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. Defibrillation: It is a process in which an electronic
device sends an electric shock to the heart to stop an
extremely rapid, irregular heartbeat and restore
normal heart rhythm.

9. Ventilation: The exchange of air between the lungs

and the atmosphere so that oxygen can be exchanged
in the alveoli
 Abbreviations & Terminologies
10. Ventricular fibrillation: Abnormal and irregular
heart rhythm in which there are rapid
uncoordinated fluttering contractions of the
ventricles.
11. 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
 The Mechanical Action
of the Heart
The heart muscle receives an impulse from
the electrical system

The muscle contacts in a synchronised and

coordinated motion causing the blood in the
four chambers to be pumped around the body
and to the lungs

After each contraction the heart muscle

relaxes which allows the chambers to refill
with blood ready for the next contraction

This contraction of the heart muscle can be felt

as a pulse
 The Electrical Action
of the Heart
Most muscles in the body require an
electrical
stimulus from a nerve to make then work

The heart is a specialised form of muscle

tissue
that can generate its own electrical impulse
without stimulation from a nerve

These impulses travel a well defined pathway

through the heart muscle called the
conduction pathway

The heart muscle responds to the electrical

impulses with a mechanical action called a
contraction
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.
 Apply the AED pads to the person.
Make sure to peel the backing off each
pad one at a time.
 Plug the connector into the AED
 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
 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 vasopressor 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

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
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.
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