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CARDIOPULMONARY RESUSCITATION

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					CARDIOPULMONARY RESUSCITATION

Introduction
This is the first segment of your training in cardiopulmonary resuscitation
(CPR). The training and practice of the skills necessary for providing CPR will
continue throughout the whole of your course, and at various times will be
formally assessed. Some of you will have had previous resuscitation training,
but it may be that the guidelines have changed since that time. In addition you
will probably have been taught as a member of the public. Today, and
throughout the course, we will concentrate on basic life support (BLS) as it
should be practiced by a healthcare professional. BLS can be reviewed using
the CPR CAL program on the MRC website. On this CAL program you can see
some of the skills and knowledge you will learn later in the course.

Further reading: The resuscitation guidelines are regularly revised. Generally
they are reviewed and updated according to the best available evidence every
4-5 years. The most up to date source for further information on life support is
the Resuscitation Council website at http://www.resus.org.uk/pages/bls.htm

Aim
The aim of this training is to enable you to assess an apparently lifeless patient,
diagnose the problem and then institute appropriate management. As you
continue through university and on through your career, the management you
yourself will be able to undertake will become more advanced, but today we will
concentrate on the skills necessary to perform BLS correctly in the adult in a
healthcare setting.

Objectives
Our objectives for this session are:
 Initial assessment of the apparently lifeless adult
 Basic life support for the unconscious adult who is breathing and has a
  pulse
 Basic life support for the adult who has stopped breathing - respiratory
  arrest
 Basic life support for the adult who is not breathing and has no pulse –
  cardiac arrest
 Basic life support management of the choking patient.

The skills we will learn and practice include:
 Assessment of Airway, Breathing and Circulation - the ABC approach
 Basic manouevres for the obstructed (not clear) airway
 How to breath for the non-breathing patient (rescue ventilation) – mouth to
   mouth or mouth to mask ventilation
 Chest compressions combined with rescue ventilation for the cardiac arrest
   patient – cardiopulmonary resuscitation (CPR).
 Optimal team management when providing BLS


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Cardiopulmonary Resuscitation
Most adult cardiac arrests in the community are the result of ischaemic heart
disease. 40% of sudden deaths from ischaemic heart disease occur within one
hour of the onset of the first symptoms of a heart attack. Over 90% of the
cardiac deaths occurring outside hospital are due to ventricular fibrillation (VF),
which is disorganised and totally ineffective electrical activity in the heart. You
can see what VF looks like on a tracing of the electrical activity of the heart by
looking through the advanced life support section of the Cardiopulmonary
Resuscitation (CPR) CAL program.

Survival from cardiac arrest has been shown to be optimal when:
 The event is witnessed
 A bystander starts effective Basic Life Support
 The rhythm during the arrest is ventricular fibrillation
 There is access to early defibrillation

Cardiac arrest may be due to causes other than ischaemic heart disease,
especially in a young person. For example drug overdose, electrocution,
immersion, massive blood loss. It is worthwhile remembering that in some
circumstances CPR can delay death for more than an hour while treatments for
an underlying reversible condition is being provided e.g. after a drug overdose
or hypothermia.

The earliest recorded description of mouth to mouth ventilations is by the
prophet Elisha in the Bible. The first medical report of success was in 1744, but
there was no progress with this technique until the 1950’s when mouth to mouth
ventilation became widely accepted.

Closed chest cardiac massage was first described in 1878, and it was
successfully applied in a few cases over the next 10 years. Open chest
massage then became the accepted technique for the next 70 years, until in
1960 a classic paper on closed chest massage was published. This coincided
with the reintroduction of mouth to mouth ventilation. 1960 can then, with some
justification be considered the year that CPR as we know it was born.

The UK and European Resuscitation Councils produce the guidelines we will
learn and practice today. They are regularly reviewed and changed
approximately every 4-5 years when evidence accumulates to suggest that a
change in method is advantageous to the patient. Throughout your career you
will need to keep up to date with the most recent resuscitation guidelines and
methods. This will be the case for many areas of your medical practice.
However there is clear evidence that if you do not revise and practice your CPR
knowledge and skills that your performance will decay after a few months. You
should revise this area of work at least every 12 months throughout your career.




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There are times when CPR is not appropriate. This would be the case in
someone whose life was known to be drawing naturally to a close due to
irreversible disease. You may want to think about this and discuss it with your
tutors throughout the medical course, when you meet patients who are
expected to die.

Basic Life Support
After ensuring the safety of the rescuer and victim, all patients with sudden
collapse or who appear apparently lifeless should be assessed for
responsiveness. Then the presence of a clear Airway, adequate Breathing and
Circulation should be assessed. If these are not present then appropriate
resuscitation should be started.

Start with the SAFE approach:
 Shout for help
 Approach with care
 Free from danger
 Evaluate the patient

Evaluation
Evaluate the patient by checking for responsiveness – gently shake the
shoulders and ask loudly “are you alright?’

   If the patient responds or moves then leave them in the position found,
    unless there is further danger, check for injuries and the general condition
    and call for help as needed. Reassess the casualty regularly.

   If the patient does NOT respond, shout for help if this has not been done,
    turn the victim onto their backs and then

Airway
Open the airway with head tilt and chin lift (avoid head tilt if trauma to the neck
is suspected)

Breathing
Check for normal breathing, while keeping the airway open by looking for chest
movements, listening at the mouth and nose for breath sounds and feeling for
air against your cheek. Look, Listen and Feel for breathing for 10 seconds
before deciding that breathing is absent.

N.B. in the initial minutes after a cardiac arrest a victim may be barely breathing
or taking infrequent noisy gasps (known as agonal breathing and present in up
to 40% of cardiac arrest victims). This should not be mistaken for normal
breathing. If you are in doubt as to whether breathing is normal then act as if it
is not normal.



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   If the patient is breathing normally then turn into the recovery position
    (see later) and send or call yourself for an ambulance by dialing 999 or 112.
    Continue to reassess.

   If the patient is NOT breathing you must now ensure if it has not already
    been done, that an ambulance is called either by a bystander or yourself.

   The new guidelines reinforce the importance of defibrillation as early as
    possible, and so when calling asking for emergency services a request
    must also be made for any available defibrillator.



Circulation
Those who are experienced in clinical assessment (you are expected to
develop this experience during the next year) may wish to assess the carotid
pulse at the same time as assessing breathing. Alternatively this may follow the
breathing check. Whichever the pulse check must take no more than 10
seconds.

   If the patient is not breathing but has a pulse (respiratory arrest) then start
    rescue breathing and check for a pulse every 10 breaths (approximately
    every minute). If there are any doubts about the presence of a pulse, then
    start chest compressions as described below and continue until more expert
    help arrives.

   If the patient is not breathing and has no pulse – or is not breathing and you
    are not sure if there is a pulse - you should now perform 30 chest
    compressions at a rate of 100 – 120 / min. After 30 compressions open
    the airway again and give two rescue breaths. Continue with chest
    compressions and rescue breaths in a ratio of 30:2.

If your rescue breaths do not make the chest rise and fall as in normal
breathing, then before your next attempt at rescue breathing
 Check the victim’s mouth and remove any visible obstruction
 Recheck that you have adequately opened the airway with head tilt and chin
    lift
 Do no attempt more than two breaths each time before returning to chest
    compressions.

Only stop to check the casualty if they start to breath normally – otherwise do
not interrupt resuscitation.

N.B. If there is more than one rescuer present then another should take over
chest compressions about every 2 minutes (5 cycles of 30:2) to maintain good
quality resuscitation and limit fatigue. There should be a minimum of delay


                                                                                 4
during the changeover period. Therefore the next person to perform chest
compressions must be prepared and get in position to start during the two
rescue breaths. At all times minimal interruptions to CPR should be
ensured.


Mouth to mouth ventilation
Turn the casualty onto their back if necessary. Pinch the soft part of the nose
closed with the index finger and thumb of the hand which is performing the
head tilt. Allow the casualty’s mouth to fall open a little, but maintain chin lift with
your other hand. Take a full breath and play your lips around the mouth, making
sure that you have a good seal. Blow steadily and slowly into the mouth
watching for the chest to rise. Each inspiration should take 1 second and
enough volume should be given to make the chest rise as in normal breathing.
If the chest does not rise then
 Check the victim’s mouth and remove any visible obstruction
 Recheck that you have adequately opened the airway with head tilt and chin
     lift
 Do no attempt more than two breaths each time before returning to chest
     compressions.

Mouth to nose ventilation
This is an effective alternative to mouth to mouth ventilation and may be
considered if there is any serious injury to the mouth, if it cannot be opened or if
a seal with mouth to mouth is difficult to achieve.

Mouth to tracheostomy ventilation
This should be used for a casualty with a tracheostomy tube or a tracheal
stoma who requires rescue breathing.

Using a face mask
The face mask must be held over the face with two hands, whilst still
maintaining chin lift and head tilt. Frequently when using the face mask with
fingers of both hands, placed behind the angle of the jaw can push the jaw
forwards (jaw thrust) taking the place of the chin lift and helping to open the
airway.
Whilst maintaining the open airway (with the manoevres described above), your
hands must press the mask down onto the face so that there is a seal all the
way round and the air blown in does not escape around the mask. If the airway
not kept adequately clear or there is an inadequate seal around the mask you
will be unable to ventilate the casualty.
Using a face mask can be a difficult skill to master. However many rescuers
carry pocket masks for use and as a future healthcare worker it is important that
you learn to use the mask. Later, when you are skilled with the mask, you will
be able to deliver oxygen with a bag attached to the mask during resuscitation.




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In any practical assessment of your CPR skills and knowledge it is likely that
you will be asked to use a mask.




Chest Compressions
The correct position for chest compressions is the middle of the lower half of the
sternum. Place the heel of one hand in the correct area, with the other hand on
top. Lean well over the casualty with your shoulders over your straight arms.
Now press vertically down on the sternum, ensuring that there is no pressure on
the ribs.
The correct depth of compression in 5 – 6cm and careful attention should be
given to achieving this depth on each and every compression. The chest should
be allowed to recoil back to resting position each time. The rate of
compression is 100 – 120 / minute (note that this is the rate, not the total
number given in a minute as there may be interruptions for delivery of
rescue breaths or opening the airway. These interruptions should be
minimized). Generally you will perform compressions best if your dominant
hand is the hand next to the sternum.

It is well documented that previously interruptions in chest compressions were
common in real life resuscitation and this is clearly associated with a reduced
chance of survival. It is essential that any interruptions should be minimized! To
ensure that quality of compressions remains high, and recognizing that
delivering compressions is tiring, when there is more than one rescuer another
should take over the compressions about every two minutes. Change over time
must be kept brief!

Compression only resuscitation
Some rescuers in the community are unable or unwilling to perform rescue
breathing. It has been recorded that reluctance to perform mouth to mouth
ventilation stops some rescuers from providing any form of resuscitation. It is
now encouraged that compressions alone are encouraged in such
circumstances. Clearly within a healthcare setting compression only ventilation
would rarely be appropriate as pocket masks or masks attached to a bag-valve
arrangement, so that the casualty can be ventilated with oxygen, are available.

Drowning
It may be that a slightly different modification to the resuscitation guideline may
improve the outcome for victims of drowning. In a drowning situation the
guideline should be modified as follows:
 Give five initial rescue breaths before you start chest compressions (c.f. all
    other causes of cardiac arrest in the adult where chest compressions should
    be performed first)




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   If you are a lone rescuer then perform CPR for approximately one minute
    before you go for help.

You will be reminded of this sequence next year when we learn basic life
support for children and infants in detail.


The recovery position
When assessment reveals there is an unconscious patient, or in the unlikely
event that circulation returns with basic life support only, it is important to
maintain a good airway and ensure that the tongue does not cause any
obstruction. It is also important to minimize the risk of inhalation of gastric
contents which may be regurgitated.
For these reasons the patient should be placed in the recovery position, which
encourages the tongue to fall forward helping to keep the airway clear. Although
there are several variations of the recovery position, each with its own
advantages we recommend the following procedure (as recommended by UK
Resuscitation Council).

   Remove the patient’s spectacles
   Kneel beside the victim and make sure that both the patient’s legs are
    straight.
   Place the arm nearest you out at right angles to the patient’s body, elbow
    bent with the hand palm uppermost.
   Bring the patient’s far arm across the chest and hold the back of this hand
    against the patient’s cheek which is nearest to you.
   With your other hand, grasp the far leg just above the knee and pull it up,
    keeping the foot on the ground.
   Keeping the patient’s hand pressed against the cheek, pull on the leg to roll
    the patient towards you onto their side.
   Adjust the upper leg so that both the hip and knee are bent at right angles
   Tilt the head back to make sure that the airway remains open
   Adjust the hand under the cheek if necessary to keep the head tilted and the
    airway open
   Check breathing regularly and get help. Reassess at frequent intervals.

If the patient has to remain in the recovery position for more than 30 minutes
you should turn them onto the other side in order to minimize pressure effects
on the lower arm (you can feel what this is like when you allow your colleagues
to practice putting you into the recovery position. You will be able to practice
with them in turn)


Choking
Choking occurs when a foreign body lodges in the back of the throat blocking
the entrance to the trachea. Someone who is choking will have difficulty


                                                                               7
breathing and may become cyanosed (blue discolouration noticed often at the
lips caused by deoxygenated haemoglobin). Symptoms may be mild or very
severe. If the patient is conscious they may try and indicated their problem by
grasping their neck with the hands or pointing to their throat while coughing.
Another clue is that choking often happens during eating. It is important to ask
the conscious patient ‘Are you choking?’

Recognition of the problem is the key to successful outcome and so it is
important not to confuse choking with fainting, heart attack, seizure or other
conditions which may cause sudden respiratory distress, cyanosis or loss of
consciousness.

Choking management sequence
The following sequence of actions should be used in anyone over the age of 1
year.

If the patient shows signs of mild airway obstruction (generally can talk,
cough, breathe) – encourage them to continue coughing but do nothing else
yourself.

If the patient shows signs of severe airway obstruction and is conscious
(unable to speak, may only respond by nodding):

Give up to five back blows
 stand to the side and slightly behind the patient
 supporting the chest with one hand, lean the patient well forward so that if
   the obstructing object is dislodged it is likely to come out of the mouth
 give up to five sharp blows between the scapulae with the heel of your hand.
 Check to see if each blow has relieved the airway obstruction – the aim is to
   relieve the obstruction rather than give all five blows.

If five blows fail to relieve the obstruction then give five abdominal thrusts
 Stand behind the patient and put both arms round the upper part of the
     abdomen
 Lean the patient forwards
 Clench your fist and place it between the umbilicus and the bottom end of
     the sternum (in the epigastrium)
 Grasp this hand with your other hand and pull sharply inwards and upwards.
 Repeat this up to five times checking each time if the obstruction is relieved
If the obstruction is not relieved then continue alternating rounds of up to five
back blows with up to five abdominal thrusts.

If the patient becomes unconscious
 Support the patient carefully to the ground
 Immediately call 999 (or 911) if outside the hospital



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   Start CPR starting chest compressions in this situation even if the patient
    has a pulse.




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Ask for AED if
  available




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