CARDIO-PULMONARY RESUSCITATION

Introduction: CPR is the basic life saving skill that is utilized in the event of cardiac, respiratory
or cardiopulmonary arrest to maintain tissue oxygenation. Once the heart ceases to function, a
healthy human brain may survive without oxygen for up to 4 minutes without suffering any
permanent damage. Unfortunately , a typical emergency medical system {EMS} response may
take 6, 8 or even 10 minutes. It is during those critical minutes that CPR can provide oxygenated
blood to the victim’s brain and the heart, dramatically increasing his chance of survival. And if
properly instructed, almost anyone can learn and perform CPR.

Definition: CPR is a sequence of actions taken during first few minutes of an emergency that
require prompt action for resuscitation of an unresponsive victim.

OR

Cardiopulmonary resuscitation (CPR) is an emergency procedure, performed in an effort to

manually preserve intact brain function until further measures are taken to restore spontaneous
blood circulation and breathing in a person in cardiac arrest It is indicated in those who are
unresponsive with no breathing or abnormal breathing.

The goal is to restore adequate coronary and cerebral blood flow

CPR not a single skill
Series of assessments and interventions
The steps of CPR vary depending on etiology of cardiac arrest.

Aspects of CPR:

Rescue breaths for respiratory arrest victims

Chest compressions and rescue breaths for cardiac arrest victims

Early defibrillation using AED.

Causes of Cardiac arrest

 Cardiac
 Extracardiac

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Causes of circulation arrest

A. Cardiac

• Ischemic heart disease (myocardial infarction)

• Arrhythmias of different origin and character

• Electrolytic disorders

• Valvular disease

• Cardiac tamponade

• Pulmonary artery thromboembolism

• Ruptured aneurysm of aorta

B. Extracardiac

• airway obstruction

• acute respiratory failure

• shock

• reflector cardiac arrest

• embolisms of different origin

• drug overdose

• electrocution

• poisoning

CPR Time Line

0 – 4 minutes: Brain damage unlikely.

4 -6 minutes. Brain damage possible.
6 -10 minutes. Brain damage probable.

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 Over 10 minutes. Probable brain death.

INDICATIONS FOR CPR

 Respiratory arrest
Respiration is absent
Respiration is inadequate to maintain effective oxygenation or ventilation
 Cardiac arrest
Circulation ceases and vital organs deprived of oxygen
May have gasping

Contraindications

 Do not resuscitate when a decision not to resuscitate has been noted in the chart.
This order is often abbreviated to DNR (do not resuscitate), is sometimes referred
to as no code, and is now discussed with the client on admission and is referred to
as advanced directive.

How CPR Works-

 The air we breathe in travels to our lungs where oxygen is picked up by our blood
and then pumped by the heart to our tissue and organs.
 When a person experiences cardiac arrest – whether due to heart failure in adults
and elderly or an injury such as near drowning, or severe trauma in a child – the
heart goes from a normal beat to an arrhythmic pattern called ventricular
fibrillation, and eventually ceases to beat altogether.
 This prevents oxygen from circulating throughout the body, rapidly killing cells
and tissue. In essence, Cardio (heart) Pulmonary (lung) Resuscitation (revive,
revitalize) serves as an artificial heartbeat and an artificial respirator.
 CPR may not save the victim even when performed properly, but if started within
4 minutes of cardiac arrest and defibrillation is provided within 10 minutes, a
person has a 40% chance of survival.

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SEQUENCES OF CPR

 Rapid scene survey

 Assess responsiveness
 Activate Emergency
 Perform:
C-Circulation or Chest compression
A-Airway
B-Breathing
D-Defibrillation bys AED’s.

ASSESS RESPONSIVENESS

Safety for the rescuer at the scene of emergency

Safety of the victim: look for trauma/head or neck injuries
Tap or gently shake the victim and shout.
‘’ARE YOU ALL RIGHT?’’

C-CIRCULATION

 Check for signs of circulation after 2 recue breaths(within 10 seconds)

 Lay persons :pulse check not reliable, so look, listen and feel, with ears near victims
mouth:
-breathing
-coughing
-movements in response to rescue breaths
 Health care providers
-Pulse check: palpate carotids/femoral artery.

A-AIRWAY

 Assess by making victim flat on a ground

 Position of the victim
-lay on a firm flat surface

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 -if lying down, roll the patient as a unit without twisting.
 Position of the rescuer
-Side of the victim to perform both rescue breathing and chest compressions.

OPENING THE AIRWAY

Tongue is the most common cause of airway obstruction in unresponsive patient

Head Tilt-Chin Lift maneuver lifts the tongue and relieves obstruction
Jaw Thrust maneuver in cases of suspected neck injuries
Quickly remove food particles, or loose dentures, if any.

B-BREATHING

 Assess :within 10 seconds

-Look for chest to rise and fall
-Listen for air escaping during exhalation
-Feel for the flow of air.
 Recovery position ,if breathing
 Provide 2 rescue breaths if respirations inadequate or absent.

RECOVERY POSITION

 For Victims who are unresponsive but breathing with signs of circulation
 Modified Lateral Position is used in which:
-Head is dependent for fluid drainage
-Avoids any pressure on chest
-Minimizes any damage to spine
-Good observation and ready access to the airway can be obtained
 Turn to other side after 30 minutes.

RESCUE BREATHING

The rescuer inflates the victim’s lungs adequately with each breath. Various techniques are used:

 Mouth to mouth

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  Mouth to nose
 Mouth to stoma
 Mouth to barrier device
 Bag and mask.

RESCUE BREATHING DURING CPR

 Give 2 slow breaths with small volumes

-Breaths should be given over 1second
-Just enough to make chest rise
-Prevents stomach distension.
 Advanced airway only after 5 cycles of CPR
 Intubation to be done by experienced personnel only
6-12 intubations for CPR /year.
 If inexperienced :do not attempt
 Can use other newer airway devices
-Laryngeal mask airway or Esophageal-Tracheal Combitube.

MOUTH TO MOUTH BREATHING

 Adult rescue breaths provide tidal volume of 800-1200ml,delivered over 1 seconds

If difficult to ventilate:
-Reposition the head and chin or,
-Repeat the maneuver and ventilate again
-Try to remove foreign body with a finger sweep.

BAG-MASK DEVICES

 Self-inflating bags
 Can be used by single or two rescuers
 Lower tidal volumes are recommended
 Squeeze the bag slowly over 2 seconds until chest rises.

BAG –MASK: TECHNIQUE ‘’EC’’

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  Apply mask with one hand using bridge of nose as guide for correct position
 Place 3rd ,4th and 5th fingers along bony portion of mandible :”E’’
 Thumb and index fingers on the mask: “C’’
 Maintain head tilt-chin lift position
 Deliver each breath over 2 seconds
 More effective with 2 rescuers
 Give cricoids pressure(Sellick’s),if 3rdRescuer+

CHEST COMPRESSIONS

 No signs of circulation :start chest compressions

 Serial rhythmic application of pressure over lower half of sternum
 Mechanism: increase of intrathoracic pressure and direct compression of the heart
 Recommended rate:100 /min
 Compression: ventilation
-30:2 when one rescuer
-30:2 when 2 rescuers
-15:2 when 2 rescuers (infants and children)

EFFECTIVE CHEST COMPRESSIONS

 Push hard and push fast

 Allow the chest to recoil completely after each compression
 Try to limit interruptions in chest compressions

COMPRESSIONS

 Press down on sternum to depress between 4-5 cms@100/min

 Release the pressure without losing contact
 Compression and release should take an equal amount of time
 Chest should be allowed to recoil to its normal position after each compression
 Do not change hand positions

RESUSCITATION: THE NEW MANTRA

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Early Defibrillation

-D is included with CAB in CPR

-Defibrillation should be widely available
-Paramedics and others should be trained in defibrillation
-Simpler defibrillating devices are needed
-AEDs (Automated External Defibrillators)

AUTOMATED DEFIBRILLATION

 Ease of use by untrained rescuers

 Automated detection of defibrillatable rhythms
 Advises shock and delivers it
 Portable and cheap.

ATTEMPTED DEFIBRILLATION

 Current Recommended:-

-One shock Biphasic 150-200j

-Monophasic 360j

 For Immediate CPR

-Rhythm checks only after 5 cycles (2 mins) of CPR.

CPR in Adults

American Heart Association’s guidelines dictate that Adult CPR is performed on any person
over the age of 8.

Purpose

 Restore cardiopulmonary functioning.

 Prevent irreversible brain damage from anoxia.

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Assessment

 Determine that the client is unconscious. Shake the client and shout at him or her to
confirm if unconscious rather than being asleep, intoxicated or hearing impaired.
 Assess for presence of respirations.
 Assess carotid artery for pulse.

Equipments

 A hard flat surface .

 No additional equipment is necessary but in hospital setting emergency(crash)cart with
defibrillator and cardiac monitoring should be brought to the bedside. A crash cart
usually contains:
 Airway equipment.
 Suction equipment.
 Intravenous equipment.
 Laboratory tubes and syringes.
 Pre packed medications for advanced life support.

Procedure

REMEMBER C-A-B

An American heart association uses acronym of CAB as circulation, airway, and breathing.

CIRCULATION

 Restore blood circulation with chest compressions.

 Put the patient on his back on a firm surface.
 Kneel next to persons neck and shoulders. Position the hands for compressions: when
performing chest compressions, proper hand placement is very important.
 Using the hand nearest to the legs place middle and index finger on the lower ridge or
near ribs and move fingers up along ribs to the costalsternal notch (in the centre of of
lower chest).
Careful attention to hand placement during heart compression prevents fractured ribs and
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 organ trauma. Place the the middle finger on this notch and the index finger next to the
middle finger on the lower end of the notch.
 Place the heel of other hand along the lower half of the sternum, next to the index finger.
 Remove first hand from the notch and place heel of that hand on the chest and interlock
the fingers, keeping them off client s chest.
 The heel of the hand must completely release pressure between compressions, but it
should remain in constant contact with the client s skin to allow the heart to fill with
blood.
 Use the mnemonic one and two and three and to keep rhythm and timing.
 Finish the cycle by giving the client 2 breaths. This process should be performed four
times -30 compressions and 2 breaths –after which remember to check the clients carotid
pulse and any signs of consciousness. Continue performing 3 compressions/2breaths,
checking for pulse after every 4 cycles until help arrives.

AIRWAY-CLEAR THE AIRWAY

 After performing the 30 compressions .open the airway of the patient by using
 Head tilt/chin lift
 Jaw thrust
 The most commonly used method is head tilt/chin lift. With the client lying flat on his
back, place your hand on his forehead and other hand under the chin .gently tilt client s
head backward.
 Use modified jaw thrust if a neck injury is suspected .place hands at the angles of the
lower jaw and lift, displacing the mandible forward while tilting the head backward. It
prevents extension of the neck and decreases the potential for further injury.
 Check for normal breathing, taking no more than 5 to 10 seconds. Look for chest motion,
listen for normal breath sounds, and feel the persons breath on your cheek and ear.
 Gasping is not considered as normal breathing.

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BREATHING

 With the airway open(using head tilt and chin lift maneuver) pinch the nostrils shut for
mouth to mouth breathing and cover the person s mouth with yours, making a seal.
 Prepare to give two rescue breaths. Give first rescue breath –lasting for one second.-and
watch to see if the chest rise, if it does rise give second breath. If it does not rises repeat
head tilt chin lift maneuver and then give the second breath. Thirty chest compressions
and two breaths is considered as one cycle.
 If the person has not begun moving after five cycles(about two minutes)and an automatic
external defibrillator(AED)is available, apply it and follow the prompts apply one shock
and, and then resume CPR-starting with chest compressions.-for two more minutes
before administering second shock
 Continue CPR until signs of movement, or medical personals take over.

TWO RESCUERS-ADULT AND ADOLESCENT

 When the second rescuer arrives, the first rescuer stops CPR after completing two
ventilations and assesses for carotid pulse for 5 seconds.
 The second rescuer moves into the chest compression position. The second rescuer
begins chest compression while counting out loud .
 The compression rate is 100/minute.
 The first rescuer gives two slow ventilations after 30 cardiac compressions .
 The first rescuer also assess carotid pulse during chest compressions to evaluate
effectiveness.
 If the second rescuer wishes to change the position, he or she states change, one and two
and three and four and five and……
 The first rescuer delivers the ventilation then moves into the chest compression position.
The second rescuer moves to the ventilator position and assesses for carotid pulse for 5
seconds. If pulse less resume CPR.

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CHILD CPR

 Cardiac arrest in pediatric population is less often of cardiac origin than from prolonged
hypoxemia secondary to inadequate oxygenation, ventilation, and circulation. Some
causes include injuries, suffocation (foreign body aspiration), smoke inhalation. If the
child is unresponsive and you are alone with him, start rescue efforts immediately and
perform CPR for at least 1 to 2 minutes .before you call an ambulance, immediately
check the victim for responsiveness by gently shaking the child and shouting, are you
okay?

CIRCULATION

C IS FOR CIRCULATION .check the child’s carotid artery for pulse by placing two fingertips
and applying slight pressure on his carotid artery for 5 to 10 seconds .

If you don’t feel pulse then the victim’s heart is not beating, and you will have to perform chest
compression.

Compressions

When performing chest compressions on a child proper hand placement is even more crucialthan
with adults. Place two fingers at the sternum and put the heel of your other hand directly on top
of your fingers .gently compress the chest about 1 inch.

Count aloud as you pump in fairly rapid rhythm. You should count 100 compressions per
minute.

AIRWAY : CLEAR THE AIRWAY

1. After 30 compresssions gently tilt the head back by lifting with one hand and pushing down
the forehead with other hand.

2. In no more than 10 seconds, put your ear near the baby s mouth and check for breathing. Look
for chest motion, listen for breath sounds and feel for breath on your cheek and ear.

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 Airway: “A” is for AIRWAY. A child’s breaths may be extremely faint and shallow
Look, Listen and feel for any signs of breathing. If there is none, the tongue may be
obstructing the airway and preventing the child from breathing on his own. Exercise extra
caution when you open the victim’s air passage using the head tilt/chin lift technique.
This will shift the tongue away from the airway. If the child is still not breathing after his
airway has been cleared, you will have to assist him in breathing.
 Breathing: “B” is for BREATHING. If the child remains unresponsive and still not
breathing on his own, pinch his nose with your fingertips or cover his mouth and nose
with your month creating a tight seal, and give two breaths.
 Keeping in mind that children’s lungs have much smaller capacity than
that of adults when ventilating a child be sure to use shallower breaths and
keep an eye on the victim’s chest to prevent stomach distension.
 In this happens and the child vomits, turn his head sideways and sweep out
all the obstructions and proceed. After you have administered two breaths
and he remains unresponsive then start checking circulation.

New Born CPR

The following are the major neonatal resuscitation changes in the 2005 guidelines:
 Supplementary oxygen is recommended whenever positive-pressure ventilation is
indicated for resuscitation; free-flow oxygen should be administered to infants who are
breathing but have central cyanosis. Although the standard approach to resuscitation is to
use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of
less than 100% or to start with no supplementary oxygen (ie, start with room air). If the
clinician begins resuscitation with room air, it is recommended that supplementary
oxygen be available to use if there is no appreciable improvement within 90 seconds after
birth. In situations where supplementary oxygen is not readily available, positive-pressure
ventilation should be administered with room air.
 Current recommendations no longer advise routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants born to mothers with meconium staining of
amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be
performed immediately after birth.

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 A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device
designed to regulate pressure and limit flow) can be used to ventilate a newborn.
 An increase in heart rate is the primary sign of improved ventilation during resuscitation.
Exhaled CO2 detection is the recommended primary technique to confirm correct
endotracheal tube placement when a prompt increase in heart rate does not occur after
intubation.
 The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose.
Higher IV doses are not recommended, and IV administration is the preferred route.
Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg)
through the endotracheal tube may be considered.
 It is possible to identify conditions associated with high mortality and poor outcome in
which withholding resuscitative efforts may be considered reasonable, particularly when
there has been the opportunity for parental agreement. The following guidelines must be
interpreted according to current regional outcomes:
 When gestation, birth weight, or congenital anomalies are associated with almost certain
early death and when unacceptably high morbidity is likely among the rare survivors,
resuscitation is not indicated. Examples are provided in the guidelines.
 In conditions associated with a high rate of survival and acceptable morbidity,
resuscitation is nearly always indicated.
 In conditions associated with uncertain prognosis in which survival is borderline, the
morbidity rate is relatively high, and the anticipated burden to the child is high, parental
desires concerning initiation of resuscitation should be supported.
 Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of
resuscitation show either a high mortality rate or severe neuro developmental disability.
After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of
resuscitation may be justified if there are no signs of life
Proper Hand Placement
Infant CPR
 According to generally accepted guidelines, Infant CPR is administered to any victim
under the age of 12 months. Infants, just as children, have a much better chance of

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 survival if CPR is performed immediately. If you are alone with the infant, do not dial 9-
1-1 unit after you have made an attempt to reususcitate.
 Check the infant for responsive by patting his feet and gently tapping his chest or
shoulders. If he does not react ( stirring, crying, etc.) immediately check his circulation.
 Cirulation: “C” is for CIRCULATION. An infant’s pulse is checked at the brachial
artery, which is located inside of the upper arm, between the elbow and the shoulder.
Place two fingers on the brachial artery slight pressure for 3 to 5 seconds. If you do not
feel a pulse within that time, then the infant’s heart is not beating, and will need to
perform chest compressions.
 Compressions: An infant’s delicate ribcage I especially susceptible to damage if chest
compressions are improperly performed: therefore it is important to use caution when
rescuing an infant. Place three finger in the centre of the infant’s chest with the top finger
on an imaginary line between the infant’s nipples. Raise the top finger up and compress
with the bottom two fingers. The compression should be approximately to ½ the depth of
infant’s chest.
 Airway: “A” is for AIRWAY. It is normal for an infant to take shallow and rapid
breaths, so carefully look, listen and feel for breathing. If you cannot detect any signs of
breathing, the tongue may be obstructing the infant’s airway. Although the head tilt/chin
lift technique is similar to adults and children, when clearing an infant’s airway it’s
important not to tilt the head too far back. An infant’s airway is extremely narrow and
overextending the neck may actually close off the air passage. Tilt the head back into
what is called the “sniffer’s position” – far enough to make the infant look as if he is
sniffing.
 Breathing: “B” is for BREATHING. Cover the infant’s mouth and nose with your
mouth creating a seal, and give a quick, gentle puff from your cheeks. Let the victim
exhale on his own – watch his chest and listen and feel for breathing. If he does not
breathe on his own, again place your mouth over his mouth and nose and give another
small puff If the infant remains unresponsive(no crying or moving).

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Why CPR may fail;

 Delay in starting
 Improper procedures (ex. Forget to pinch nose)
 No ACLS follow-up and delay in defibrillation
 Only 15% who receive CPR live to go home
 Improper techniques
 Terminal disease or unmanageable disease (massive heart attack)

Injuries related to CPR

o Fractures of ribs & Xiphoid process

o Laceration related to the tip of the sternum, Liver, lung, spleen

Complications of CPR

 Vomiting
 Aspiration
 Place victim on left side
 Wipe vomit from mouth with fingers wrapped in a cloth
 Reposition and resume CPR
 Pneumothorax
 Intra abdominal haemorrhage

Summary
A universal compression - ventilation ratio of 30:2 performed by lone rescuers for
victims of all ages was one of the most controversial topics discussed during the 2005
International Consensus Conference, and it was a major change in the 2005 AHA
Guidelines for CPR and ECC. In 2005 rates of survival to hospital discharge from
witnessed out-of-hospital sudden cardiac arrest due to ventricular fibrillation (VF) were
low, averaging ≤6% worldwide with little improvement in the years immediately
preceding the 2005 conference.

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 References
 American Heart Association. 2005American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. International
Consensus on Science. Circulation. 2005.

 Inamdar Madhuri. Nursing Arts: Principles and Practice.1st Edition. Vora Publishers;(2006). Part
II. 36-39
 Hazinski MF, Editor. Currents in Emergency Cardiovascular Care. Citizen CPR
Foundation, Inc. and American Heart Association; Vol 16, Number 4, Winter 2005-
2006.
 Field JM, Hazinski MF, Gilmore D. 2005 Handbook of Emergency Cardiovascular Care
for Health Care Providers. American Heart Association; 2006.
 Shabeer .P.Basheer “a concise textbook of advanced nursing practice” emmess
publishers.
 Wilson hockenbery” nursing care of infants and children”7th edition,pp-1337-1339

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