward pressure with the palm to tilt the head back. The fingers of palm to tilt the head back. The fingers of the free hand are placed under the bony the free hand are placed under the bony portion of the lower jaw near the chin to lift portion of the lower jaw near the chin to lift and bring the chin forward (chin left). This and bring the chin forward (chin left). This supports the jaw and helps tilt the head supports the jaw and helps tilt the head back.back.

The jaw thrust is accomplished by grasping the The jaw thrust is accomplished by grasping the angle of the victim’s lower jaw and lifting with angle of the victim’s lower jaw and lifting with both hands, one on each side, displacing the both hands, one on each side, displacing the mandible upward and outward.mandible upward and outward.

In suspected neck injuries the jaw thrust In suspected neck injuries the jaw thrust method should be used while the cervical spine method should be used while the cervical spine is completed immobilized.is completed immobilized.

After restoration of a patient airway by removal After restoration of a patient airway by removal of foreign material and secretions (in indicated) of foreign material and secretions (in indicated) and if the child is not breathing continuing of the and if the child is not breathing continuing of the airway is maintained and rescue breathing is airway is maintained and rescue breathing is initiate.initiate.

To ventilate the lungs in the infant (birth to 1 To ventilate the lungs in the infant (birth to 1 year of age), the bag valve mask or operator’s year of age), the bag valve mask or operator’s mouth is placed that both the mouth and the mouth is placed that both the mouth and the nostrils are covered.nostrils are covered.

Children (older than 1 year of age) are Children (older than 1 year of age) are ventilated through the mouth while the ventilated through the mouth while the nostrils are firmly pinched for airtight nostrils are firmly pinched for airtight contact.contact.

If air enters freely and the chest rises, the If air enters freely and the chest rises, the airway is assumed to be clear.airway is assumed to be clear.

The correct volume for each breath must The correct volume for each breath must be provided without causing abdominal be provided without causing abdominal distention.distention.

After the initial to breaths, the pulse is After the initial to breaths, the pulse is palpated to determine the presence of a palpated to determine the presence of a heart beat.heart beat.

The carotid is the most central and The carotid is the most central and accessible artery in children older than 1 accessible artery in children older than 1 year of age.year of age.

In infant, it is preferable to use the In infant, it is preferable to use the bacterial pulse, located on the inner side bacterial pulse, located on the inner side of the upper arm midway between the of the upper arm midway between the elbow and shoulder.elbow and shoulder.

Absence of a carotid or brachial pulse is Absence of a carotid or brachial pulse is considered sufficient indication to begin considered sufficient indication to begin external cardiac massage.external cardiac massage.

Chest CompressionChest Compression

External chest comparison consists of External chest comparison consists of serial, rhythmic compressions of the chest serial, rhythmic compressions of the chest to maintain circulation to vital organs until to maintain circulation to vital organs until the child achieves spontaneous vital signs.the child achieves spontaneous vital signs.

For optimal compressions, it is essential that For optimal compressions, it is essential that child’s spine is supported on a firm surface child’s spine is supported on a firm surface during compressions of the sternum and that during compressions of the sternum and that sternal pressure is forceful but not traumatic.sternal pressure is forceful but not traumatic.

For an infant the hard surface can be rescuer’s For an infant the hard surface can be rescuer’s hand or forearm, with the palm supporting the hand or forearm, with the palm supporting the infants back.infants back.

The child’s head is positioned for optimal The child’s head is positioned for optimal airway opening using the head tilt/chin lift airway opening using the head tilt/chin lift maneuver. It is essential to prevent maneuver. It is essential to prevent overextension of the head of small infants, overextension of the head of small infants, because this tends to close the flexible trachea.because this tends to close the flexible trachea.

The placement of the fingers for The placement of the fingers for compression sternum one finger breadth compression sternum one finger breadth below the intersection of the sternum and below the intersection of the sternum and an imaginary line drawn between the an imaginary line drawn between the nipples.nipples.

Compressions on the child 1 to 8 years of age Compressions on the child 1 to 8 years of age are applied to the lower half of the sternum.are applied to the lower half of the sternum.

Sternum compression to infants applied with Sternum compression to infants applied with two or three fingers on the sternum exerting a two or three fingers on the sternum exerting a firm downward thrust, for children, pressure is firm downward thrust, for children, pressure is applied with the heel one hand.applied with the heel one hand.

When two health care provides are present two When two health care provides are present two thumb technique can be applied.thumb technique can be applied.

In the two thumb technique, one of the two In the two thumb technique, one of the two rescuers places both thumbs side by side over rescuers places both thumbs side by side over the lower half of the infants sternum, the the lower half of the infants sternum, the remaining fingers encircle the infants chest and remaining fingers encircle the infants chest and support back.support back.

The depth of compression is adapted to the The depth of compression is adapted to the child’s size. The location, rate and depth for child’s size. The location, rate and depth for children older than 8 years of age are the same children older than 8 years of age are the same as for adults.as for adults.

CPR is continues at the appropriate ration of CPR is continues at the appropriate ration of breaths to compressions for age until signs of breaths to compressions for age until signs of recovery appear.recovery appear.

These signs include palpable peripheral These signs include palpable peripheral pulses, return of pupils to normal size, pulses, return of pupils to normal size, disappearance of cyanosis and possible disappearance of cyanosis and possible return of spontaneous respiration. return of spontaneous respiration.

RisksRisks

CPR can cause injury to the person's ribs, CPR can cause injury to the person's ribs, liver, lungs, and heart. But these risks liver, lungs, and heart. But these risks must be accepted if CPR is necessary to must be accepted if CPR is necessary to save the person's life.save the person's life.

'Heimlich-Manoeuvre''Heimlich-Manoeuvre'

Choking is the mechanical obstruction of Choking is the mechanical obstruction of the flow of air from the environment into the flow of air from the environment into the lungs. Choking prevents breathing, the lungs. Choking prevents breathing, and can be partial or complete, with partial and can be partial or complete, with partial choking allowing some, although choking allowing some, although inadequate, flow of air into the lungs. inadequate, flow of air into the lungs. Prolonged or complete choking results in Prolonged or complete choking results in asphyxiation which leads to hypoxia and is asphyxiation which leads to hypoxia and is potentially fatal.potentially fatal.

IndicationsIndications

The person cannot speak or cry out. The person cannot speak or cry out.

The person's face turns blue from lack of The person's face turns blue from lack of oxygen. oxygen.

The person desperately grabs at his or her The person desperately grabs at his or her throat. throat.

The person has a weak cough, and labored The person has a weak cough, and labored breathing produces a high-pitched noise. breathing produces a high-pitched noise.

The person does any or all of the above, The person does any or all of the above, then becomes unconscious. then becomes unconscious.

TreatmentTreatment

Step OneStep One

Ask the choking person to stand if he or Ask the choking person to stand if he or she is sitting. she is sitting.

Step TwoStep Two

Place yourself slightly behind the standing Place yourself slightly behind the standing victim. victim.

Step ThreeStep Three

Reassure the victim that you know the Reassure the victim that you know the Heimlich maneuver and are going to help. Heimlich maneuver and are going to help.

Step FourStep Four

Place your arms around the victim's waist.Place your arms around the victim's waist.

Step FiveStep Five

Make a fist with one hand and place your Make a fist with one hand and place your thumb toward the victim, just above his or thumb toward the victim, just above his or her belly button. her belly button.

Step SixStep Six

Grab your fist with your other hand. Grab your fist with your other hand.

Step SevenStep Seven

Deliver five upward squeeze-thrusts into Deliver five upward squeeze-thrusts into the abdomen. the abdomen.

Step EightStep Eight

Make each squeeze-thrust strong enough Make each squeeze-thrust strong enough to dislodge a foreign body. to dislodge a foreign body.

Step NineStep Nine

Understand that your thrusts make the Understand that your thrusts make the diaphragm move air out of the victim's diaphragm move air out of the victim's lungs, creating a kind of artificial cough. lungs, creating a kind of artificial cough.

Step TenStep Ten

Keep a firm grip on the victim, since he or Keep a firm grip on the victim, since he or she can lose consciousness and fall to the she can lose consciousness and fall to the ground if the Heimlich maneuver is not ground if the Heimlich maneuver is not effective. effective.

Step Eleven Step Eleven

Repeat the Heimlich maneuver until the Repeat the Heimlich maneuver until the foreign body is expelled. foreign body is expelled.

Tips & WarningsTips & Warnings

If a victim is coughing strongly or able to If a victim is coughing strongly or able to talk, let the person try to expel the foreign talk, let the person try to expel the foreign body using his or her own efforts. body using his or her own efforts.

If the choking victim displays a weak or If the choking victim displays a weak or ineffective cough, this indicates that air ineffective cough, this indicates that air exchange is minimal and that you should exchange is minimal and that you should start the Heimlich maneuver. start the Heimlich maneuver.

Teach your family the universal choking sign--Teach your family the universal choking sign--clutching the throat. Encourage everyone you clutching the throat. Encourage everyone you know to become familiar with this sign and use it know to become familiar with this sign and use it when choking. when choking.

To avoid breaking bones, never place your To avoid breaking bones, never place your hands on the victim's breastbone or lower rib hands on the victim's breastbone or lower rib cage when performing the Heimlich maneuver. cage when performing the Heimlich maneuver.

If choking persists, call 911 immediately. This If choking persists, call 911 immediately. This information is not intended to be a substitute for information is not intended to be a substitute for professional medical advice or treatment. professional medical advice or treatment.

Objectives

Actions

Over 8 years Child 1 to 8 years Under one year

A. Airway Assessment :Determine unresponsiveness

Tap or gently shake shoulder. Say “Are you OK?”

Tap or gently shake shoulder.Say “Are you OK?”

Tap or gently shake shoulder.Speak loudly.

Get help Active EMS Shout for help, if second rescurer available, have person active EMS

Position the victim

Turn on back as a unit, supporting head and neck if necessary

Open the airway

Head tilt/Chin lift

B. Breathing

Assessment :Determine breathlessness

Maintain open airway, place ear over mouth, observe chest, look, listen, feel for normal breathing (not more than 10 sec)

Give 2 rescue breaths

Maintain open airway

Pinch nose, seal mouth to mouth Mouth to nose and mouth

Give 2 slow effective breaths, observe chest rise. Allow lung deflation between breaths

2 sec each 1 to 1 ½ sec each

Option for obstructed airway

A. Reposition victims head. Try again to give rescue breaths

B. Active EMS

C. Give 5 subdiaphramatic abdominal thrusts (the Helmlich maneuver)

C. Give 5 back blowsC. Give 5 chest thrusts

D. Tongue-jaw life and finger sweep

D. Tongue – jaw life, but finger sweep only if you see a foreign object.

If fail, repeat A, C and D until successful.

C. Circulation

Assessment :Determine pulselessness

Feel for cadiotid pulse with one hand, maintain head tilt with one hand (no more than 10 sec)

Feel the brachid pulse, keep head tilt.

CPR Pulse absent : Being chest compression, land mark check

Use 2 – 3 finder to locate lower margin of ribcage. Follow rib margin to base sternum (Xiphoid process)

Imagine the line between the nipples

Hand position Place the one hand over finger of first hand on half of sternum

Place 2 finger on sternum 1 fingers width below line. Depress ½ to 1 inch.Place other hand

on top of hand on sternum, depress 1 ½ - 2 inch

Use heel of one hand, depress 1 – 1 ½ inch

Compression rate 80 – 100 per min 100 per min Atleast 100 per min

Compressions to breaths

2 breaths to every 15 compressions

One breath to every 5 compressions

Number of cycles 4 20 (approximately 1 min)

Reassessment Feel for carotid pulse

Feel for brachial pulse

Pulse present :No breathing : begin rescue breathing

1 breath every 5 sec (12 per min)

One breath every 3 sec (20 per min)

Drug /dose Action Implication

Epinephrine HCLIv/io 0.01mg/kg

Adrenergic action on both alpha and beta receptor sites, especially heart and vascular and other smooth muscle

Most useful drug in cardiac arrest May produce renal vessel constriction and decreased urine formation

Sodium bicarbonate iv/io 1meq/kgNew born:0.5 meq/ml 2mg/kg

AlkalinizerBuffers ph

Infuse slowly and only when ventilation is adequate, flush with saline before and after administration .don’t mix with calcium

Atropine sulfate 0.02 mg/kg/doseMaximum dose .1 mg Maximum single dose infants and children ,0.5 mg adolescents 1mg

Ant cholinergic parasympatholytic Increases cardiac out put, heart rate by blocking vagal stimulation in heart.

Used to treat Brady cardiac after ventilatory assessment Always provide adequate

Calcium chloride 10% 20 mg/kg/iv Electrolyte replacement Needed for maintain of normal cardiac contractility

Used only for hypocalcemia ,calcium blocker over dose , hyper kalemia or hyper magnesemia Administer5 slowlyAdminister in central vein

Lidocaine HCL1 mg/kg/dose

AntidysrhythmicInhibits nerve impulse from sensory nerves.

Used for ventricular arrhythmics only.

Naloxone 0.1mg/kg/dose

Reverses respiratory arrest due to excessive opiate administration

Evaluate level of pain following administration because analgesic effects of opioids are reversed with large dose of naloxone.

Magnesium 25-50mg/kg.maximum: 2g.

Inhibits calcium channels and causes smooth muscle relaxation.

Given by rapid IV infusion for suspected hypermagnesaemia.Have calcium gluconate available as antidote.