CARDIOPULMONARY RESUSCITATION

CARDIOPULMONARY RESUSCITATION
Objectives:
After 5 hours of classroom discussion, the level II students will be able to:

1. define the following terms:
1.1 airway
1.2 artificial respiration
1.3 basic life support
1.4 breathing
1.5 circulation
1.6 cardiopulmonary resuscitation
1.7 crackles
1.8 external cardiac compression
1.9 rales
1.10 respiratory arrest
1.11 cardiac arrest
1.12 rhonchi
1.13 ventilation
1.14 wheezing

2. explain the principles related to CPR
2.1 basic principles of breathing and circulation

2. identify the ABC of basic life support

3. discuss the following according to its causes and signs and symptoms
3.1 cardiac arrest
3.2 respiratory arrest

4. cite the importance of performing cardiopulmonary resuscitation

5. enumerate the different methods of artificial resuscitation

6. explain the following:
6.1 indications of cardiopulmonary resuscitation
6.2 contraindications of cardiopulmonary resuscitation
6.3 techniques for external chest compression

7. show table of comparison for adult, child and infant

8. determine ways to check for effectiveness in doing cardiopulmonary
resuscitation


9. list guidelines in performing cardiopulmonary resuscitation

11. demonstrate beginning skills in performing the following
11.1 one man rescue
11.2 two man rescue
11.3 artificial resuscitation
11.4 Heimlich maneuver
11.5 back blows
11.6 jaw thrust maneuver






























Definition of Terms
1. AIRWAY- protection and maintenance of patient airway including the use of airway adjuncts such as an oral or nasal airway.

2. ARTIFICIAL RESPIRATORY- a procedure used to restore or maintain respiration in
a person who has stopped breathing

3. BASIC LIFE SUPPORT- refers to first aid given if victim’s breathing or heart stops

4. BREATHING- actual flow of air through respiration, natural or artificial
respiration often assisted by emergency oxygen

5. CIRCULATION- the movement of blood through beating of the heart or the
emergency measure of CPR

6. CARDIOPULMONARY RESUSCITATION- is a combination of oral resuscitation
which supplies oxygen to the lungs and external cardiac massage, which is
intended to reestablish cardiac function and blood circulation

7. CRACKLES- fine, short, interrupted crackling sounds

8. EXTERNAL CARDIAC COMPRESSION- is delivered on the midline of the lower half
of the sternum.

9. RALES- abnormal or pathological respiratory sounds heard on auscultation

10.RESPIRATORY ARREST- sudden cessation of breathing

11.CARDIAC ARREST- the absence of pulse and respiration

12.RHONCHI- coarse rattling sounds that are produced by secretions on the
bronchial tubes

13.VENTILATION- is also used to refer to the movement of air in and out of the
lungs

14.WHEEZING- continuous, high-pitched, musical squeak or whistling sound
occurring on expiration and sometimes on inspiration when air moves through a
narrowed or partially obstructed airway




Basic Principles of Breathing and Circulation

1. Air that enters the lungs contains 21% of oxygen and the trace carbon dioxide. Air that is exhaled from the lungs contains 16% oxygen and 4% carbon dioxide.
2. The right side of the heart pumps blood to the lungs when blood picks up oxygen and releases carbon dioxide.
3. The oxygenated blood then returns to the left side of the heart, where it will be pumped to the different tissue of the body.
4. In the body tissues, the blood releases oxygen and takes up carbon dioxide after which it flows back to the right side of the heart.
5. All body tissues require oxygen, but brain requires more than any other tissue.
6. When breathing and circulation stops, this is called Clinical Death ; 0-4 min.(brain damage is most not likely) , 4-6 min. (brain damage is probable)
7. When the brain has been deprived of oxygenated blood for a period of 6 min. or more, an irreversible damage will probably occur. This is called Biological Death: over 10 min. (brain damage is certain).
8. Both respiration and circulation is/are required to maintain life.
9. When respiratory breathing stops, the pulse and circulation may continue for sometime, this condition is known as Respiratory Arrest.
10. When circulation stops, the pulse disappears and breathing stops at the same time or soon thereafter. This is called Cardiac Arrest


The ABC’s of Basic Life Support

Airway

The protection and maintenance of patient airway includes the use of airway adjuncts such as an oral or nasal airway

If the airway is not obstructed by food or vomitus, turn the person on his or her back, remove pillows, and then open the airway by one of the following methods:

Head tilt-chin lift
1. Position yourself at the person’s head.
2. Place your fingers behind the angle of the jaw and lift upward and forward.
3. Place the other hand on the person’s forehead and press downward to tilt the head backward and help lift the chin.

Head tilt-neck lift method
1.Tilt the head back by lifting behind the neck with one hand while
pushing down on the forehead with the other.

Jaw thrust method
1.Place your fingers (both hands) behind the angle of the jaw.
2.Lift the jaw forward.

Breathing

It is the actual flow of air through respiration, natural or artificial respiration, often assisted by emergency oxygen.

To check for breathing:
1. Look for the person's chest to rise and fall.
2. Listen for the sounds of inhaled or exhaled air.
3. Feel for exhaled air by putting your cheek near the person's mouth.

Circulation

It is the movement of blood through the beating of the heart or the emergency measure of CPR

To assess for circulation:
1. Feel for a pulse, by gently pressing two fingers (do not use the thumb) on the person's neck between the Adam's apple, or voice box, and the muscle on the side of the neck. This is the carotid pulse.
2. To feel for an infant's pulse, press two fingers (do not use the thumb) on the inside of a baby's arm between the armpit and elbow.

If the pulse is absent is absent or questionable, start external heart compression.


Cardiac arrest

Cardiac arrest is the sudden, abrupt loss of heart function. The victim may or may not have diagnosed heart disease. It's also called sudden cardiac arrest or unexpected cardiac arrest. Sudden death (also called sudden cardiac death) occurs within minutes after symptoms appear.


Causes:
 Coronary heart disease.
 Ventricular tachycardia
Sudden death occur when the electrical impulses in the diseased heart
become rapid
 Ventricular fibrillation
Sudden death occur when the electrical impulses in the diseased heart
become chaotic.
 Arrhythmia
Irregular heart rhythm (arrhythmia) causes the heart to suddenly stop beating.
 Bradycardia
Some cardiac arrests are due to extreme slowing of the heart.

Signs and symptoms:

 victim loses consciousness
 victim stops normal breathing
 victim loses pulse
 victim loses blood pressure

Respiratory arrest

A premorbid condition in which there is insufficient transfer of oxygen and/or inadequate elimination of carbon dioxide resulting in the patient’s inability to respire.

Causes:
 airway obstruction
 drowning
 stroke
 smoke inhalation
 drug overdose
 trauma
 infection
 allergy
 Decreased respiratory effort due to CNS impairment may result from drug overdose, carbon monoxide or cyanide poisoning, CNS infection, brain stem infarct or hemorrhage, and intracranial hypertension (due to mass lesions, hydrocephalus, or brain injury).

Signs and symptoms:
 patient is unable to breathe spontaneously
 the patient is unconscious, or about to become so
 cyanotic (unless markedly anemic)
 Before complete respiratory arrest, patients with intact neurologic function may be agitated, confused, and struggling to breathe.
 Tachycardia and diaphoresis are present; there may be intercostal or sternoclavicular retractions.
 Patients with CNS impairment or respiratory muscle weakness exhibit feeble, gasping, or irregular respirations and paradoxical breathing movements.
 Patients with a foreign body in the airway may choke and point to their necks.
 Infants, especially if less than 3 months old, may develop acute apnea without warning, secondary to overwhelming infection, metabolic disorders, or respiratory fatigue.

Importance of Performing Cardiopulmonary Resuscitation

 The earlier CPR is given to a person in cardiopulmonary arrest (no breathing, no heartbeat), the greater the chance of a successful resuscitation
 Keep the blood oxygenated flowing to the heart and brain
 Gives the victim a chance for survival
 It restores minimal breathing until EMS units arrive
 It maintains blood circulation
 It is highly recommended in emergency situations regarding cardiopulmonary arrest
 To provide artificial breathing and circulation until patients recovers or brought to the hospitals

The Different Methods of Artificial Respiration
A. Mouth to Mouth
 Artificial ventilation with the mouth to mouth technique is a quick, effective way to provide oxygen to the patient.
 The exhaled air contains enough oxygen to supply the patient’s needs.
 To perform the mouth to mouth ventilation, the air way must be open. To open the airway, perform the head tilt-chin lift or jaw thrust maneuver.
 If there is no spontaneous breathing, start artificial ventilation
1. Pinch the nose closed with your thumb and index.
2. Take a deep breath and seat your lips around the patient’s mouth (creating an airtight seal) and give two ventilations (1 ½ to 2 seconds per breath).
3. If the patient still does not respond, continue mouth to mouth ventilations at the rate of 10-12 ventilations per minute or one breathe every 5 seconds.
4. Periodically, check the pupils for reaction to light: constriction is a sign of adequate oxygenation.








B. Mouth to Nose
 Mouth to nose ventilation is effective when the patient’s mouth cannot be opened (lockjaw), extensive facial or dental injuries occur, or an airtight seal of the mouth cannot be achieved.
 To administer this technique:
1. Tilt the head back with one hand on the patient’s forehead and use the other hand to lift the jaw (as in the head tilt chin lift maneuver).
2. Close the victim’s mouth. Take a deep breath, seal your lips around the patient’s nose and give to ventilations.
3. Allow the victim’s lungs to deflate passively after each ventilation
4. If the victim does not respond, then you must fully inflate the lungs at the rate 10-12 ventilations per minute or one breath every 5 seconds until the victim can breathe spontaneously.






C. Mouth to Stoma
 Breathing is done when the person has had a laryngectomy
 A stoma is a permanent opening in the neck through which the person breathes following removal of the larynx.
 To perform this technique:
1. Cover the casualty’s mouth with your hand, take a deep breath, and seal your mouth over the stoma.
2. Breathe slowly, using the procedures for mouth-to-mouth breathing.
3. Do not tilt the head back. (In some situations, a person may breathe through the stoma as well as his nose and mouth. If the casualty’s chest does not rise, cover his mouth and nose, and continue breathing through the stoma)

D. Mouth to Mask

 The mouth-to-mask breathing device includes a transparent mask with a one-way valve mouth piece.
 The one-way valve directs the rescuers breathe into the patient’s airway while diverting the patient’s exhaled air away from the rescuer.
 Some devices have an oxygen adaptor that permits the administration of supplemental oxygen.









A. Mouth to Mouth and Nose

 It is usually done for infants and children whose mouths are very small for effective mouth-to-mouth resuscitation. Artificial respiration is inflated and maintained in essentially the same manner.
 Used on infants (usually up to around 1 year old), as this forms the most effective seal

D. Bag Valve Mask

 This is a simple device manually operated by the rescuer, which involves squeezing a bag in order to expel air into the patient.














Indications of Cardiopulmonary Resuscitation

 Unconsciousness
 Breathing is absent
 No pulse detected
 Patients who have cardiopulmonary arrest
 Death-like appearance and pallor
 Dilated fixed pupils
 Children choking

Contraindications of Cardiopulmonary Resuscitation

 Person with massive facial injuries
 An adult who is definitely known to have no effective circulation
 Broken ribs
 Patient known to be in terminal state of fatal disease
 Should never be performed on a healthy person

Techniques for External Chest Compression

 Lay down the casualty’s flat and kneel beside him. Locate the point where the ribcage meets in the middle. Position your middle finger here and your index finger on the bone above. Place the heel of your other hand on the breastbone just above your fingers.

 Cover the hand with the heels of your other hand and then lock your fingers together.

 Kneel up right so that your shoulders one directly over the casualty’s breastbone and your arms are straight. Press down about 4.5 cm (11/2 – 2 in.) then release the pressure but do not remove your hand. Complete is compressions at a rest of about 80 per minute


 When you reach 30, move back to the casualty’s head, tilt the chin back and give him two breaths of mouth-to-mouth resuscitation.

 Continue giving 30 heart compressions followed by two breaths of mouth-to-mouth if there is any sigh that the circulation is returning, check organ for a carotid pulse.

 If you can feel pulse again, stop pumping immediately. Continue mouth-to-mouth until natural breathing is restored.


Table for Comparison for Adult, Child and Infant

Infant
0-1 yr. old Child
1-8 yrs. old Adult
Older than 8 yrs. old
Compression
Landmarking
Method Just below the nipple line at the center of the chest Center
of the chest or at the sternum Center
of the chest or at the sternum
Compression with… 2 to 3 fingers Heel of 1 hand 2 hands
Depth of compression ½ to 1 inch 1 to1½ inches 1½ inches
Compression
Rate About 100/minute
About 100/minute About 100/minute

Chest Compression
to Ventilation Ratio
30:2
30:2
30:2


Rescue Breaths
1 breath/3 seconds
20 breaths per minute 1 breath/2seconds
15 breaths per minute

1 breath/5 seconds
12 breaths per minute


Ways to Check for Effectiveness in Doing Cardiopulmonary Resuscitation

 Bilateral chest movement is visible
 Bilateral breath sounds are heard on auscultation
 The heart rate increases to a regular 100 beats per minute or more
 There is an improvement in skin color and peripheral pulses
 A comparative change from dilated, fixed pupils to smaller or reactive pupils
 Movement of extremities

Termination of Basic Life Support

Cardiopulmonary resuscitation is stopped as a result of a number of circumstances:
 Restoration of spontaneous respiration and/or circulation.
Signs of restored ventilation or circulation include:
a. struggling movements (although these may not necessarily
mean the person has recovered)
b. decreased pupil size
c. improved color
d. return of or stronger pulse
e. return of systemic blood pressure
 Complete rescuer exhaustion
When a rescuer is entirely alone (seldom the case in health care
facilities), he/she may not be able to continue because of exhaustion.
When this occurs, people often feel very guilty. These people may need support to deal with their feelings and to realize that they did the best they could.
 Medical decision to stop CPR
On occasion, a medical decision is made to stop CPR without going
on to advanced life support techniques, owing to the nature of the
person’s underlying disease or condition. Sometimes these decisions are
made “in advance” by the person and significant others in consultation
with the physician.

Guidelines in Performing CPR

 When finding a person that appears to be unconscious, the most important thing to do is to establish if person is unconscious or sleeping.
This prevents injury of person who has not suffered cardiac or
respiratory arrest.
 The person must be flat on his/her back on a hard surface for external compression to be effective
If the person sinks into a soft mattress instead of a hard surface,
It is difficult to evaluate the amount of sternal depression obtained
during each compression, and thus the amount of intrathoracic pressure
generated. The person must be horizontal because blood pressure
generated by external compression is not adequate to pump blood up to
the head when the person is seated.
 Correct hand placement
Compression landmarking: center of the chest for adult/children and just below the nipple line at the center of the chest for infants. If it is too low, the xiphoid process may be fractured and driven into the upper abdomen, damaging the liver, spleen, or stomach. If it is too high, compressions are not effective because the upper sternum is rigid and very difficult to depress.
 In chest compressions use a 30:2 compression to ventilation ratio for all ages
Frequent interruption of chest compressions significantly decreases blood flow in the circulatory system. A higher number of consecutive compressions will improve blood flow to the brain and other internal organs.
Additionally, a universal compression to ventilation ratio of 30:2 will be easier to remember for the lay provider.
 If normal breathing is not present take a normal breath and deliver two ventilations. Ventilations should be 1 second in length for all ages.
Taking a normal before ventilations will prevent a rescuer from becoming light-headed. It will also help prevent complications of air getting in the stomach during ventilations. Current evidence gives greater importance on the need for quality compressions during CPR. Shortening ventilation time will result in a shorter interruption between compressions.
 In opening an Airway, use a head tilt-chin lift in all situations
The head tilt-chin lift is more effective. In the unlikely event that a neck injury is present, an open airway is still a higher priority of care.
 Never interrupt CPR for more than five seconds.
Do not wait for special equipments, such as oxygen, self-inflating resuscitation bags, endotracheal tubes, defribrillators, or suction equipment. Continue CPR technique until special treatment arrives and is ready to be used by trained personnel. Failure to perform legal this vital function may be for the victim
 Push hard, push fast, allow full chest recoil, and minimize interruptions in chest compressions.
This coordinated effort provides better maintenance of blood flow than the interrupted pattern if cardiac compression necessary when there is only one rescuer.

Beginning Skills

Cardiopulmonary Resuscitation on an Adult (One Rescuer)

Procedure Rationale
1. Assume rescuer’s position. Allows performance of rescue breathing and chest compressions without moving knees.
2. Determine the patient’s level of consciousness: Tap or gently shake patient while shouting, “Hey, hey are you okay?” Prevents injury of person who has not suffered cardiac or respiratory arrest.
3. Call for help or activate EMS
(Emergency Medical System) Activated mechanism for additional personnel.
4. Place patient in a supine position on a firm surface. Kneel at the level of the patient’s shoulder. Firm surface provides maximum compression and proper positioning It facilitates external compression of heart. Heart is compressed between sternum and a hard surface.
5. Open the airway.
a. Head tilt and chin lift maneuver.
Place one hand on the patient’s forehead and apply firm back pressure to tilt the head back. Then place the fingers of the other hand on the underside of the chin an lift it up to bring the jaw forward and the teeth almost to occlusion. Maneuver is more effective in opening airway than previously recommended head-tilt/neck-lift.

Removes tongue or epiglottis as airway obstruction.
Breathing
Determine presence or absence of spontaneous breathing.
1. Place cheek over patient’s mouth and nose while observing the rise and fall of the chest. Listen for air escaping during exhalation, and feel for the flow. Determines return of respiratory and need to continue CPR.
2. Perform rescue breathing (mouth to mouth). While keeping the airway open, pinch the nostrils with the thumb and index finger of the hand that is placed on the forehead. Take a deep breath and open mouth wide and give two full breaths (1-1½ seconds each breath). Take a breath after each ventilation. Pinching of nose shut allows maximum ventilation with no escape of air through nostrils.

In most adults, volume is 800 ml and is sufficient to make chest rise. Excess of air volume and fast inspiratory rates can cause pharyngeal pressures that exceed esophageal opening pressures, allowing air to enter stomach and resulting in gastric distention, thereby increasing risk of vomiting.
3. If the initial ventilation is successful, reposition the patient’s head and repeat the mouth to mouth breathing. Ensures that artificial respiration enters lungs.
Circulation
Determine pulselessness
1. While maintaining head tilt with one hand on the forehead, palpate the carotid pulse with the other hand. In the absence of the carotid pulse, start external chest compressions. Carotid artery is large, centrally located, and ordinarily readily accessible. A 5 to 10 second pulse is needed to adequately assess for pulselessness. Performing external cardiac compressions on victims who has pulse may result in serious medical complications.
External Chest Compressions
Consist of serial, rhythmic application of pressure over the lower half of the sternum.
1. Kneel as close to side of patient’s head as possible. Trace ribcage with the left finger towards the xiphoid process. Kneeling facilitates proper position.

Results in maximal compression of heart between sternum and vertebrae. If compression over xiphoid process, liver can be lacerated.
2. Place the heel of the left hand on the sternum just above two fingers from the xiphoid process. The heel of the right hand is placed on top of the left keeping fingers of both hands raised. Reduces risk of rib fracture during compression.

Interlocking the fingers helps keep them off the victim’s ribs, where pressure may cause fractures of the ribs.
3. While keeping your arms straight elbows locked and shoulders positioned directly over your hands, quickly and forcefully depress the lower half of the patient’s sternum straight down 1½-2 inches. Thrust of each compression is straight down on the sternum.

Faster rate increases blood flow with increased blood for to brain and heart.
4. Release the external chest compression completely and allow chest to return to its normal position after each compression. The time allowed for release must be equal the time required for compression. Do not lift hands off the chest or change position. Frequent interruption of chest compression significantly decreases blood flow in the circulatory systems.
5. For one rescuer, do 30 compressions at a rate of 80-100/min and then perform 2 ventilations. A higher number of consecutive compressions will improve blood flow ti the brain and other internal organs.
6. For CPR performed by 2 rescuers, the compression rate is 20-100/min. The compression-ventilation ration is 5:1 Promotes adequate cardiac output.

Faster rate allows pause for ventilation.
7. While resuscitation proceeds, simultaneous efforts are made to obtain and use resuscitation equipment for better management of situation and to provide definitive care. Resuscitation equipments increase survival rates.

Continuation of compression/ventilation rate is necessary to sustain life


Cardiopulmonary Resuscitation of an Adult (Two Rescuers)

Procedure Rationale
1. Rescuer who will ventilate initiates airway assessments. Sequence continues as for one rescuer. Assessment determines need for CPR
2. After pulselessness is determined, first rescuer states, “No pulse.” This indicates clearly to second rescuer to initiate compression sequence.
3. Compressor gets into position, locates anatomic landmarks and begins chest compressions. Correct ratio of compressions to ventilations is 5:1 with a compression rate of 80 to 100 per minute. Stop compressing for each ventilation. Continue for a minimum of 5 cycles The rate of 10 to 15 regularly spaced breaths per minute is considered necessary to supply the victim with sufficient oxygen to maintain cell integrity.
4. Compressor calls for switch when fatigued and gives clear signal. Compressor completes fifth compression, and ventilator completes ventilation after fifth compression. Rescuers switch simultaneously. The person who becomes ventilator does a 5-second pulse check, “No pulse” (if absent) and ventilates once. Person who becomes compressor then begins compressions at 5:1 ratio. It is important to carry out CPR without interruption and adequate flow of oxygenated blood to maintain cell integrity.

Heimlich Maneuver

Procedure Rationale
1. Assess victim. Ask, “Are you choking?” Determine if victim can speak or cough. Inability to speak or cough indicates that airway is obstructed.
2. If victim is obstructed, initiate abdominal thrust (Heimlich maneuver):
a. Stand behind victim.
b. Wrap arms around victim’s chest
c. Make a fist with one hand with thumb outside of fist. Place thumb side of fist against victim’s abdomen above navel and well below the xiphoid process.
d. Grasp fist with the other hand, and press inward and upward with quick, firm thrusts.
e. Continue distinct thrusts until foreign object is expelled or victim becomes unconscious. Firm abdominal thrusts force exhalation of air through the victim’s airway and aid in dislodging obstruction.


Chest thrust

Chest thrusts are to be administered only to women in advanced stages of pregnancy and markedly obese persons who cannot receive the Heimlich maneuver.
Procedure Rationale
1. Determine if the person can speak or cough
2. Call for help
3. Stand behind the person’s with your arms
under the person’s armpits and circling the
person’s chest.
4. Place the thumb side of the fist on the middle
of the breast bone, not on the xiphoid
process.
5. Grab the fist with the other hand and deliver a
quick backward thrust.
6. Exert four quick backward thrusts.
Inability to speak or cough indicates that airway is obstructed.

Chest thrusts force exhalation of air through the victim’s airway and aid in dislodging obstruction.

Back Blows

Procedure Rationale
1. Put the baby facedown on your forearm so the baby's head is lower than his or her chest.
2. Support the baby's head in your palm, against your thigh. Don't cover the baby's mouth or twist his or her neck.
3. Use the heel of one hand to give up to 5 back slaps between the baby's shoulder blades. When back blows are delivered to an infant placed in the head down position, gravity facilitates the moment of the foreign object from the airway toward the mouth.

Jaw Thrust Maneuver

Procedure Rationale
1. Kneel near the top of the patient’s head.
2. Grasp the angles of the patient’s lower jaw
3. Lift the patient’s lower jaw with both hands, one on each side.


This will displace the mandible (jawbone) forward while tilting the head backward.

The jaw-trust technique without head tilt is considered the safest approach to opening the airway of patients with suspected neck injuries because it usually can be done without extending the neck.










One-rescuer CPR














Heimlich Maneuver




Back Blows




















Chest Thrust





Jaw thrust maneuver