Cardiac Arrest Data Collection From

Cardiac Arrest Data Collection Form

Date of Arrest: Portea ID:

Patient Name: Age/ Sex:

Cardiac arrest determined by:

Location of arrest

Witnessed By : If witnessed, time of arrest

________________(hh:mm)

Air entry checked : Yes Or No Chest compressions : ventilations

Result:

Name & Designation Signature

 CHECKLIST FOR CARDIO PULMONARY RESUSCITATION
Date of Arrest: Portea ID:
Patient Name: Age & Sex:
Cardiac arrest Location of
determined by: arrest:
Sr.
Check List Yes No Remarks
No
Assess the condition of the patient to ascertain the
1.
need for CPR
Assess the responsiveness by shaking and calling the
2.
patient.
Assess the cardiac and respiratory status of the
3. patient (Presence of respiration and pulse) and
previous history of cardiac arrest.
4. Check that CPR kit is complete
5. Follow the steps of CAB of basic life support.
6. Ensures the safety of self and the victim.
Place the patient on hard surface in supine position
7.
and rescuer also in correct position.
Make sure that airway is cleared by proper position
8. (Hyperextension of head & neck) and artificial
dentures are removed.
Initiate mouth-to-mouth breathing if breathing not
9.
restored.
Ensure the closing of nostrils of victim with thumb
and index finger and enclosing his mouth with
10.
rescuers mouth to maintain the air tight seal for
effective ventilation of lungs.
Repeat the procedure 12-20 times at the rate of one
11.
inflation every 3-5 sec.
Ensure the inflation of lungs corresponds to the
12.
respiration of the victim.
13. If victim is pulse less, give cardiac compression
Correct location of lower half of the sternum when
14
cardiac compression is used.
Artificial breathing and cardiac massage corresponds
to normal respiration and pulse rate 15:2 for infants
15.
with two rescuers and 30:2 with one or two rescuer
in adult, children and one rescuer in infant
 Ensure the establishment of respiration and
circulation: constriction of pupils, regular pulse,
16.
normal B.P, normal skin colour & rhythmic
respiration.
Observe for any complications: sternal and rib
17.
fracture, pneumothorax evident.
Document the procedure, date, time, method and
18.
response of patient.
After care of patient
1. Make the patient comfortable
Observe for any complication again and take
2.
appropriate action.
Name & Designation: Date: Signature:

CPR Post Event Analysis (By N.S / SME)

Date of Arrest: Portea ID:
Patient Name: Age & Sex:
Cardiac arrest Location of
determined by: arrest:

Cause of cardiac Arrest:

Analysis of steps taken to resuscitate:

Outcome:

Action/Remarks: