4th class
Critical care nursing
lecturer: mohammed abdul-karee
1- Cardio-pulmonary resuscitation (CPR):CPR is the process of externally supporting the circulation and respiration of a person who
has suffered a cardiac. In addition, refers to CPR as an attempt to restore spontaneous
circulation by performing chest compressions with or without ventilation.
2- Background about Cardiopulmonary Resuscitation:
a- The inversion method of resuscitation has been described in texts that date from three
and a half millennia (3500 years) ago in Egypt. This method involves hanging the patient
by the feet, and then alternately applying chest pressure to produce expiration and releasing
pressure to produce expiration.
b- There are also references to resuscitatory practices in the Old Testament of the Bible.
The most notable of these references to resuscitation appears in the following words from
Kings II.
c- The technique for closed chest cardiac massage that was first described in (1878) by
Boehm, was successfully applied in a few cases of cardiac arrest over the following decade.
d- But modern CPR techniques as we know them only really began to develop during the
(1940s) Beck and colleagues performed the first successful application of internal
defibrillation during cardiac surgery in (1947). This technique was expanded by Zoll and
his colleagues in (1956) when they performed the first successful external human
defibrillation.
e- But it was not until the (1950s) that mouth to mouth ventilation was rediscovered and
became accepted universally as the method of choice.
f- Open chest massage became the standard practice for treating cardiac arrest until the
landmark paper by Kouwenhoven, Jude, & Knickerbocker in (1960) described closed chest
massage.
g- Ever since the advent of modern CPR, several countries in collaboration with
professional bodies or associations (European Resuscitation Council, American Red Cross,
American Heart Association, Australian Resuscitation Council, the Heart and Stroke
Foundation of Canada, the Resuscitation Council of Southern Africa and Resuscitation
Councils among many others) have come up with standardized guidelines and/or algorithms
for conducting CPR.
*Basic resuscitation involves maintaining an airway, breathing and circulation of a
patient who has had cardiac or pulmonary arrest, without the use of equipment. Basic
resuscitation has the following four components: initial assessment; airway
maintenance; expired air ventilation; and closed chest compression. Some of the
critical steps in CPR include:
•Removing danger to both rescuer and the patient (safety comes first)
•Noting the circumstances of the patient’s collapse and his/her prior clinical state through
rapid assessment without delaying treatment
4th class
Critical care nursing
lecturer: mohammed abdul-karee
•Delivery of adequate oxygen to the brain and the myocardium through chest compressions
and expired air ventilation.
•Applying definitive treatment early i.e. defibrillation and advanced life support.
•Providing post resuscitation care to maximize cerebral recovery and prevent recurrence of
the arrest if CPR is successful.
•Judging when to discontinue the resuscitation attempt in case of failure in respond
treatment.
3- The Chain of Survival:
Successful resuscitation depends on four links of “the chain of survival.” The links are
early access to the emergency services, early basic life support (BLS), early defibrillation
and early advanced life support. It has been demonstrated that manual chest compression
by a bystander on an arrested victim improved resuscitation outcome both in terms of
survival rate and maintaining a good neurological outcome, than the use of automated
chest compression device. The following two representations figure (1) of the "chain of
survival illustrate the sequence of actions that, when complete and well linked, optimize
the chance of survival from cardiac arrest.
(Figure 1) The Chain of Survival
4- The Role of Cardiopulmonary Resuscitation:
a- CPR is a critical component of BLS and is the established first-line response to cardiac
arrest in the interim before defibrillation and ALS are available.
b- CPR also has the potential to save lives in other life-threatening emergencies such as
strokes, respiratory arrests, trauma, and drowning and airway obstruction.
c- The fundamental aim of CPR is to produce a neurologically sound patient who is able
to breath without assistance and who has spontaneous cardiac output.
d- The role of CPR is to maintain cerebral and myocardial perfusion until a definitive
treatment can be given.
4th class
Critical care nursing
lecturer: mohammed abdul-karee
5- Components of CPR:
a- External Chest Compression Technique:
The aim here should be to exert sufficient pressure (pressure of 50 kg) to provide adequate
cardiac output with minimal damage to the tissues. The recommended rate of compression
is (80-100) per minute, the depth of compression for adults should be (4-5) cm and the
duration of the compression should be (50%) of the compression relaxation cycle. This is
important because blood flow is more dependent on compression duration than the rate. The
pressure applied should be firm, controlled and vertical in order to avoid fracturing the ribs
or damaging the underlying organs. Coronary circulation which is a critical determinant of
recovery during resuscitation is significantly enhanced when rapid compressions are done
with minimum interruptions. Interruption for chest compression should only be allowed in
the following instances during brief pulse checks, during defibrillation and when giving
ventilation in a situation where the rescuer is one. The compression ventilation ratio should
be maintained at (15:2) in an adult no matter the number of rescuers.
b- Ventilation Technique:
For gas exchange to occur at the alveoli level during resuscitation sufficient tidal volumes
(800-1000) ml of air which is equivalent to a deep breath is needed to ensure adequate
oxygen delivery and removal of carbon dioxide. The fraction of inspired oxygen that is
delivered by the rescuer to the casualty is (16%) and is sufficient to support life for a short
period of time and (100%) oxygen if available should be given. Removal of carbon dioxide
depends on the amount of ventilation. Thus it is important that enough tidal volume is
delivered and at a rate that enables adequate minute ventilation to meet oxygenation needs
and removal of carbon dioxide. The recommended rate is (10) breaths per minute. The
inspiratory breath should be given over one second and passive expiration allowed for
approximately (2) seconds. The breath should be blown in gently but firmly to avoid
barotraumas and the chest should be observed to rise and fall before the next breath is
attempted.
c- Defibrillation:
Is a process by means of which an electronic device delivers a strong electrical shock to the
heart that puts an end to the characteristically extremely rapid and irregular heartbeat and
restores a normal heart rhythm. Defibrillation is administered to correct the life-threatening
fibrillations of the heart which can cause cardiac arrest. It should be performed immediately
after it has been established that a patient is experiencing a cardiac emergency, has no pulse,
and is unresponsive. Defibrillation interrupts fibrillatory electrical activity in the heart and
allows normal pacemakers to produce an effective rhythm that ensures systemic perfusion.
6- Cardiac Arrest:
Cardiac arrest occurs when the heart ceases to produce an effective pulse and blood
circulation. It may be caused by a cardiac electrical event, as when the HR is too fast
(especially ventricular tachycardia or ventricular fibrillation) or too slow (bradycardia or
AV block) or when there is no heart rate at all (asystole). Cardiac arrest may follow
respiratory arrest; it may also occur when electrical activity is present but there is ineffective
cardiac contraction or circulating volume, which is called pulseless electrical activity (PEA).
4th class
Critical care nursing
lecturer: mohammed abdul-karee
7- Patient Characteristics during CPR:
a- During cardiac arrest, a patient is in a highly complex and vulnerable state because of
his or her compromised cardiopulmonary system.
b- The stability of a patient decreases if blood pressure is un-recordable and if there is an
absence of a carotid pulse and poor oxygenation.
c- Patients tend to become ever more unstable and unpredictable because of the decreasing
stability and complexity of their conditions.
d- Such patients might have little or no resiliency because of the altered levels of their
consciousness.
8- Potential Roles for Nurses Resuscitations:
a- Recognition of Arrest
The necessary first step in the treatment of cardiac arrest is immediate recognition.
Bystanders may witness the sudden collapse of a victim or find someone who appears
lifeless. At that time several steps should be initiated. Before approaching a victim, the
rescuer must ensure that the scene is safe and then check for response. To do this, tap the
victim on the shoulder and shout, “Are you all right?” If the victim is responsive he or she
will answer, move, or moan. If the victim remains unresponsive, the lay rescuer should
activate the emergency response system. The health care provider should also check for no
breathing or no normal breathing (ie, only gasping) while checking for responsiveness; if
the healthcare provider finds the victim is unresponsive with no breathing or no normal
breathing (ie, only gasping), the rescuer should assume the victim is in cardiac arrest and
immediately activate the emergency response system. the healthcare provider should take
no more than (10) seconds to check for a pulse; and if the rescuer does not definitely feel a
pulse within that time period the rescuer should start chest compressions.
b- Chest Compressions Technique:
1- To maximize the effectiveness of chest compressions, place the victim on a firm surface
when possible, in a supine position with the rescuer kneeling beside the victim’s chest (eg,
out-of-hospital) or standing beside the bed (eg, in hospital).
2- Rescuer should place the heel of one hand on the center (middle) of the victim’s chest
(which is the lower half of the sternum) and the heel of the other hand on top of the first so
that the hands are overlapped and parallel.
3- Correct performance of chest compressions requires several essential skills. The adult
sternum should be depressed at least (2) inches (5 cm), with chest compression and chest
recoil /relaxation times approximately equal.
4- Allow the chest to completely recoil after each compression (80).
5- The total number of chest compressions delivered to the victim is a function of the chest
compression rate and the proportion of time that chest compressions are delivered without
interruption.
6- Compressions are reasonable for lay rescuers and healthcare providers to perform chest
compressions for adults at a rate of at least (100) compressions per minute the term “duty
cycle” refers to the time spent compressing the chest as a proportion of the time between
the start of (1) cycle of compression and the start of the next.
4th class
Critical care nursing
lecturer: mohammed abdul-karee
7- Limiting the frequency and duration of interruptions in chest compressions may
improve clinically meaningful outcomes in cardiac arrest patients.
c- Managing the Airway Technique:
A healthcare provider should use the head tilt– chin lift maneuver to open the airway of a
victim with no evidence of head or neck trauma. Although the head tilt– chin lift technique
was developed using unconscious, if healthcare providers suspect a cervical spine injury,
they should open the airway using a jaw thrust without head extension. Because maintaining
a patent airway and providing adequate ventilation are priorities in CPR, use the head tilt–
chin lift maneuver if the jaw thrust does not adequately open the airway.
d- Rescue breathing technique:
Recommendations regarding rescue breathing:
● Deliver each rescue breath over (1) second.
● Give a sufficient tidal volume to produce visible chest rise
● Use a compression to ventilation ratio of (30) chest compressions to (2) ventilations.
● When an advanced airway (ie, endotracheal tube, Combitube, or laryngeal mask airway
(LMA) is in place during (2) person CPR, give (1) breath every (6-8) seconds without
attempting to synchronize breaths between compressions (this will result in delivery of (810) breaths/minute. There should be no pause in chest compressions for delivery of
ventilations.
*Method of breathing in CPR:
a- Mouth -to-Mouth Rescue Breathing.
b- Mouth-to–Barrier Device Breathing
c- Mouth-to-Nose and Mouth-to-Stoma Ventilation.
d- Ventilation with Bag and Mask
e- The Bag-Mask Device
f- Ventilation with a Supraglottic Airway.
8- Recovery Position and follow-up Monitoring:
a- Once successfully resuscitated, the patient is transferred to an intensive care unit for
close monitoring.
b- Continuous ECG monitoring and frequent blood pressure assessments are essential
until hemodynamic stability is reestablished.
c- Etiologic factors that precipitated the arrest, such as metabolic or rhythm abnormalities
must be identified and treated. Possible contributing factors, such as electrolyte or acid-base
imbalances, need to be identified and corrected.
d- Selected medications, may be used during and after resuscitation.
e- The recovery position is used for unresponsive adult victims who clearly have normal
breathing and effective circulation. This position is designed to maintain a patent airway
and reduce the risk of airway obstruction and aspiration. The victim is placed on his or her
side with the lower arm in front of the body there are several variations of the recovery
position, each with its own advantages. No single position is perfect for all victims. The
position should be stable, near a true lateral position, with the head dependent and with no
pressure on the chest to impair breathing.