Cardio-pulmonary resuscitation (CPR) involves artificial ventilation and external chest compressions to establish blood circulation to vital organs after cardiac arrest or respiratory failure. It is indicated for cardiac, pulmonary or respiratory causes of arrest. The key steps of CPR are maintaining airway, providing rescue breathing, and performing external chest compressions at a rate of 100-120 per minute. Signs of successful resuscitation include return of pulse, breathing and consciousness. Ongoing nursing care and monitoring is critical for survival in the hours after resuscitation.

1. DEFINITION
It is defined as the use of artificial
ventilation with external heart
compression to establish blood
circulation to the vital organs ie. Brain,
heart, kidney and lungs.

2. INDICATION
i) Cardiac causes
ii) Pulmonary causes
iii) Respiratory arrest causes

3. Cardiac causes
•Myocardial infarction
•Heart failure
•Dysrrhythmia
•Coronary artery spasm
•Cardiac tamponade
•Hypotension
•Hypothermia

4. Pulmonary causes
•Respiratory failure, secondary to respiratory
depression
•Airway obstruction (anoxia)
•Impaired gas exchange, in acute respiratory
distress.
•Impaired ventilation, such as pneumothorax.
•Pulmonary embolus
•Electrolyte imbalance
•Hyperkalemia
•Hypomagnesemia
•Retention of CO2
•Carbon monoxide and other type of poisoning.

5. Respiratory arrest causes
•Drowning
•Stroke
•Heart attack
•Drug over dose
•Suffocation
•Accident/injury
•Head trauma
•Neuro muscular paralysis
•Spinal injuries
•Post-operative cervical laminectomy

6. SIGNS AND SYMPTOMS OF CARDIAC
ARREST
The three cardinal signs of cardiac arrest are
Apnea,Absence of carotid and femoral pulse and
dilated pupils.
i. Apnea
ii. Absence of carotid and femoral pulse
iii) Dilated pupil
iv) Cyanosis
v) Unconsciousness
vi) Fits

7. SEQUENCE OF CARDIO-PULMONARY
RESCESCITATION
C - Circulation
B - Breathing
A - Airway

8. PULMONARY ASSESSMENT
Because of an emergency no time is cost to initiate
cardio pulmonary resuscitation procedures. The success
of the cardio pulmonary resuscitation depends on the
speed with which basic life supporting measures are
presence of cardio pulmonary arrest in the patient
making the three cardinal signs and symptoms such as
•Apnea
•Absence of carotid and femoral pulse
•Dilated pupils

9. PURPOSES
•To initiate breathing
•To restore blood circulation
•Restore – cardio pulmonary functioning
•Prevent irreversible brain damage form Anoxia.

10. PREPARATION OF EQUIPMENT
•Oxygen administration sets
•IV infusions sets and cut down set
•Ambu bag and mark devices.
•Endotracheal tubes of different sizes.
•Oropharyngeal and nasal airway
•Laryngeal scope of different sizes.
•Tracheotomy sets
•Suction apparatus
•Cardiac monitor and defibrillator
•Mechanical respiratory aids.
•Emergency drugs such as epinephrine, sodium bi
carbonate, cardiac and respiratory stimulants etc.
•Clear rag pieces or gauze pieces in containers.

11. PREPARATION OF THE PATIENT AND
ENVIRONMENT
The patient may be shifted to a hard surface or a
hard board is placed under the patient’s thorax.
Remove or push aside the clothing which covered
the patient’s chest to observe the chest for cardiac
beats and respiration.
Place patient flat on his back with out any pillows.
This position helps to maintain the airway and to give
external cardiac compression
Hyper extended the head and neck.
External cardiac massage and artificial ventilation
must be started with in 4-6 mts following cardiac
asset or irreversible brain damage will occurs as a
result of oxygen deprivation and lack of circulation.

12. GENERAL INSTRUCTION
a)Cardio pulmonary resuscitation techniques are used
in persons whose, respirations and circulation of blood
have suddenly and unexpectedly stopped.
b)The CPR must be initiate with in 3-4 minutes in
order to prevent permanent brain damage.
c)Strike the centre of the chest sharply with the side of
the clenched fist twice.
d)Call for assistance.
e)Trace the last rib, and follow the rib to the notch
where the ribs meet the sternum. Then place the heel
of the other hand on the lower part of the sternum
above 1- above the palpating hand

13. GENERAL INSTRUCTION
a)Clear the airway of false teeth, vomitus, food
materials etc.
b)Initiate ventilation & external cardiac massage
without wasting time.
c)To prevent the tongue falling back and obstructing
the airway, tilt the head and neck into a hyper
extended position.
d)The artificial breathing and cardiac massage should
correspond to the normal respiration and pulse rate.
e)Watch for the complications that may occur during
the CPR.
f)Discontinue the procedure only when you are sure
that his respirations and circulation are reestablished

14. Look for,
constriction of pupils
change in feeling of pulse regular, rhythm
and good volume
the systemic blood pressure return to
normal.
There is improved co lour of skin.
The respiratory movements are taking place
rhythmically.

15. STEPS RATIONALE
TO MAINTAIN
CIRCULATION
Begin external cardiac
compression immediately
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 a bed or on a table. It is
often necessary to kneel on the
bed or table at the side of the
patient.
Tissue hypoxia will cause
irreversible brain damage if an
adequate circulation is not
restored within 3 -4 mts.
If bed is sagging it is difficult
to evaluate the amount of
sternal pressure existed during
each compression.
To use the pressure effectively.

16. STEPS RATIONALE
Place the heel of open hand on
the lower third of the sternum
of above the xiphoid process.
Place the heel of the other
hand on the top of the first
hand, keep the fingers
elevated from the chest wall or
they may be kept interlocked.
Straighten arms by locking
elbows. Lean forward until
your shoulders are directly
over your hands, depress
patient’s sternum
1 ½ to 2 inches with each
compression.
Using the heel of the hand
exerts pressure only on the
sternum. Pressure elsewhere
can create with fracture.
Locking the elbows and
straightening the back adds
pressure of chest compression.

17. STEPS RATIONALE
Release pressure on the
sternum quickly and
completely taking care not to
change the position of your
hands, nor to move them off
the chest wall.
Rhythmically continue cardiac
compression a rate of 100 per
minute. For young children
and infants the rate of
compression is 80-100mt.
Periodically assess the vital
signs.
Each compression on squeezes
blood out of the heart and
relaxation period allows time
for the heart to fill with blood
before the next compression.
Improvement of color and
return of spontaneous
movement of the chest are the
only observation possible to
note by one rescuer.

18. STEPS RATIONALE
BREATHING: MOUTH TO
MOUTH BREATHING
Maintain the position of the head
as discussed.
Pinch the patient’s nostrils closed.
Using an index finger and thumb of
the hand near the patients face.
Take a deep breath. Place your
widely opened mouth over the
patient’s 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.
Keep the airway clear.
Closing the nostrils with
fingers and enclosing the
patient’s mouth into the
rescue’s mouth ensures
air tight seal.

19. STEPS RATIONALE
After each inflation move your
mouth away from the patient’s
mouth.
Repeat inflation 12 to 15 times
per minute at the rate of one
inflation every three to five
seconds. Until the patient
breaths spontaneously. In
children, less volume of air is
introduced but they are given
about 20 or 30 times per
minute.
To allow air to escape when the
patient exhales and for you to
inhale.
The inflation of the lungs
should. Correspond to the
normal respiration.

20. STEPS RATIONALE
MAINTAINING THE
AIRWAY
Clear the airway of obvious
foreign matter eg. Vomitus,
secretion etc.
Hyper extended the head and
neck of the patient by lifting it
backward as for as possible.
Pull the victim’s jaw forward
by placing the finger behind
the angle of jaw and is lifted
forwarded until the teeth on
the upper jaw and the lower
are approximated.
Clearing of airway obstruction
may restore the spontaneous
respiration and circulation.
Prevents the tongue falling.
Helps to keep airway open and
prevents falling back of the
tongue.

21. STEPS RATIONALE
With the above steps. If
breathing is restored, placed
an oro-pharyngeal airway. If
breathing is not restore start
artificial ventilation.
Placing an oro pharyngeal
airway helps to keep the
airway patent. It also prevents
biting of tongue

22. AFTER CARE OF THE PATIENT
•Skilled after care of the patient who has suffered
cardiac arrest is crucial for survival. The patient
should be continually watched by skilled person
over a period of 48-72 hours.
•If the patient is not in the intensive care unit shift
him to the ICU for constant observation and
expert care.
•Give oxygen continuously for 48 hour following
resuscitation are depressed for some time after
the cardiac arrest.
•Frequently checking the victim’s head and jaw
position because his tongue may fall back and
obstruct the airway.

23. •Assess the patient’s respiration by nothing the
rhythm, rate and depth of respiration.
•Check the colour of the skin. Persisting cyanosis
indicates adequate oxygenation of blood.
•Watch for the signs of restored circulation and
respiration.
•contraction of pupils
•improved colour
•change in the quality of pulse
•normal breathing pattern

24. •return of systemic blood pressure
check temperature every hour
watch for convulsion.
Insert entotracheal tube, if not already in
place. This maintains the airway patient.
Insert foly’s catheter. Write output is one of
the measures of the cardio-vascular status.
Start I.V infusion to administer enough fluid.
Blood gas and PH determinations are done to
detect metabolic acidosis.
Record the procedure on the nurses record
with date and time.

25. MEDICATIONS USED IN CPR
i. Vasopressors
Adrenaline or epinephrine enhances cerebral and myocardial
blood flow by preventing arterial collapse. The dose is 1mg every
3-5 minutes.
In children 10Mg/Kg or 0.1ml/kg of in 10000 solution.
ii. Anti arrhythmic agents
Lignocaine is of undoubted value in treatment of ventricular
tachycardia (vt) and its ability to prevent (VF) has also been
demonstrated.
Dose: 1 – 1.5mg/kg bolus
ii) The other drugs such as amiodorone, procainamide, sotalol and
flecainide. The amiodorone is a complex drug with effects on
sodium, potassium and calcium channel as well as alpha, betas
blocking properties. It is useful in treatment of both AF & VF.
Dose: 150mg diluted in 20ml of 5% dextrose given over 10min,
followed by infusion 1mg/min for to hours then 0.5mg/ml.

26. iii) Others
a. Sodium-bicarbonate (NaHCO3):
Whenever possible, bicarbonate therapy should be guided by the
bicarbonate concentration or calculated base deficit obtained from blood
gas analysis.
b. Calcium (Ca++): (Calcium gluconate)
Usually has no role unless patient present with calcium channel blocker
toxicity or if there is evidence of hypocalcaemia or hyperkalemia.
Dose: 0.5ml/kg
c)Magnesium (Mg++)
It is indicated only if hypokalemia or hypomagnesaemia.
Dose of magnesium sulfate: 1-2 gm/ diluted in 100ml of 5% dextrose
gain over 30-60mints followed by an infusion of 0.5 – 1.0gm/hour.
d) Atropine
It enhances automaticity and conduction of both sinoatrial and
atrioventricular node and is most effective in haemodynamically
significant bradycardia.
Dose: 1.0mg IV repeated 3-5 minutes if required.
For brady cardia, 10mg/kg repeated every 3-5mints.

27. Step Procedure
Prepare the patient Assemble a laryngoscope, ET
Tubes, stylet, suctioning
equipment and a bag value mark.
Determine which medications
will be used and prepare them for
administration. Begin cardiac and
O2 saturation monitoring.

28. STEPS PROCEDURE
Provide cervical spine immobilization
or indicated.
Provide 100% oxygen.
Pre-medicate if appropriate.
Push (IV) sedative
Paralyze
Prevent cervical spine damage in
trauma patients.
Pre oxygenate using a bag-value mark.
Lidocaine 1 to 1.5 mg/kg IV should be
sued if there is concern about
increased intracranial pressure.
Atropine 0.02mg/kg IV should be used
in children.
Edomidate 0.2 to 0.6mg/kg IV.
Thiopental 3-5mg/kg IV. Fentanyl 3-
5mg/kg c midazolam.
Succinyl choline 1-5 to 2mg/kg IV or
propofol 3-5mg/kg IV cricoids
pressure should be applied to prevent
regurgitation.

29. Pressure is applied to the cricoids
Pass the tube
Placement is confirmed.
Post intubation plan is made
After 40 seconds of cricoid pressure
intubate the patient. This procedure
should be accomplished with 30
seconds. Visualize tube placement.
Look for the rise and fall of the
patient’s chest. Auscultate for lung
sounds bilaterally. Check oxygen
saturation 98-100% perform a chest x-
ray to check tube placement.
Secure the ET stube inflate the cuff.
Continuously assess O2 saturation.
Determine ventilation setting. Assess
whether the patient should remain
paralyzed and sedated.

30. FAILURE OF CARDIO-PULMONARY
RESUSCITATION CAUSED BY
•Massive myocardial infarction
•cardiac tampon
•Enlarged heart with incompetent values.
•Obstructed airway.
•Severely decreased / damaged lungs.
•Pulmonary embolism
•Chest deformity
•Fracture of ribcage.

31. FAULTY TECHNIQUE OF CPR RESULT IN
1.In adequate airway opening.
2.Placement of patient on soft yielding
surface.
3.In adequate chest compression
4.Improper seal around the patient’s
mouth.
5.Improper or on adequate drug therapy
6.Prolonged interruption.

32. SIGNS OF SUCCESSFUL CPR
•Perceptive lung expansion
•Palpable pulse
•The pupil will react to light or will appear
normal.
•Normal heart rate will be return.
•A spontaneous gasp or breathing will
occur.
•Move body parts, colour may improve from
cyanosis.

33. NURSING INTERVENTION
In effective airway clearance related to airway
obstruction secondary to aspiration or obstruction
with foreign matter.
Risk for aspiration secondary to
unconsciousness.
Risk for fall related to unconsciousness
Fatigue related to impaired blood circulation
secondary to cardiac arrest

34. THANK YOU