Cardio-Pulmonary Resuscitation (CPR) – Emergency Care. Nurse’s Responsibility and Care.
AUTHOR : R A SOMA SANTRA
NURSE’S RESPONSIBILITY IN THE CARDIOPULMONARY RESUSCITATION
Because of an emergency no time is lost to initiate cardio-pulmonary resuscitation procedures. The success of the CPR depends on the speed with which basic life supporting measures are effectively initiated. Rapidly determine the presence of cardio-pulmonary arrest in the patient by noting the three cardinal signs and symptoms such as apnoea, absence of carotid and femoral pulse and dilated pupils. Call loudly for help as soon as you confirm or have strong suspicion of respiratory or cardiac failure.
Preparation of the Equipment
No equipment is absolutely necessary for effective performance of cardio-pulmonary resuscitation. But the following equipments may be helpful if they are at hand. They may be kept ready where there are easily available round the clock e.g. in the intensive care unit. Remember, that waiting for some equipments (e.g. ambu bag) wastes valuable time.
1. Oxygen administration sets.
2. I.V. infusion sets and cut down sets.
3. Ambu bag and mask devices.
4. Endotracheal tubes of different sizes.
5. Oropharyngeal and nasal airways.
6. Laryngoscope of different sizes.
7. Tracheostomy sets.
8. Suction apparatus.
9. Cardiac monitor and defribrillator.
10. Mechanical respiratory aids.
11. Emergency drugs such as epinephrine, sodium bicarbonate, cardiac and respiratory stimulants etc.
12. Clean rag pieces or gauze pieces in containers.
To maintain the airway clear
1. Clear the airway of obvious foreign matter, e.g. vomitus secretions etc.
Reason: clearing of airway obstruction may restore the spontaneous respiration and circulation.
2. Hyperextend the head and neck of the patient by tilting it backward as far as possible.
Reason: keeping the head and neck in a hyper-extended position prevent the tongue falling back and obstructing the airway.
3. Pull the victim’s jaw forward by placing the fingers behind the angle of the jaw and is lifted forward until the teeth on the upper jaw and the lower jaw are approximated.
Reason: helps to keep the airway open and prevents falling back of the tongue.
4. With the above steps, if breathing is restored, place an oro-pharyngeal airway. If breathing is not restored start artificial ventilation.
Reason: placing an oropharyngeal airway helps to keep the airway patent. It also prevents biting of the tongue, should be patient develops a fit.
To initiate breathing (mouth to mouth breathing)
1. Maintain the position of the head as discussed.
Reason: to keep the airways clear.
2. Punch the patient’s nostrils closed, using an index finger and thumb of the hand near the patient’s face. Take a deep breath, place your widely opened mouth over the patient’s mouth and blow forcefully enough to make the patient’s chest rise. Turn the face towards the patient’s chest to observe its expansion.
Reason: closing the nostrils with fingers and enclosing the patient’s mouth into the rescuer’s mouth ensures air-tight seal. The expansion of the chest ensures ventilation of the lungs. In children, the rescuer’s mouth is placed over the mouth and nose.
3. After each inflation move your mouth away from the patient’s mouth.
Reason: to allow air to escape when the patient exhales and for you to inhale.
4. Repeat inflation 12 to 20 times per minute at the rate of one inflation every three to five seconds, until the patient breathes spontaneously. In children, less volume of air is introduced, but they are given about 20 or 30 times per minute.
Reason: the inflation of the lungs should correspond to the normal respiration.
5. If cardiac massage is to be given, the artificial breathing should be carried at a rate of 5:1 or 15:2 i.e. one inflation after every 5 cardiac massage when there are two rescuers or two inflations after every 15 cardiac massage when there is only one rescuer.
Reason: as the inflations of the lungs should correspond to the respiration, the cardiac massage should correspond to the pulse rate.
To maintain circulation.
1. Begin external cardiac compression immediately following initial four rapid breaths.
Reason: tissue hypoxia will cause irreversible brain damage if an adequate circulation is not restored within 3 to 4 minutes. An artificial circulation is possible because the heart lies between the sternum and the vertebrae. Pressure on the sternum squeezes the heart against the spine, forcing blood out of the heart into the aorta, thus initiating the circulation.
2. Position the patient on his back on a flat, firm surface.
Reason: if the bed is sagging, it is difficult to evaluate the amount of sternal pressure exerted during each compression.
3. Kneel along one side of the patient’s chest. If the patient is on the bed or on the table, it is often necessary to kneel on the bed or table at the side of the patient.
Reason: to use the pressure effectively.
4. Place the heel of one hand on the lower third of the sternum above the xiphoid process. Place the heel of other hand on the top of the first hand. Keep the fingers elevated from the chest wall or they may be kept interlocked.
Reason: using the heel of the hand exert pressure only on the sternum. Pressure elsewhere can create rib fracture if excessive force is used.
5. Straighten your arms by locking your elbows. Lean forward until your shoulders are directly over your hands, depress patient’s sternum 1 ½ to 2 inches with each compression.
Reason: locking the elbows and straightening the back adds pressure for chest compressions by bringing the weight of the body over the hands.
6. Release the pressure on the sternum quickly and completely, taking care not to change the position of your hands, nor to move them off chest wall.
Reason: each compression squeees blood out of the heart and relaxation period allows time for the heart to fill with blood before the next compression.
7. Rhythmically continue cardiac compression at a rate of 60 to 80 per minute. For young children and infants, the rate of compression is 80 to 100 per minute.
Periodically assess the vital signs.
Reason: improvement of color and return of spontaneous movement of the chest are the only observations possible to note by one rescuer.
8. Lung inflations and cardiac compressions must be followed at a rate described above until the patient starts spontaneous respirations and pulse.
After Care of the Patient
1. Skilled after care of the patient who has suffered cardiac arrest is crucial for survival.
2. The patient should be continually watched by skilled persons over a period of 48 to 72 hours.
3. If the patient is not in the intensive care unit, shift him to the ICU for constant observation and expert care.
4. Give oxygen continuously for 48 hours following resuscitation. This is necessary because respirations are depressed for some time after the cardiac arrest.
5. Frequently check the victim’s head and jaw positions because his tongue may fall back and obstruct the airway.
6. Assess the patient’s respirations by noting the rhythm, rate and depth of respiration.
7. Check the color of the skin. Persisting cyanosis indicate inadequate oxygenation of blood.
8. Watch for the signs of restored circulation and respiration.
They are : contraction of pupils, improved color, change in the quality of pulse, free movements of the chest wall and no retraction of muscles over the intercostal space, return of systemic blood pressure, struggling movements.
8. Temperature is taken every hour. A high temperature usually indicates cerebral damage or cerebral oedema. Temperature should be brought under normal limits by appropriate methods.
9. Watch for convulsions. It may occur due to brain damage or acidosis.
Insert endotracheal tube, if not already in place. This maintains an open airway for the unconscious patient who cannot clean secretions by coughing.
10. Insert Foley’s catheter. Urine output is one of the measures of the cardiovascular status. Report if the urinary output is below 30 ml. per hour.
11. Start I.V. infusions to administer enough fluids in the patient.
Blood gas and pH determinations are done to detect metabolic acidosis.
Watch the complications that might have occurred during the procedure:
a. Damage to the cervical spine due to hypertension of the neck.
b. Fracture of the rib and xiphoid process. A chest X-ray will reveal any fracture.
c. Haemopericardium, pneumothorax, intra-abdominal haemorrhage etc.
d. Gastric distension with air.
e. Aspiration of vomitus into the lungs.
15. Record the procedure on the nurse’s record with date and time. Record the following:
a. Time the victim was discovered.
b. Type of arrest (respiratory or cardiac or both).
c. Any complications developed during the CPR.
d. Time at which spontaneous respiration and pulse returned.
e. Time at which CPR started and discontinued.
f. Vital signs when the CPR team left the patient.
Cyanosis – Cyanosis is developed due to the lack of oxygenation of blood resulting from hypoventilation of the lungs and circulatory failure.
Unconsciousness – Hypoxia of the cerebral cortex causes unconsciousness. Brain cell are very sensitive to the paucity of oxygen than any other tissues of the body. To make sure whether the patient is sleeping or drowsy with alcoholism etc., call the patient by name shouting by his ear and then shaking him. Mild hypoxia leads to confusion and disorientation.
Fit (grand mal seizure)
This is also occurring due to cerebral anoxaemia.
Sequence of Cardio-Pulmonary Resuscitation
A – Airway
B – Breathing
C – Circulation
In a cardiac arrest, the airway is established first, then breathing is assisted and finally circulation is restored. If there are two nurses, both breathing and circulation can be started simultaneously.
1. Cardio-pulmonary resuscitation (CPR) techniques are used in persons whose respirations and circulation of blood have suddenly and inexpectedly stopped. There is no need of attempting CPR techniques in patients in the last stage of a incurable illness and in the persons whose heart beat and respiration have been absent for more than 6 months.
2. The immediate responsibilities of the resuscitator are :
a. To recognize the signs of cardiac arrest.
b. Protect the patient’s brain from anoxia by immediately starting the artificial ventilation of the lungs and external cardiac massage.
c. Call for help.
3. The cardio-pulmonary resuscitation must be initiated within to 4 minutes in order to prevent permanent brain damage.
a. Strike the centre of the chest sharply with the side of the clenched fist, twice.
b. Call for assistance.
c. Clear the airway of false teeth, vomitus, food materials etc.
d. Initiate ventilation and external cardiac massage without wasting time.
4. The CPR techniques should not be discontinued for more than 5 seconds before normal circulation and ventilation of lungs are established. Exceptions to this rule are :
a. When the patient is being moved to a hard surface.
b. When the endotracheal intubation is being surface out.
Note: The maximum time allowed for these two procedures are 15 seconds.
5. Since the nurses are often involved in the cardio-pulmonary resuscitation, every nurse should be proficient in the techniques of CPR.
6. Before the Cardio-pulmonary resuscitation is attempted in a patient make sure that the airway is clear. It may be obstructed due to many reasons. The following steps will be helpful to make an airway clear.
a. If the food or vomitus is found in the mouth, turn the patient to his side and remove the food material by introducing two fingers into the mouth.
b. Wipe off the excessive secretions with a piece of cloth.
c. If the food material has been lodged deep into the trachea and is giving resistance to the entry of air into the lungs, it can be removed by giving quick blow to the back of patient between his shoulder blades.
d. Artificial dentures may be removed if they are loose. But presence of dentures may be helpful to keep the mouth airtight during the CPR techniques.
e. To prevent the tongue falling back and obstructing the airway, tilt the head and neck into a hyper extended position. This can be done by other means also. (i). keep the patient lie flat on bed with no pillows under the head. (ii). Holding the jaw forward in addition to the head tilt to open the airway.
7. Use of precordial thumb (striking the chest) is effective in case of witnessed cardiac arrest. Precordial thumb is a blow which is delivered to the lower half of the patient’s sternum with the fleshy part of the fist, from 8 to 12 inches above the patient’s chest. This blow generates a small current of electricity which shocks the myocardium and stimulate the cardiac beating and circulation. To be effective, it must be done within a minute of cardiac arrest. If delayed, it may precipitate ventricular fibrillation.
8. Cardiac compressions help to stimulate the circulation. Locate correctly the lower half of the sternum when cardiac compressions are used. If the hands are placed too far to the right or left sides of the chest, the ribs may be fractured. If they are placed too low, the liver may be damaged. To locate the lower part of the sternum, follow the following steps :
First of all trace the last rib and follow the rib to the notch where the ribs meet the sternum, about 1 to 1 and half inches above the palpating hand. The palpating hand is then placed on the top of the hand which is resting on the sternum. Both hands should be parallel and aimed away from the resuscitator. Keep the fingers off the chest or interlocked. If the fingers are resting on the chest, the force will be dissipated.
9. The artificial breathing and the cardiac massage should correspond to the normal respiration and pulse rate. The ratio of cardiac compression to ventilation rate is 5: 1 i.e., 5 cardiac compression to one ventilation. Cardiac compressions are given at a rate of 60 per minute. Ventilations are given between the cardiac compressions without interrupting or slowing the rate of compressions. Thus 60 cardiac compressions and 12 ventilations per minute are achieved. When there are two rescuers, both position themselves on either sides of the victim i.e., one rescuer does artificial ventilation while the other does external cardiac compressions. When there is only rescuer, interrupt the compressions after every 15 compressions to give two quick deep lung inflations. This results in a cardiac compression to ventilation ratio of 15: 2.
10. The circulation of blood is initiated with the external cardiac massage because, the pressure exerted on the pliable sternum squeezes the heart, against the spine forcing blood out of the heart into aorta. In order to be effective, the following precautions are to be followed during the cardiac compressions.
a. The patient should be placed on a hard surface.
b. The body of the patient should be horizontal, because the blood pressure generated is not adequate to pump the blood up to the head.
11. Watch for the complications that may occur during the cardiopulmonary resuscitation. The possible complications are:
a. Damage to the spinal cord at the cervical region due to the hyperextension of the head and neck.
b. Gastric distension with air.
c. Aspiration of vomitus into the lung, should the patient vomits during the resuscitation.
d. Fracture of the ribs, sternum, collar bone etc.
e. Rupture of the liver, myocardium, stomach etc.
g. Haemopericardium and intra-abdominal haemorrhage.
12. Discontinue the procedure only when you are sure that the respirations and circulations are re-established. Look for :
a. Constriction of pupils.
b. Change in the feeling of pulse. The pulse is regular, rhythmic and good in volume.
c. The systemic blood pressure is returned to normal.
d. There is improved color of the skin.
e. The respiratory movements are taking place rhythmically.
13. Patient’s vital signs are watched constantly over a period of 24 to 48 hours after the cardiac arrest, because of the danger of recurring another cardiac arrest at any time.
14. A naso-gastric intubation and aspiration of gastric contents are necessary for a patient with a full stomach to prevent vomiting and aspiration of vomitus into the lungs.
It includes all measures that are applied to revive patients who have stopped breathing suddenly and unexpectedly due to their respiratory or cardiac failure. Cardiac arrest is one of the common causes of cardio-respiratory failure. Cardiac arrest refers to a sudden state of apnoea and circulatory failure. Cardiac arrest is synonymous with the term sudden death; it means that the victim’s heartbeat, circulation of blood and respiration has suddenly and unexpectedly stopped. Prompt action is vitally important for the success of cardio-pulmonary resuscitation.
Causes of Cardiac Arrest
1. Anoxia caused by airways obstruction
2. Myocardial infarction
3. Anaesthetic depression
5. Retention of carbon dioxide.
6. Drowning and other forms of asphyxia resulting in an inadequate ventilation of the lungs.
7. Electric shock
8. Carbon monoxide and other types of poisoning.
9. Drug reactions (anaphylactic shock).
10. Pulmonary embolism
11. Extensive haemorrhage
12. Brain injuries
14. Electrolyte disorder and drug therapy
Signs and Symptoms of Cardiac Arrest
The three cardinal signs of cardiac arrest are apnoea, absence of carotid and femoral pulse and dilated pupils.
Apnoea – Apnoea which indicates respiratory failure can be diagnosed by the absence of movements of the chest and abdominal muscles, by noting the retraction of the soft tissues in the patient’s suprasternal and intercostal spaces which indicates airway obstruction and by not feeling the exhalations when the ear is placed next to the patient’s face.
Absence of Carotid and Femoral Pulse – Pulse in the large arteries close to the heart, are palpable even when the peripheral pulse id absent. Carotid pulse can be checked easily. It is palpable by gentle pressure over the depression between the trachea and the sterno-cleido-mastoid muscle at the level with the Adam’s apple. Absence of carotid pulse indicates cardiac arrest.
Dilated Pupils – cerebral hypoxia (lack of oxygen to the brain tissues) causes loses of muscle control in the entire body, including eyes. Pupils that are dilated and do not react to light indicate that the patient is having a cardiac arrest. It is because; the centres in the brain that control the movements of the iris of eyes are not receiving enough oxygen to cause normal response (constrictions of pupils) of the iris to light.
The other signs and symptoms include cyanosis, unconsciousness, fit, (grand mal seizure) and complete loss of muscle tone.