1

SEMINAR
ON

Cardiopulmonary
resuscitation

SUBMITTED TO SUBMITTED BY

SUBMITTED ON
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CENTRAL OBJECTIVES
At the end of the class, the students will be Able to get adequate knowledge on CPR,
develops positive attitude and apply their skills while giving care to patients who are
critically ill.

SPECIFIC OBJECTIVES
define CPR

explain the history

define cardiac arrest

list down the causes of cardiac arrest

enlist the signs and symptoms of cardiac arrest

explain chain of survival

narrate preliminary assessment

explain the procedure of CPR

describe basic life support

discuss advanced cardiac life support

explain the contraindications of CPR

list down the complications of CPR

describe the nurses role in CPR

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Sl. No CONTENT PAGE No.

1 INTRODUCTION 4
2 DEFINITION 4
3 HISTORY 4
4 CARDIAC ARREST 5
5 INCIDENCE 5
6 CAUSES 5
7 SIGNS AND SYMPTOMS 5
8 CHAIN OF SURVIVAL 6
9 PRELIMINARY ASSESSMENT 6
10 PROCEDURE 7
11 BASIC LIFE SUPPORT 9
12 ADVANCED CARDIAC LIFE SUPPORT 12
13 CONTRAINDICATIONS 15
14 COMPLICATIONS 15
15 NURSES ROLE 16
16 CONCLUSION 18
17 BIBLIOGRAPHY 18

CARDIOPULMONARY RESUSCITATION
INTRODUCTION

Birth and death are the two natural phenomena that all of us have to admit.
Death can occur at any time due to any etiology. However death in a certain situations
can be prevented.
For life to be sustained, a constant supply of oxygen must be maintained and
delivered to the brain and other vital organs by the circulating blood. The pump that
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maintains circulation is the heart. If the heart stops, urgent action must be taken if
death is to be prevented.
DEFINITION

 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.
 CPR is a technique used in cardiac arrest to establish heart and lung function until
advanced life support is available.
 CPR is an essential emergency measure consisting of a series of sequential
measures undertaken for the specific purpose of delivering oxygenated blood to
the heart and brain through artificial respiration and manual cardiac massage till
spontaneous and effective circulation is restored through further treatment.

HISTORY
At first only medically trained personnel were allowed to perform CPR, since chest
compression could produce internal injuries. In 1960, Kouwenhoven and his colleagues
set a new landmark, for effective external cardiac compression, coupled with mouth to
mouth breathing id the resuscitation of victim who had total circulatory hand skill. As a
result, the combination of closed chest cardiac massage and mouth to mouth rescuer
breathing, coupled with the introduction of external defibrillation, created CPR as it is
known today.

CARDIAC ARREST
Cardiac arrest is the sudden abrupt loss of heart function. It is defined as the stoppage
of the beating of the heart which is fatal unless corrective measures restore the beating
within a couple of minutes.

INCIDENCE

• Less than 300,000 people experience sudden cardiac death in pre hospital
settings each year.
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• If resuscitation begins within a few minutes, many of these individuals have a

chance for survival.

CAUSES

 Traumatic- motor vehicle accidents, burns

 Pulmonary- drowning, respiratory failure
 Infections- sepsis, meningitis
 CNS disturbances- head trauma, seizures
 Iatrogic- digitalis intoxication, KCl overdose
 Others- poisoning, suicide, and drug overdose,
 Electric shock
 Anesthetic effect
 Anaphylaxis

SIGNS AND SYMPTOMS OF CARDIAC ARREST

 Apnea- by absence of movement of the chest and abdominal muscle

 Very poor or almost imperceptible pulse
 Cyanosis
 Unconsciousness
 Dilated pupils-due to cerebral hypoxia causes loss of muscle control in the entire
body, including eyes. Pupils dilated do not reacted to light because centers in the
brain that control movements of iris of eye are not receiving enough oxygen to
cause normal response of iris to light
 Others- seizures, complete loss of muscle tone, ECG reveals asystole.

CHAIN OF SURVIVAL

The chain of survival refers to a series of actions that, when put into motion, reduce the
mortality associated with cardiac arrest. The four interdependent links in the chain of
survival are early access, early CPR, early defibrillation, and early advanced cardiac life
support

Early CPR
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In order to be most effective, bystander CPR should be provided immediately after

collapse of the patient. Properly performed CPR can keep the heart in a shockable
ventricular fibrillation for 10–12 minutes longer.

Early defibrillation

Most adults who can be saved from cardiac arrest are in ventricular fibrillation or
pulseless ventricular tachycardia. Early defibrillation is the link in the chain most likely to
improve survival. Public access defibrillation may be the key to improving survival rates
in out-of-hospital cardiac arrest, but is of the greatest value when the other links in the
chain do not fail.

Early advanced care

Early advanced cardiac life support by paramedics is another critical link in the chain of
survival. In communities with survival rates > 20%, a minimum of two of the rescuers are
trained to the advanced level. In some countries, EMS delivery may be performed by
ambulance officers, paramedics, nurses, or doctors.

PRELIMINARY ASSESSMENT
It must be done in 60 seconds. Assess the patient in emergencies by ABCD and E.

AIRWAY AND CERVICAL SPINE

Evaluate the airway patency to determine whether it is open. Keep in mind the injuries,
mechanism, location and scope and stabilize the person’s airway.

BREATHING

 Assess breathing by listening for breath sounds, watching for chest movements
and feeling for breath against cheek and ear.
 Observe respiration: assess the respiration- its depth, normal, examine or
cyanosis
 Look for life threatening chest injuries like rib fracture, punctured lung, flail chest,
stabbings, gunshot wounds and compression injuries.
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CIRCULATION AND BLEEDING

 Check pulse. Palpate the pulse 5-10 sec. if no pulse BLS is needed. Carotid pulse is
mainly checked.
 If pulse is present, note its rhythm and regularity.
 Assess for any shock and if there is any hemorrhage, it should be controlled.

DISABILITY

A - Alert: speak and moves spontaneously. Answer to questions

V- Response to Verbal stimuli only. Answer when directly addressed

P – Responsive to Painful stimuli only.

U- Unresponsive

Eye signs: assess pupillary response, both eyes should be same. Check for PERRLA and C.

Expose and examine- exam any area or part if the person complaints about. After
controlling the immediate life threatening problem, collect medical history, check vital
signs and other assessment etc.

PROCEDURE OF CPR
To maintain the airway

 Clear the airway of obvious foreign matter, e.g.: vomitus, secretions

 Hyperextend the head and neck of the patient by tilting it backwards 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.
 With the above steps, if the breathing is restored, place an oropharyngeal airway.
If breathing is not restored start artificial ventilation.

To initiate breathing

 Maintain the position of the head

 Pinch the patients nostrils closed, using an index finger and thumb of the hand
near the patients face.
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 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.
 After each inflation move your mouth away from the patients mouth.
 Repeat inflation 12 to 20 times per minute at the rate of one inflation every three
to five seconds, until the patient breathes spontaneously.
 If cardiac massage is to be given the artificial breathing should be carried out at a
rate of 5:1 or 15:2 i.e. one inflation after every 15 cardiac massage when there is
only one rescuer.

To maintain circulation

 Begin external cardiac compression immediately following initial four rapid

breaths
 Position the patient on his back on a flat, firm surface
 Kneel along one side of the patient’s chest. If the patient is on bed or table, it is
often necessary to kneel on the bed or table at the side of the patient.
 Place the heel of the hand on the lower third of the sternum above the xyphoid
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.
 Straighten your arms by locking the elbows. Lean forward until the shoulders are
directly over the hands, depress patients sternum one and half to 2 inches with
each compression.
 Release pressure on the sternum quickly and completely, taking care neither to
change the position of the hands, nor to move the off the chest wall.
 Rhythmically continue cardiac compression at a rate of 60 to 80 per minute.

BASIC LIFE SUPPORT (BLS)

GOAL

The goal of BLS is to support or restore effective oxygenation, ventilation and circulation
with return of spontaneous circulation. Early CPR and early defibrillation with an AED
are stressed. CPR must be initiated immediately in the event of an arrest to improve the
patient’s chance of survival.
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The 2010 AHA guidelines for CPR recommend a change in the BLS sequence from A-B-C
(airway, breathing, circulation) to C-A-B (chest compressions, airway, and breathing) and
determining whether defibrillation is needed. BLS providers must be trained in the use
of an AED. Assessment is a part of each step, and the steps are performed in order.

SAFETY OF THE RESCUER

The rescuers first duty is to ensure their own safety, whatever the setting: the potential
hazards in the community are limitless and include speeding road traffic, electrical
cables and wires, noxious substances and falling masonry, drunken or aggressive
onlookers. In hospital hazards such as electrocution, slippery floors and spilled water
from a bedside locker should not be overlooked

RESPONSIVENESS

The first intervention is to assess unresponsiveness by tapping or shaking a patient and

shouting, ‘Are you ok?” the patient is positioned on his or her back and assessed for
absent or abnormal breathing by looking at the chest. If the patient is unresponsive, the
nurse calls for help by shouting to fellow caregivers or by using the nurse call system. If
the patient must be turned to the supine position, the head and body are turned as a
unit to prevent possible injury.

CIRCULATION

The second step of CPR is to ensure adequate circulation. The presence or absence of a
carotid pulse is assessed for 5 to 10 seconds to detect bradycardia. The pulse is assessed
even if the patient is attached to a cardiac monitor because artifact or a loose lead may
mimic a cardiac dysrhythmia. The nurse checks the patient’s carotid pulse on the side
nearest the nurse. The pulse is assessed for at least 5 seconds but no longer than 10
seconds to detect bradycardia.

If a pulse is present, rescue breathing is initiated at the rate of 10 to12 breathes per
minute, or 1 breathe every 5 to 6 seconds. The pulse should be assessed every 2
minutes for no longer than 10 seconds.

If the pulse is absent, the nurse begins cardiac compressions. The patient is placed
supine on a firm surface. Proper hand position is essential for performing compressions.
The location for compressions is the lower half of the sternum in the centre of the chest
between the nipples. The heel of one hand is placed on top of the first hand so the hand
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is overlapped and parallel. Using both hands, the nurse begins compression by
depressing the sternum 1.5 to 2.0 inches for the average adult and then letting the chest
return to its normal position. Compressions are performed at a rate of 100 per minute
at a ratio of 30 compressions to 2 breathes (30:2).

Every effort is made to minimize any interruptions in chest compressions. CPR is

continued until an AED arrives, electrode pads are placed, and the AED is ready to
analyze the rhythm. Shocks are provided as indicated. After each shock, immediately
resume CPR beginning with compressions for 2 minutes.

AIRWAY

There are two methods for opening the airway to provide breaths. The patient is
positioned on his or her back, and the airway is opened by use of the head tilt/ chin –lift
method. The fingers of the other hand are placed under the bony part of the lower jaw
near the chin. The jaw is then lifted to bring the chin forward. Two people are usually
needed to perform the jaw thrust and provide breaths with a bag-mask device. A jaw
thrust is used when a head or neck injury is suspected.

 Jaw thrust method

If neck injury is suspected use the jaw thrust method to open the person’s airway.
Position your hands at the angles of the persons jaw. Displace the jaw first forward
while tilting the person head backward. Take caution to avoid extending the persons
neck. Support the head to keep it from moving side to side.

 Finger sweep

Before beginning resuscitation remove any foreign matter vomitus or liquids from the
person’s mouth and airway. In many cases removing the foreign body will restore
breathing. If a foreign body is visible in mouth remove it with fingers. Wear gloves
whenever possible, when doing so perform it for unconscious patients only. If sternly
suspect a foreign body but cannot see it, use abdominal thrust to move or dislodge it.

BREATHING

Early initiation of rescue breathing may prevent a cardiac arrest in a patient who stops
breathing but still has a pulse. To assess breathing, the nurse looks, listens and feels for
breathing while maintaining an open airway. The nurse looks at the chest wall to see
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whether it is moving up and down, listens for air movement, and feels for exhaled air.
Rescue breathing, or ventilation, is initiated if the patient is not breathing.

If possible, the code team is notified of the arrest at this time. The first person who
arrives to help should “call the code”. Some units and emergency departments have an
emergency call system that can be activated from the patient’s room by the pressing of
a button. If the nurse is alone and an emergency call system is not available, the nurse
presses the nurse-call system and begins CPR. When the call is answered the nurse
states, “Call a code!”

In mouth – to – mouth resuscitation, the open airway is maintained, and the nurse seals
his or her mouth, pinches off the patient’s nose, and gives two slow breathes to the
patient, the patients head should be repositioned, because an improperly opened
airway is the most common cause of an inability to ventilate.

If the patient has a mouth injury or the nurse has difficulty maintaining a good seal,
mouth to nose ventilation can be performed. Mouth to stoma ventilation is performed
when the patient has a tracheal stoma or laryngectomy.

Although health care providers should be able to provide mouth- to –mouth breathing,
mouth to nose breathing and mouth to stoma breathing, barrier devices must be
available in the workplace for individuals who are expected to perform CPR. In the
hospital setting these include a BVD and a face mask. Many hospitals have a pocket
mask at every patient’s bed side. In addition, most critical care units have a BVD at every
patient’s bedside.

The mask to mask technique involves placing a mask over the patient’s mouth and
breathing through a mouth piece connected to the mask. Masks have a one-way valve
that protects the nurse from the patient’s exhalation. Some masks have an oxygen inlet
for administration of supplemental oxygen. When oxygen is available, a minimum flow
rate of 10 to 12 L/min should be provided.

Ventilation of the patient with a BVD and a face mask requires that an open airway be
maintained. Frequently, an oral airway is used to keep the airway patent and to
facilitate ventilation. The BVD is connected to an oxygen source set at 15 L/min. the face
mask is positioned and sealed over the patient’s mouth and nose. The patient is
manually ventilated with the BVD. Personnel should be properly trained to use the BVD
effectively.
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ADVANCED CARDIAC LIFE SUPPORT (ACLS)

DEFINITION

Advanced cardiac life support or advanced cardiovascular life support (ACLS) refers to a
set of clinical interventions for the urgent treatment of cardiac arrest, stroke and other
life threatening medical emergencies, as well as the knowledge and skills to deploy
those interventions.

For cardiac or respiratory emergencies, many institutions follow the AHA standards of
ACLS. The conceptual tools of management are the BLS primary survey ACLS secondary
survey.

Primary survey

The BLS primary survey focuses on early CPR and early defibrillation. The ABCs of ACLS
are the same as for BLS: airway, breathing and compressions or circulation. “D” refers to
early defibrillation that can be accomplished with an AED or a conventional defibrillator.
It is a requirement that BLS providers be trained in the use of an AED.

Secondary survey

At the time of defibrillation, the secondary survey is initiated. The ABCD in the ACLS
secondary survey involves the performance of more in depth assessments and
interventions.

AIRWAY

Airway management involves reassessment of original techniques established in BLS.

Endotracheal intubation provides definitive airway management and should be
performed if needed by properly trained personnel as soon as possible during any
resuscitation effort. Endotracheal intubation is associated with the following
advantages:

1. Keep the airway patent

2. Enables the administration of a high concentration of oxygen.
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3. Ensure delivery of a selected tidal volume to maintain adequate lung inflation

4. Protects the patient form gastric distension and aspiration of stomach contents.
5. Permits effective suctioning of the trachea
6. Provides a route for administration of certain medications

During a cardiopulmonary arrest, CPR should not be disrupted for longer than 10
seconds except as needed for interventions as intubation. Once intubated, the patient is
annually ventilated with a BVD attached to the endotracheal tube. The BVD have a
reservoir and be connected to an oxygen source to deliver 100% oxygen while providing
a tidal volume of 6-7 mL/Kg. chest compressions are not stopped for ventilations. Chest
compressions are delivered continuously at a rate of 100 per minute. Ventilations are
delivered one breath every 6 to 8 seconds or approximately 8 to 10 breathes per
minute.

BREATHING

Breathing assessment determines whether the ventilatory efforts are causing the chest
to rise. After intubation, the nurse first auscultates the epigastrium. If stomach gurgling
is heard in this area and no chest expansion is present, the ETT has mistakenly been
placed in the esophagus and is removed immediately. ETT placement should be
confirmed by bilateral breath sounds and observation of chest movement with
ventilation. A secondary method of assessing ETT placement is done with an exhaled
CO2 detector or esophageal detector device. A chest x-ray study confirms placement
after the code.

CIRCULATION

Circulation initially focuses on chest compressions, IV access, attachment of monitor

electrodes and leads, rhythm identification, blood pressure measurement and
medication administration. A patent IV is necessary during an arrest for the
administration of fluids, medications or both. Intraosseus cannulation may be
performed when IV access is not available. IO cannulation provides access to the bone
marrow and is a rapid, safe and reliable route for administering medications, blood and
IV fluid during resuscitation.
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Most critically ill patients have an IV access. If the patient does not have an IV access or
needs additional IV access, a large bore IV should be inserted. The antecubital vein is the
first target for IV access. Other areas of IV insertion include the dorsum of the hands and
the wrist. If a peripheral IV cannot be stared, the physician inserts a central line for IV
access.

NS is the preferred fluid because it expands intravascular volume better than dextrose.
When any medications is administered by the peripheral IV route, it is best followed
with a 20 ml bolus of IV fluid and elevation of the extremity for about 10 to 20 seconds
to enhance delivery to the central circulation.

DEFIBRILLATION
Defibrillation is the delivery of an electrical current to the heart through the use of a
defibrillator. The current can be delivered through the chest wall by use of external
paddles or adhesive electrode pads connected to cables.
Smaller internal paddles may be used to deliver current directly to the heart during
cardiac surgery when the chest is open and heart is visualized.
It delivers energy or current in waveforms. Monophasic waveforms deliver current in
one direction. Biphasic waveforms deliver current that flows in a positive direction for a
specified duration and then reverses and flows in a negative direction. As a result, fewer
joules are needed for defibrillation

Precautions

Defibrillation should not be performed on a patient who has a pulse or is alert, as this
could cause a lethal heart rhythm disturbance or cardiac arrest. The paddles used in the
procedure should not be placed on a woman's breasts or over an internal pacemaker.

AUTOMATED EXTERNAL DEFBRILLATION

An automated external defibrillator (AED) is a portable electronic device that

automatically diagnoses the potentially life threatening cardiac arrhythmias of
ventricular fibrillation and ventricular tachycardia in a patient, and is able to treat them
through defibrillation, the application of electrical therapy which stops the arrhythmia,
allowing the heart to reestablish an effective rhythm.
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The AED is an external defibrillator with rhythm analysis capabilities. It is used to

achieve early defibrillation. Because of the ease of use, AEDs may be placed on medical
surgical patient units, emergency response vehicles, and in public places.
CARDIOVERSION
It is the delivery of a shock that is synchronized with the patient’s cardiac rhythm. The
purpose of Cardioversion is to disrupt an ectopic pacemaker that is causing a
dysrhythmia and to allow the Sino atrial node to take the control of the rhythm.
DRUGS USED IN CPR
Adenosine – 6mg IV bolus over 1-3 seconds, followed by 20 ml rapid NS flush
Amiodarone-300mg IV or IO push followed by dose of 150mg in cardiac arrest
Atropine- 0.5 mg IV every 3-5 mins to maximum dose of 3 mg
Dopamine- 2-10 mcg /kg/min
Epinephrine- 1 mg IV/IO or 2-2.5 mg in 10 ml sterile water or NS via ETT.
CONTRAINDICATIONS OF CPR
The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other
advanced directive indicating a person’s desire to not be resuscitated in the event of
cardiac arrest. A relative contraindication to performing CPR is if a clinician justifiably
feels that the intervention would be medically futile.
 Chest wall deformities
 Prosthetic valve obstruction
COMPLICATIONS OF CPR
 Sternal and rib fractures
 Pneumothorax, hemothorax or both
 Injury to the heart and great vessels
 Organ lacerations
 Aspiration of stomach contents
SIGNS OF EFFECTIVE CPR
 Distinct carotid pulsations with each cardiac compression
 Blinking upon stimulation of eyelid
 Breathing that begins spontaneously
 Movement and struggling
 Decreased cyanosis
AFTER CARE
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 Skilled after care of the patient who has suffered cardiac arrest is crucial for
survival. The patient should be continually watched by skilled persons over a
period of 48 to 72 hours
 If the patient is not in ICU, shift to the ICU for constant observation and expert
care
 Give oxygen continuously for 48 hours following resuscitation
 Frequently check the victim’s had and jaw positions because his tongue may fall
back and obstruct the airway.
 Check the color of the skin.
 Watch for signs or restored circulation and respiration
 Watch convulsions
 Insert ET tube and Foley’s catheter
 Start IV infusion to administer enough fluids to the patient
 Blood gas analysis has to be done to detect metabolic acidosis
 Watch for the complications
RECORDING AND REPORTING
 The time victim was discovered
 Type of arrest (respiratory/ cardiac or both)
 Complications during CPR
 The time at which spontaneous breathing and respiration returned
 Time at which CPR started and discontinued
 Vital signs when CPR team left the patient

NURSES ROLE IN CPR

Nurses play a key role in the management of in-hospital cardiac arrest. Often they are
first on the scene of an arrest initiating cardiopulmonary resuscitation (CPR) as well as
summoning assistance from the 'advanced life support'/'arrest' team. Thus it is argued
that nurses should be willing (and able) to perform defibrillation when required. Not
with standing this, the community has an expectation (rightly or wrongly) that all nurses
are able to appropriately manage a collapse situation. However, research clearly
demonstrates that not all nurses are competent in CPR. There is obviously a mismatch
between community expectations and reality, which nursing needs to address. Nurses
can contribute to the prevention of cardiac arrest in the community by promoting the
importance of seeking medical care in the event of chest pain. Furthermore, skilled
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clinical assessment and recognition of the prodromes of cardiorespiratory collapse may

reduce the incidence of in-hospital cardiac arrests.
Nurses are generally the first responders to a cardiac arrest and initiate basic life
support while waiting for the advanced cardiac life support team to arrive.
There are several factors that support the involvement of nurses in CPR decision
making. As a result of lengthy stays, nurses spend a lot of time with many long- term
care patients, and could be expected to have a good understanding of their values and
beliefs.
Nurses are usually the first persons on a cardiac arrest scene, and must either initiate
CPR or withhold it. In order to fulfill their role as patient advocates, nurses need to be
informed about decisions that affect their patients. Due to the fact that they are
infrequently consulted before the CPR decision making process, several studies have
reported that nurses desire greater involvement in CPR decision making and that nurses
believe they can offer a unique and worthwhile perspective.

CONCLUSION
Cardiac and respiratory arrest requires artificial support of circulation and ventilation if
the victim is to survive. Often just a holding procedure, effective CPR buys time while
the means of reversing the underlying cause of the arrest can be obtained. When faced
with an emergency situation the nurse may act impulsively and place ourselves in
harmless way.
BIBLIOGRAPHY
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 Richard Hatchet, David R Thompson. Cardiac Nursing. 2 nd Edition. New York:

Churchill Livingstone.2010.pp: 569-584
 Shebeer P Basheer. Advanced Nursing Practice. 1 st Edition. Bangalore: Emmess
Medical Publishers. 2012. Pp.: 297-305
 Sole, Klein, Moseley. Introduction to Critical Care Nursing. 5 th edition. New Delhi:
W.B Saunders Company. 2005. PP: 251-268
 Jaya Kuruvila. Critical Care Nursing. 5th edition. New Delhi: Jaypee Medical
Publishers.2009. Pp. 302-314
 Chinthamani. Lewis’s Medical Surgical Nursing 2nd edition. Haryana: Elsevier
Publications.2011. Pp.55-71
 Lemone, Burke. Medical Surgical Nursing. 4th edition. , New Delhi: Elsevier
publications. 2010. Page No.680-687
 K V Krishna Das. Text book of Medicine. Jaypee Brothers Medical Publishers
Kolkata Page No. 1028-1053
 en.wikipedia.org/wiki/Cardiopulmonary_resuscitation
 www.mayoclinic.com/health/first-aid-cpr/FA00061
 depts.washington.edu/learncpr/quickcpr.html