CARDIAC ARREST

INTRODUCTION:

Cardiac arrest is a condition in which the heart has stopped beating or is not beating
efficiently enough to sustain life. Cardiac arrest is also known as sudden cardiac arrest, is
rapidly fatal within minutes if not immediately treated with CPR, defibrillation and
advanced life support. Cardiac arrest can occur without any underlying cause. Cardiac
arrest can happen in any age group people but people most at risk include those who have
a history of coronary heart disease and or at a risk of previous heart attack. Other risk
factor includes smoking, diabetes, congenital heart defects, electrolyte imbalance, obesity,
cardiovascular disease.

DEFINITION:

Cardiac arrest occurs when the heart ceases to produce an effective pulse and blood
circulation.
It may be due to cardiac electrical event , as when the HR is too fast(especially ventricular
tachycardia or ventricular fibrillation) or too slow (bradycardia pr AV block), or when there
is no heart rate at all(asystole).Cardiac arrest may follow respiratory arrest;it may also
occur when electrical activity is present but there is ineffective cardiac contraction or
circulating volume, which is called pulselesss electrical activity(PEA)
PEA can be caused by:
 Hypovolemia
 Cardiac tamponade
 Hypothermia
 Massive pulmonary embolism
 Drug overdoses(calcium channel blockers,betablockers,digitalis)
 Massive acute myocardial infarction

Three cardinal signs of a cardiac arrest are:

 Apnea
 Absence of a carotid or femoral pulse and dilated pupils
 Person’s skin appears pale or grayish and feels cool

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VARIOUS CAUSES OF CARDIO PULMONARY ARREST

Cardiac arrest can result from :

 Ventricular fibrillation
 Ventricular tachycardia
 Asystole
 Electromechanical dissociation

Respiratory arrest can result from:

 Coma
 Airway obstruction
 Injuries
 Stroke
 Smoke inhalation

CLINICAL MANIFESTATIONS:

1. Immediately loss of consciousness

2. Loss of blood pressure and pulse
3. Gasping may occur
4. Pupils of eye begin dilating within 45 seconds
5. Seizures may or may not occur
6. Risk of irreversible brain damage or death increases with every minute from the time
that circulation ceases

EMERGENCY MANAGEMENT:

 Cardio pulmonary Resuscitation

 Maintaining Airway And Breathing
 Restoring Circulation
 Follow-Up Monitoring

CARDIOPULMONARY RESUSCITATION :

The ABCDs of basic cardiopulmonary resuscitation are

 Airway
 Breathing
 Circulation
 Defibrillation

Resuscitation consists of the following steps:

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Airway: Maintaining an open airway
Breathing: Providing an artificial ventilation by rescue breathing
Circulation: Promoting artificial circulation by external cardiac compression
Defibrillation: Restoring the heart beat

If the patient is monitored or is immediately placed on the monitor using defibrillation and
the ECG shows ventricular tachycardia or ventricular fibrillation defibrillation rather than
CPR is the treatment of choice. I f the patient has not defibrillated within 10 minutes,the
chance of survival is close to zero.

MAINTAINING AIRWAY AND BREATHING:

The first step in CPR is to obtain an open airway. Any obvious material in the mouth or
throat should be removed. The chin is directed up and the back or the jaw (mandible) is
lifted forward. The rescuer “looks, listens, and feels for air movement. An oropharyngeal
airway is inserted if available. Two rescue ventilation over 3 to 4 seconds are provided by
using a bag or mouth mask device. An obstructed airway should be suspected when
rescuer cannot give the initial ventilations, and appropriate actions should be taken to
relieve the obstruction.
If the first rescue ventilation entered easily, then the patient is ventilated with 12 breaths
per minute and the open airway is maintained. Endotracheal intubations is frequently
performed by a physician, nurse, anesthesist during a code to ensure an adequate airway
and ventilation. The resuscitation bag device is then connected directly to the endotracheal
tube. Arterial blood gas levels are measured to guide oxygen therapy.

RESTORING CIRCULATION:

After performing ventilation, the carotid pulse is assessed and external cardiac
compression are provided when no pulse is detected. Compression are performed with the
patient on a firm surface, such as the floor, a cardiac board, or a meal tray. The rescuer
(facing the patient’s side) places the heel of one hand on the lower half of the sternum,
two fingerwidth (3.8cm) from the tip of xiphoid and the position of the other hand on top
of the first hand. The fingers should not touch the chest wall.
Using the body weight while keeping the elbow straight, the rescuer presses quickly
downward from the shoulder area to deliver a forceful compression to the victim’s lower
sternum about (3.8 to 5 cm) towards the spine. The chest compression rate is 80 to 100
times per minute. If one rescuer is available , the rate is two ventilation to every 15 cardiac
compressions. When two rescuer is available, the first person performs the cardiac
compression when the second rescuer ventilates the patient, with each ventilation taking
1.5 to 2 seconds.

FOLLOW-UP MONITORING:
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Once successfully resuscitated, the patient is transferred to an intensive care unit for close
monitoring. Continuous ECG monitoring and frequent blood pressure assessments are
essential until the patient is hemodynamic stable. Etiologic factors that precipitated the
arrest, such as metabolic or rhythm abnormalities, must be identified and treated.

Medications Used
AGENTS AND ACTION:

1.Oxygen:(Improves tissue oxygenation and corrects hypoxemia)

INDICATONS:
Administered to all patients with acute cardiac ischemia or suspected hypoxemia, including
those with COPD

NURSING CONSIDERATIONS:

Use 100% FiO2 during resuscitation

Recognise that no lung damage occurs when used for less than 24 hours.
Monitor dose by end- tidal CO 2 or pulse oxymeter.

2. Epinephrine:(Increases systemic vascular resistance and blood pressure, improves

coronary and cerebral perfusion and myocardial contractility)

INDICATIONS:
Given to patients in cardiac arrest caused by ventricular tachycardia, ventricular fibrillation,
asystole, or pulseless electrical activity

NURSING CONSIDERATIONS:

Administer by IV or through endotracheal tube.

Avoid adding to IV lines that contain alkaline solution (eg. Bicarbonate)

3. Atropine (blocks parasympathetic action, increases SA node automaticity and AV

conduction)

INDICATIONS:
Given to patients with symptomatic bradycardia

NURSING CONSIDERATIONS:

Should be given rapidly as 2.0 to 2.5 mg through IV Or ET tube

Monitor patient for reflexive tachycardia

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4.Sodium Bicarbonate:(corrects metabolic acidosis)

INDICATIONS:
Given to correct metabolic acidosis

NURSING CONSIDERATIONS:
Initial dose should be 1 mEq/kg IV ; then the dose is based on the base deficit calculated
from ABG

5. Magnesium(promote adequate functioning of the cellular sodium-potassium pump)

INDICATIONS:
Given to patients with torsades de pointes

NURSING CONSIDERATIONS:
May give dilute over 1-2 min or IV
Monitor for hypotension, asystole, bradycardia, respiratory paralysis

CARDIOPULMONARY RESUSCITATION
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INTRODUCTION:

The American Heart Association estimates that one American suffers a coronary event
every 29 seconds and that someone dies from a coronary event every minute.
Approximately 220,000 people die of coronary heart disease each year without reaching a
hospital. Most of these are sudden deaths caused by cardiac arrest, usually resulting from
VF. Sudden death from ischemic heart disease is one of the most serious and most
important medical emergencies.

DEFINITION:
CPR is a procedure used when a patient’s heart stops beating and breathing stops. It can
involve compressions of the chest or electrical shocks along with rescue breathing.
It combines rescue breathing (also known as mouth-to –mouth breathing) and external
chest compressions.
Cardio refers to the heart, and pulmonary refers to the lungs, and resuscitation means “to
revive”.

CPR GUIDELINES FOR THE HEALTH CARE PROVIDER:

A. Chest compressions:
 “push hard and push fast”
 Compress chest at rate of 100/minute
 Allow complete chest recoil after each compressions
 Minimize interruptions in chest compressions

B. Compression- to-ventilation ratio:

 Compression-ventilation ratio of 30:2 for single rescuer for all clients except
newborns

C. 1-second breath:
 Each rescue breath should be given over 1 second
 Chest should rise with each breath
 Avoid delivering too many breaths or breath too large and / too forceful

D. Attempted defibrillation:
 Deliver one shock followed by immediate CPR beginning with chest
compressions
 Check rhythm after 5 cycles of CPR

BASIC LIFE SUPPORT:

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Basic life support is an emergency procedure that consists of recognising an arrest and
initiating proper CPR techniques to maintain life until the victim either or is transported to
a medical facility where advanced life-support measures are available. Basic life support
(BLS) is a level of medical care which is used for patients with life-threatening illness or
injury until the patient can be given full medical care. It can be provided by trained medical
personnel, including emergency medical technicians and by laypersons who have received
BLS training. BLS is generally used in the pre-hospital setting, and can be provided without
medical equipment.

There are eight steps for performing basic life support:

1. Check the victim’s responsiveness
2. Call 9-1-1
3. Open airway
4. Check breathing
5. Check circulation
6. Perform CPR
7. Recheck circulation
8. Perform rescue procedures based on findings

ALGORITHM FOR BASIC LIFESUPPORT:

The 2006 American Heart Association recommendation for chest compression

Ventilation ratio is 30:2 The recommended rate until 2006 was 15:2

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 The “ABCD” stands for airway, breathing, circulation, and defibrillation/ definitive
treatment. Safe implementation of CPR involves five steps.

STEP I: Assess Level Of Consciousness

Person who appear to be unconscious may be asleep, deaf, or possibly intoxicated.

Unconsciousness is confirmed by shaking the victim’s shoulder and shouting “Are you OK?”
If the person does not respond, the emergency response system is activated immediately
and the victim is cautiously placed in the supine position on a firm surface, remembering
the potential for head injury.

STEP II :Open The Airway:

The tongue is a most common cause of airway obstruction in the unconscious person. The
head tilt-chin lift method and the jaw thrust are the two recommended methods for
opening and maintaining the airway. Jaw thrust (without head tilt) is the safest approach to
use with a victim with a suspected neck injury. The head must be carefully supported to
avoid turning or tilting it backward. While maintaining an open airway, the rescuer takes 3
to 5 seconds to look, listen, and feel for spontaneous breathing. The rescuer places an ear
over the victim’s nose and mouth while looking at victim’s chest to see if the chest moves
with respiration, listen for air escaping during exhalation, and feels for air movement
against the face

STEP III: Initiate Artificial Ventilation

Mouth- to- Mouth Ventilation:

To initiate artificial ventilation give two breath lasting 2 seconds each, and observe for
adequate ventilation. If the patient does not resume breathing, continue mouth-to-mouth
ventilation. One breath is delivered every 5 seconds.
1. Maintain victim in head tilt-chin lift position.
2. Pinch nostrils
3. Take a deep breath and place mouth around outside of victim’s mouth, forming a
tight seal. Use a rescue airway if available.
4. Blow into victim’s mouth
5. Adequate ventilation is demonstrated by
a. Rise and fall of chest
b. Hearing and feeling air escape as victim passively exhales
c. Feeling the resistance of the victim’s lung expanding

Mouth-to-Nose Ventilation:

Mouth-to- Nose ventilation is indicated when the mouth is seriously injured or if a tight
seal cannot be established around the mouth. The rescuer places one hand on the
forehead to tilt the head back and the uses the other hand to lift the lower jaw and close

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the mouth. After taking a deep breath, the rescuer seals the mouth around the victim’s
nose and begin to blowing until the lung expand. Occasionally, when mouth-to-nose
ventilation is used, it may become to necessary to open the victim’s mouth or lips to allow
air to escape on exhalation because the soft palate may produce nasopharyngeal
obstruction.

Mouth-to-Stoma Ventilation:

Direct mouth-to-stoma artificial ventilation is performed for the laryngectomy patient. For
the patient with a temporary tracheostomy tube, mouth-to-tube ventilation should be
initiated after the cuff is inflated.

Mouth-to-Barrier Ventilation:

A mouth-to-barrier device is an apparatus that is placed over a victim’s face as a disease

prevention for the rescuer during rescue breathing. There are two types of mouth-to-
barrier devices:
1. Masks: Resuscitation mask covers the victim’s mouth and nose. Most have a one
way valve so exhaled air from the victim does not enter the rescuer’s mouth.

2. Face shields: these clear plastic device have a mouth piece through which the
rescuer breathes, but lack a one way valve. Some models have a short airway that is
to inserted into victim’s mouth over the tongue. They are smaller and less
expensive than masks but air can leak around the shield. Also, they cover only the
victim’s mouth, so that the nose must be pinched.

CHECK FOR SIGNS OF CIRCULATION:

After you have given the first two breaths, check the victim’s for signs of circulation to see
if the heart is beating.
If the victim has no signs of circulation, CPR must be started immediately.
If the victim has ns of circulation but is not breathing, continue rescue breathing at a rate
of one breath every five seconds, or 12 times per minute.

PERFORM EXTERNAL CHEST COMPRESSIONS:

External chest compressions are required when the signs of circulation are absent.
Chest compression and rescue breathing are combined in a procedure known as
cardiopulmonary resuscitation (CPR). Chest compressions require a smooth applications of
pressure over the lower half of the sternum (breast bone). External pressure applied to the
sternum increases pressure in the chest (intrathorasic pressure), and moves blood to the
brain. Compressions must not be sharp or jabbing or applied over the tip of the sternum
(xiphoid process). Proper hand position and placement on the victim’s chest are necessary
to avoid internal injury such as bruising of the heart, laceration of the liver, or rupture of
the spleen.

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Steps For Effective Chest Compressions:

1. Place the victim on his or her back on a firm, flat surface.

2. Locate the lower part of the victim’s sternum by placing your hands between the
nipples on the center of the chest. Another method is to slide your middle and
index finger along the margin of the victim’ rib cage until you locate the notch in
the center of the lower chest where the ribs and the sternum meets. Keep the
middle finger on the center of the notch and place your index finger on the lower
end of the victim’s sternum, next to your middle finger.
3. Place the heel of the other hand on the back of the first hand. Your finger should be
pointing away from you. Interlace or extend your fingers but keep them off the
victim’s chest wall to avoid rib fractures and other internal injuries. The heel of the
hand that is in direct contact with the sternum must remain in contactwith the
chest during both the compression and the release to prevent bouncing and jerking
movements.
4. Lean forward so your shoulders are directly over your hands. Keeping your arms
straight, press straight downward on the sternum 1 to 2 inches, using the weight of
the upper part of your body, then relax pressure on the sternum completely. The
pressure and relaxation phase of each chest compression should be equal duration;
do not pause between each phase. Be sure to push straight downward on each
compression
5. Give 30 chest compression at a rate of about 100 per minute. The compression rate
refers to the speed of compression and not the actual number given in one minute.
6. After 30 compressions, immediately give two slow breaths (take a breath between
them). After the two breaths, quickly reassess your hand location and position,
then begin another cycle of 15 compressions and two breaths.
7. After you have completed four cycles which should take about one minute, check
the victim for signs of circulation for 10 seconds. If there are no signs of circulation,
continue CPR starting with 15 compressions. Check the signs of circulation every
few minutes.

ADVANCED CARDIAC LIFE SUPPORT:

ACLS involves a systematic approach to treatment of cardiac emergencies with knowledge
and skills necessary to provide early treatment.
Most hospitals have trained teams of personnel, including physicians, nurses,
anaesthesiologists, and technicians, who provide immediate care in the event of a cardiac
arrest. ACLS includes ( 1.) basic life support (2). The use of adjunctive equipment and
special techniques for establishing and maintaining effective ventilation and circulation
(e.g.ECG machine, suction device, oxygen, defibrillator, breathing bag, laryngoscope, a
variety of endotracheal tubes, intravenous fluids, and a tracheostomy set). Medications
administered during a cardiac arrest are usually stored on a emergency cart. A American
Heart Association office can provide the most current practice guidelines and information
about available training sessions for advanced cardiac life support.

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ACLS ALGORITHM:

POST RESUSCITATION COMPLICATIONS:

1. Trauma fractured ribs and sternum

2. Pneumothorax
3. Ruptured spleen
4. Skin burns

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 5. Cervical neck injury
6. Oral, tracheal and laryngeal damage
7. Congestive heart failure
8. Anoxic encephalopathy

FOLLOW-UP INTERVENTIONS:

Diagnostic tests are often made during and after resuscitation to determine precipitating
causes, evaluate the effectiveness of resuscitation, and detect complications. Test
commonly performed are
1. Chest radiograph
2. ECG
3. Hemodynamic monitoring
4. Laboratory studies (including arterial blood gases, electrolytes, BUN, creatinine,
blood glucose and cardiac enzyme)

Client who survive cardiopulmonary arrest are admitted to a critical care unit, where they
receive continuous cardiac monitoring and have vital signs taken every 15 minutes until
stable. Post resuscitation assessment provides important information regarding the
effectiveness of resuscitation. Common disorders include recurrent dysrhythmias, coma,
other neurological disorders, and renal failure.

NURSING CONSIDERATIONS:

After the client regains consciousness, profound anxiety often appears.

1. The nurse should remember that clients need psychological support when they
have undergone such as catastrophic physiologic event. Many clients have a very
clear recall of the events surrounding the resuscitation, including the verbal
communication that occurred.
2. The nurse should take time to assess the client’s coping mechanisms.
3. The nurse should encourage expression of the clients feelings and concerns not
only by the client but by significant others who are equally stressed by the sudden,
serious nature of the disorder
4. Clear clarifications and explanations of misconceptions about what has happened
help move the client forward to optimal physiologic and psychological recovery

EMERGENCY CODES:

Hospital Emergency Codes are used in hospitals worldwide to alert staff to various
emergency situations. The use of codes is intended to convey essential information
quickly and with a minimum of misunderstanding to staff, while preventing stress or
panic among visitors to the hospital. These codes may be posted on placards

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 throughout the hospital, or printed on employee/staff identification badges for ready
reference.

Code Blue:Cardiac arrest

Generally is used to indicate a patient requiring immediate resuscitation, most often

as the result of a cardiac arrest. May also be used as a radio call to indicate that a
patient en route to the hospital requires resuscitation.
This phrase was coined at Bethany Medical Center in Kansas City, Kansas

EVIDENCE- BASED PRACTICE FOR CPR PRACTICE:

Alice Jones, PhD, FACP, from the Hong Kong Polytechnic University in Hong Kong, served as
lead author of this EBR article. Because of anecdotal information she’d been provided by
students during and after CPR training courses, she saw physical exhaustion during
administration of chest compressions as a fundamental issue that affected a significant
number of critical care professionals. But when she searched the literature, she found no
reports on either energy consumption or spinal kinetics associated with CPR.

In the study that followed, it was found that female rescuers delivered fewer effective
compressions and consumed more oxygen than did male rescuers in the standing position.
"We believe this is due to the small female stature," said Dr Jones.

When the CPR administrator is on the floor in the kneeling position, the downward
compression force is assisted by gravity and the weight of the clinician’s trunk. "In the
standing or erect posture, however, even though the trunk could be ‘thrown’ forward, the
resultant downward compressive force is found to be less. In order to maintain the same
compression depth, female nurses must generate more force by actively bending their
trunk to supplement the compression force, thereby consuming more oxygen during the
process. Male subjects were larger and their forward momentum was able to provide a
sufficient compressive downward force to overcome the resistive forces of the victim’s
chest, resulting in less energy expenditure," said Dr Jones.

CONCLUSION:
Cardiopulmonary Resuscitation (CPR) is a relatively a new medical procedure. CPR is an
organized approach to maintaining the vital functions of a person who has been rendered
incapable of continuing those functions on their own. BLS and ACLS is an emergency
procedure that consists of recognising an arrest and initiating proper CPR techniques to
maintain life of the victim.

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BIBLIOGRAPHY:

1. Black. M. Joyce, “Text Book Of Medical Surgical Nursing”, W. B. Saunder’s Company,

Fourth Edition, Page no. 1208, 1203

2. Thygerson Alton, “Text Book Of First Aid And CPR”, Jones And Bartlett Publishers,
Fourth Edition, Page no.69, 75

3. Polaski. Arlenne and Tatro Suzanne, “Luckmann’s Core Principles Of Medical Surgical
Nursing”, Elsevier Publishers, Fourth Edition, Page no. 728-731

4. Smeltzer. C. Suzzane , Bare. G. Brenda , Brunner And Suddarth’s Text Book Of Medical
Surgical Nursing”, Lippincott- Raven Publishers, Ninth Edition, 676,677

5. Linton. Dill. Adrianne, “Introduction To Medical Surgical Nursing”, Elsevier Publishers,

Fourth Edition, Page no. 196, 197

6. Jacob Annamma, R. Rekha ,” Clinical Nursing Procedures” J.P. Publishers, Page no. 138-
148

7. Lemone Priscilla, Burke Karen, “Text Book Of Medical Surgical Nursing”,Dorling

Kindersley Publishers, Fourth Edition, Page no.1330-1333.

8. Phipps, Monahan, Sands, Marek, Neighbours,” Text Book Of Medical Surgical Nursing”,
Mosby Publishers, Seventh Edition, Page no. 566-580

9. Loscalvo, Griggs, Carpenter, Cecil, “Essentials Of Medicine”, Elsevier Publication, 6 th

Edition, Page no. 423-430s

10. Burke Karen, LeMone Priscilla, “Text Book Of Medical Surgical Nursing”, Dorling
Kindersely Publication, 4th Edition, Page no. 697-703

NURSING JOURNALS:
Sheiline Melita, 2008, “Asian Journal Of Cardiovascular Nursing”, Vol.24 No.1

NET REFERENCE:
www.emergencymed.com

www.e-medicine.com

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FOLLOW-UP MONITORING:

Once successfully resuscitated, the patient is transferred to an intensive care unit for close
monitoring. Continuous ECG monitoring and frequent blood pressure assessments are
essential until the patient is hemodynamic stable. Etiologic factors that precipitated the
arrest, such as metabolic or rhythm abnormalities, must be identified and treated.

Medications Used In Cardiopulmonary Resuscitation

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