Chapter 34 Emergency Cardiovascular Life Support Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier.

Chapter 34

Emergency Cardiovascular Life Support

Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives

List the causes of sudden cardiac arrest (SCA). List the signs of SCA, heart attack, stroke, and

foreign-body airway obstruction (FBAO). Describe how to perform cardiopulmonary

resuscitation (CPR) on adults, children, and infants.

Describe how to defibrillate with automated external defibrillators (AEDs) and manual defibrillators.

2Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives (cont.)

State how to administer synchronized cardioversion.

Describe how to evaluate quality and effectiveness of CPR.

List the complications that can occur as a result of resuscitation of SCA.

State when not to initiate CPR.


Learning Objectives (cont.)

Describe how to apply key adjunct equipment during advanced cardiovascular life support (ACLS).

State common drugs and drug routes are used during ACLS.

Describe how to monitor patients prearrest, during CPR, and postarrest.


Causes & Prevention of Sudden Death

Sudden cardiac arrest (SCA) is leading cause of death in many parts of world

Approximately 350,000 people/year have SCA & receive attempted resuscitation

About 25% of all cardiac arrests present with pulseless ventricular rhythms

Successful resuscitation is dependent on immediate CPR & delivery of shock before pulseless ventricular rhythms deteriorate into asystole


Steps for Administering Single Healthcare Practitioner BLS

1. Check for lack of movement & no normal breathing or only gasping

2. If unresponsive, check pulse within 10 seconds (healthcare providers only)

3. Activate emergency response system (get automated external defibrillator [AED] if close to your location)

4. If no AED is available, start chest compressions & rescue breathing for adult cardiac arrest (use cycles of 30 compressions to two ventilations)


Steps for Administering Single Healthcare Practitioner BLS (cont.)

5. Open airway & check breathing

6. If not breathing, give two breaths that produce chest rise & immediately resume chest compressions (push hard & deep)

7. AED arrives with response team

Steps 4-7 are referred to as CABDs of resuscitation – Circulation, Airway, Breathing, & Defibrillation



If a victim is unresponsive, what is the next critical step in the basic life support sequence for a healthcare provider?

A.activate emergency response system

B.check pulse within 10 seconds

C.begin chest compressions

D.give two breaths

Determining Unresponsiveness

BLS begins when victim is found unresponsive & not moving

If head or neck injuries are apparent, rescuer needs to be careful with subsequent moving of head or neck

Rescuer should call for help & activate EMS system if victim is unresponsive


Restoring Circulation After two rescue breaths, rescuer should check

to see if pulse is present Palpate carotid artery in neck or femoral artery

in adults & children older than 1 year If patient has pulse but is not breathing,

ventilation must be started immediately at rate of 8 to 10 breaths/min (every 6-8 seconds)

If no pulse is present, external chest compressions must be interposed with ventilatory support


Restoring Circulation (cont.)


Providing Chest Compressions

Rescuer should compress lower half of sternum (for adult patient) at rate of 100/min

Duty-cycle for downstroke & upstroke (release) is 600 milliseconds with 1:1 downstroke/upstroke ration

Good compressions can produce cardiac output that is one-fourth of normal with blood pressure of 60 to 80 mm Hg


Chest Compressions in Adults

1. Place victim in supine position on firm surface

2. Expose patient’s chest to identify landmarks for correct hand position

3. Choose position close to patient’s upper chest so that weight of your upper body can be used for compression

4. Identify lower half of victim’s sternum, in center of chest between nipples, & place heel of your hand on sternum with your other hand on top, & lock your elbows


Chest Compressions in Adults (cont.)5. Perform chest compression with weight of

your body exerting force on your outstretched arms, elbows held straight

6. Compress sternum 2 inches (5 cm) at rate of 100/min

7. If CPR must be interrupted for transportation or ALS measures, chest compression should resume as quickly as possible.

• Compressions should not cease for more than 5 seconds


Chest Compressions in Adults (cont.)

For children, BLS is similar to adults except heel of one hand is sufficient to achieve compression


Chest Compressions in Adults (cont.)


Chest Compressions in Infants

1. Imagine line across chest connecting nipples- Place your index fingers along this line on sternum- Place your middle & ring fingers next to index

fingers- Raise your index finger & perform compressions

with middle & ring fingers- Use other hand to maintain infant’s head position &

airway

2. Compress sternum approximately 0.5 inch (4 cm) at rate of at least 100/min


Chest Compressions in Infants


Chest Compressions Under Special Circumstances

Near drowning When cardiac arrest occurs as result of drowning,

victims need to be moved to firm surface Stabilization of cervical spine is not necessary

unless circumstances indicate trauma is likely Electrical shock

Can cause either cardiac or respiratory arrest Victim still in contact with source of electricity should

not be touched; power must be turned off first


Chest Compressions Under Special Circumstances (cont.)

Implanted pacemakers & defibrillators Generally located in upper left chest or

occasionally in abdomen Compressions are done same way as other

victims When using AED, pads should be placed at least

one inch from location of implanted pacemaker/defibrillator


Restoring the Airway

After calling for help, rescuer should open victim’s airway If victim is found lying on his/her side or stomach,

use manual in-line spinal restriction to move victim to supine position before airway procedures are begun

Use head-tilt/chin-lift method in most cases Use jaw-thrust method when neck injury may be

present• Not recommended for lay rescuers

• If maneuver does not open airway, healthcare providers should use head-tilt/chin-lift procedure


Restoring the Airway (cont.)


Restoring the Airway (cont.)


Restoring Ventilation

Before attempting to provide artificial ventilation, rescuer should assess for presence of breathing

Rescuer should place his ear over victim’s mouth & nose to listen for breathing while looking at chest wall for movement for 3-5 seconds


Restoring Ventilation (cont.)



Mouth-to-Mouth Ventilation Rescuer should take slightly deeper breath than

normal & exhale directly into victim’s mouth over 1 second to produce visible chest rise

Exhaled air has 16% oxygen. Tidal volume

• Volumes between 700 & 1000 mL are ideal for most adults

• Only about 500 mL is delivered when chest compressions are being administered

• Children should be given smaller volumes

• Excessive volumes (>500 mL) or an inspiratory rate that is too fast (> 8-10/min) can cause gastric distention & increase intrathoracic pressure.





Mouth-to-nose ventilation Used when mouth-to-mouth ventilation cannot be

performed• Trismus

• Traumatic jaw or mouth injury

• Tight seal with lips cannot be maintained

Mouth-to-stoma Used in patients with tracheostomies or

laryngectomies




One- vs. Two- Rescuer Adult CPR

When performing CPR alone, lay rescuer must remember to give only compressions for adults, children, & infants until AED arrives

When two rescuers are present, one provides ventilation & evaluates effectiveness of CPR while other provides compressions 30:2 for adults & children 3:1 for infants with 90 compressions & 30 breaths

delivered/min (120 events/min)• Each breath will be delivered over ½ second with exhalation

occurring on next compression


One- vs. Two-rescuer Adult CPR (cont.)

Rescue attempts should continue until: Advanced life support is available Rescuers note spontaneous pulse & breathing Or physician pronounces victim dead

Victims who survive CPR should be transported quickly to tertiary care facilities, ideally only after advanced life support is instituted



An infant is in need of CPR. There are two rescuers present. What is the proper compression and ventilation ratio?

A.30:2

B.15:2

C.15:1

D.3:1

Automated External Defibrillation

Early defibrillation is to be done after CPR has been initiated

This recommendation is based on following facts: Ventricular fibrillation (VF) is very common in

victims of sudden cardiac arrest Probability of successful defibrillation diminishes

rapidly over time VF tends to convert to asystole within few minutes


Automated External Defibrillation (cont.)

If adult drowning victim or victim of foreign body airway obstruction becomes unconscious, healthcare provider working alone may give 5 cycles of CPR before activating emergency response system


Automated External Defibrillation (cont.)


Evaluating the Effectiveness of CPR

Effective chest compressions are essential for providing blood flow

Ventilation evaluated by observing chest wall rise & fall

Compressions at rate of 100/min with depth of 2 inches (for adults) are most effective


Evaluating the Effectiveness of CPR (cont.)

Allow chest to recoil completely after each compression

Minimize interruptions in chest compressions


Hazards & Complications

Neck or spine injuries can be aggravated Gastric inflation Vomiting

Hazard is aspiration of vomitus into lung Aspiration can be prevented by using

endotracheal tube, laryngeal mask airway, or Combitube

Internal trauma Advancement of foreign objects in upper

airway



What is/are the major complication(s) of CPR?

A.neck injuries

B.gas inflation

C.internal trauma

D.All of the above

Contraindications of CPR

Patient is biologically dead “Do not resuscitate” (DNR) order is in effect Properly executed living will (advanced

directive) specifically requests that CPR is not to be initiated


Health Concerns of CPR

Risk of disease transmission during mouth-to-mouth resuscitation is small Use of appropriate barrier device (e.g., pocket

mask) will reduce risk of disease transmission


Treating a Foreign Body Airway Obstruction

Conscious victim with obstructed upper airway will usually clutch his or her throat (universal distress signal)

Back blows & chest thrusts can be used with infants & pregnant women


Treating a Foreign Body Airway Obstruction (cont.)



Abdominal thrusts (Heimlich maneuver) should be used to clear obstruction Stand behind victim & wrap your arms around

victim’s waist Make fist with one hand & place thumb side

midline on abdomen slightly above navel & well below tip of xiphoid process

Grasp fist with other hand & deliver quick upward & inward thrust

Repeat movement until obstruction is removed or victim loses consciousness





Evaluating effectiveness of foreign body removal Successful removal of obstructing body is

indicated by:• Confirmed expulsion of foreign body

• Clear breathing & ability to speak

• Return of consciousness

• Return of normal color



Evaluating effectiveness of foreign body removal (cont.) If successive attempts to clear airway fails, more

aggressive techniques are needed, such as:• Direct laryngoscopy

• Foreign body removal with Magill forceps

• Transtracheal catheterization

• Cricothyrotomy

• Tracheotomy


Advanced Cardiovascular Life Support (ACLS)

Measures include Using accessory equipment to support ventilation &

oxygenation Monitoring ECG Establishing intravenous route for drugs Applying selected pharmacological agents &

electrical therapies RT assumes primary responsibility

Supports oxygenation Establishes & maintains airway Providing ventilation


Advanced Cardiovascular Life Support (ACLS) (cont.)


Support for Oxygenation

Low cardiac output, pulmonary shunting & abnormalities during CPR lead to hypoxia

Highest concentration of oxygen should be administered as soon as possible

Concerns about oxygen toxicity are not valid


Airway Management Pharyngeal airways can help restore airway

patency & improve ventilation, especially when using bag-mask device

Two types exist1. Nasopharyngeal

• Appropriate length can be estimated by measuring distance from patient’s earlobe to tip of nose

2. Oropharyngeal • Geudel airway has single center channel

• Berman type uses two parallel side channels

• Correct size airway measures from corner of patient’s mouth to angle of jaw following natural curve of airway


Airway Management (cont.)


Endotracheal Intubation

Allows delivery of ventilations that are nonsynchronous with chest compression

Restores airway patency Maintains adequate ventilation Reduce risk of aspiration Provides access for clearance of secretions Provides alternate route for drug

administration Preferred method for securing airway during

CPR.


Endotracheal Intubation (cont.)


Bag-Mask Devices

Health care providers who respond to cardiac arrests should be trained in use of bag-mask devices

Rescuer should deliver tidal volumes adequate to produce visible chest rise over 1 second


Bag-Mask Devices (cont.)

Achieve highest possible FIO2 with bag-mask device by: Using oxygen reservoir of adequate size Setting oxygen input flow at 10-15 L/min Delivering appropriate tidal volume for 1-second

period Ensuring longest possible bag refill time


Bag-Mast Devices (cont.)


Bag-Mask Devices (cont.)

Hazards &Troubleshooting Gastric insufflation minimized by providing low to

moderate inspiratory flows (<30 L/min) Barotrauma reduced with average mask leak Hyperventilation


Restoring Cardiac Function

ECG monitoring during CPR should be started as soon as possible

Rescuers may see Supraventricular tachycardia Ventricular tachycardia Ventricular fibrillation Pulseless electrical activity


Supraventricular Tachycardia


Ventricular Tachycardia


Ventricular Fibrillation



Common pharmacologic agents used during ACLS include all of the following, except:

A.atropine

B.epinephrine

C.lidocaine

D.racemic epinephrine

Pharmacological Intervention

Unless central vein is already cannulated, ideal route for drug administration during emergency situations is peripheral IV line

Drugs are given by rapid bolus injection, followed by 20-mL bolus of IV fluid & elevation of extremity

Selected drugs such as epinephrine, lidocaine, & atropine also may be given through endotracheal tube when intravenous & intraosseous access are not available


Electrical Therapy

Three general types:1. Unsynchronized countershock, or defibrillation

• Used to simultaneously depolarize myocardial fibers

• Definitive treatment for ventricular tachycardia & pulseless ventricular tachycardia

2. Synchronized countershock, or cardioversion• Countershock is synchronized with heart’s electrical

activity

• Shock uses less energy

• Used in patients with organized arrhythmias producing high ventricular rate & exhibiting signs of cardiac decompensation


Electrical Therapy (cont.)

3. Electrical pacing• Intermittently timed, low-energy discharges to replace or

supplement heart’s natural pacemaker



A countershock that is synchronized with the heart’s electrical activity is what type of electrical therapy?

A.defibrillation

B.electrical pacing

C.electroconvulsive

D.cardioversion

Monitoring During ACLS

Usually limited to ECG, pulse, blood pressure, & intermittent arterial blood gas sampling

ECG provides basis for selecting various drugs & electrical therapies during CPR


Post-Resuscitative Patient Care

Conscious & spontaneously breathing patients following resuscitation require Supplemental oxygen Maintenance of IV infusion Continuous cardiac & hemodynamic monitoring


Post-Resuscitative Patient Care (cont.)

Post-cardiac arrest patient care providers should: Control body temperature Identify & treat acute coronary syndromes Optimize mechanical ventilation to minimize lung

injury Reduce risk of multi-organ injury Objectively assess prognosis for recovery Assist survivors with rehabilitation services if required


Respiratory Management

If patient remains apneic or exhibits irregular breathing after resuscitation Provide 100% oxygen initially Institute mechanical ventilation through properly

positioned endotracheal tube• Mechanical ventilation adjusted accordingly to maintain

normal PaCO2 level


Respiratory Management (cont.)

ABGs are analyzed as needed until oxygenation & acid-base status of patient stabilizes

RTs maintain ventilation & oxygenation, & assist physician & nurses in monitoring patient’s condition


Chapter 34 Emergency Cardiovascular Life Support Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier.

Documents

imprint of elsevier

chest compressions rescue

chest compressions d

learning objectives

check pulse

result of resuscitation

attempted resuscitation

signs of sca