For All the Nursing Students and Teachers

1. Bsc.Nsg 4th year 1 4/6/2013

2. Objectives
At the end of this educational program, participants will be
able to:
- Review cardiac arrest
- Review basic life support
- Describe Advanced Life Support
- Demonstrate
- Basic life support
- Airway insertion
- Defibrillation
Bsc.Nsg 4th year 2 4/6/2013

3. TOPIC TIME SPEAKER
Welcome note 2 min Divya Labh
Background 2 min Divya Labh
Pretest 5 min
Review of cardiac arrest 5 min Divya Labh
Review of basic life support 10 min Divya Labh
Anu Aryal
Advanced life support(ALS) 5min Anu Aryal
Defibrillation and nurses role 5min Anita Gurung
Drugs used in ALS 5 min Anita Gurung
Flowchart of adult ALS sequence 15 min Hricha Neupane
Post resuscitation care 2 min Hricha Neupane
Break for refreshment 15 min
Demonstration on 30 min All
BLS, airway insertion, defibrillation
Post test 10 min Hricha Neupane
Vote of thanks
Bsc.Nsg 4th year 3 4/6/2013

4. Bsc.Nsg 4th year 4 4/6/2013

5. Cardiac arrest
Cardiac arrest is the abrupt cessation of cardiac pump
function, which may be reversible by a prompt
intervention but will lead to death in its absence.
It is due to asystole, pulseless electrical activity,
ventricular tachycardia or fibrillation.
Bsc.Nsg 4th year 5 4/6/2013

6. CAUSES OF CARDIAC ARREST
CARDIAC:
Coronary artery OTHERS
disease Severe anaphylaxis
M.I. Suffocation
Arrhythmia Electrocution
Low Trauma
C.O.,failure,shock Stroke
Cardiomyopathy Exsanguinations
Myocarditis Drowning
Massive pulmonary
emboli
Bsc.Nsg 4th year 6 4/6/2013

7. REVERSIBLE CAUSES OF CARDIAC
ARREST:
4 Ts:
 Thromboembolism 4Hs:
Tension Hypoxia
pneumothorax Hypovolemia
Tamponade Hypo/hyperkalemia
Toxicity(TCAs,b- Hydrogen ions
blockers,ca channel
blocker,dogoxin)
Bsc.Nsg 4th year 7 4/6/2013

8. CLINICAL MANIFESTATIONS:
Consciousness , pulse ,and blood pressure are lost
immediately.
Pupil start dilating within 45 seconds.
Seizure may or may not occur.
! Nursing alert
The most reliable sign of cardiac arrest is absence of
pulse. In adult &child carotid pulse is assessed while in
infant brachial pulse is assessed. Valuable time not to
be wasted taking BP, listening for heartbeat, or
checking proper contact of electrode.
Bsc.Nsg 4th year 8 4/6/2013

9. MANAGEMENT :
Basic Life Support (BLS)
 Advanced Cardiac Life Support (ACLS)
 Post Resuscitation Care
The urgency of cardio respiratory arrest & the fact that
brain damage can occur within 4-6 mins without
circulation (except in hypothermia)make it necessary
to start early BLS within 4 mins and rapid ACLS within
8 min to establish neurological recovery and survival.
Bsc.Nsg 4th year 9 4/6/2013

10. Chain of survival
Bsc.Nsg 4th year 10 4/6/2013

11. Bsc.Nsg 4th year 11 4/6/2013

12. BASIC LIFE SUPPORT (BLS)
It comprises of cardiopulmonary resuscitation(CPR)
which is a series of measures aimed at delivery of
oxygenated blood to the heart and brain until further
therapy can restore spontaneous and effective
circulation.
Bsc.Nsg 4th year 12 4/6/2013

13. Bsc.Nsg 4th year 13 4/6/2013

14. WHY C-A-B ?
Bsc.Nsg 4th year 14 4/6/2013

15. ADULT BLS Sequence
• Recognize unresponsive adult with no breathing or no
normal breathing (ie, only agonal gasps)
Bsc.Nsg 4th year 15 4/6/2013

16. Activate emergency
response, retrieve
AED (or send
someone to do this)
Bsc.Nsg 4th year 16 4/6/2013

17. • Check for pulse (no more than 10 seconds)
• If no pulse, begin sets of 30 chest compressions and
2 breaths
• Use AED as soon as available
Bsc.Nsg 4th year 17 4/6/2013

18. Bsc.Nsg 4th year 18 4/6/2013

19. Before you begin
Check for:
Is the person conscious or unconscious?
If the person appears unconscious, tap or shake his or
her shoulder and ask loudly, "Are you OK?“
If the person doesn't respond and two people are
available, one should begin CPR another should call
Emergency team.
Bsc.Nsg 4th year 19 4/6/2013

20. If an AED is immediately
available, deliver one shock
if instructed by the device,
then begin CPR immediately.
Bsc.Nsg 4th year 20 4/6/2013

21. Chest compressions
Put the person on his
or her back on a firm surface.
Kneel next to the person's
neck and shoulders.
Place the heel of one
hand over the center
of the person's chest, between the nipples. Place your
other hand on top of the first hand. Keep your elbows
straight and position your shoulders directly above
your hands.
Bsc.Nsg 4th year 21 4/6/2013

22. Chest compressions
Use your upper body weight (not just your arms) as you
push straight down on (compress) the chest at least 2
inches (approximately 5 centimeters). Push hard at a
rate of about 30compressions:2 breath.
Bsc.Nsg 4th year 22 4/6/2013

23. Chest compressions
If you haven't been trained in CPR, continue chest
compressions until there are signs of movement or
until emergency medical personnel take over. If you
have been trained in CPR, go on to checking the
airway and rescue breathing.
Bsc.Nsg 4th year 23 4/6/2013

24. Airway: Clear the airway
After 30 chest compressions,
open the person's airway
using the head-tilt, chin-lift
maneuver.
Bsc.Nsg 4th year 24 4/6/2013

25. Jaw thrust
Bsc.Nsg 4th year 25 4/6/2013

26. Breathing: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or
mouth-to-nose breathing if the mouth is seriously
injured or can't be opened.
Bsc.Nsg 4th year 26 4/6/2013

27. RESCUE BREATH
Prepare to give two rescue breaths. Give the first
rescue breath — lasting one second — and watch to
see if the chest rises. If it does rise, give the second
breath.
If the chest doesn't rise, repeat the maneuver and
then give the second breath. 30 chest compressions
followed by 2 rescue breaths is considered one cycle.
Resume chest compressions to restore circulation.
Bsc.Nsg 4th year 27 4/6/2013

28. If the person has not begun moving after five cycles
(about two minutes) and an automatic external
defibrillator (AED) is available, apply it and follow the
prompts.
Administer one shock, then resume CPR — starting
with chest compressions — for two more minutes
before administering a second shock.
Bsc.Nsg 4th year 28 4/6/2013

29. Continue CPR until there are signs of movement or
until the patient is taken to emergency.
Bsc.Nsg 4th year 29 4/6/2013

30. Key Issues and Major Changes
• “Look, listen, and feel for breathing” has been
removed from the algorithm.
• Continued emphasis has been placed on high-quality
CPR (with chest compressions of adequate rate and
depth, allowing complete chest recoil after each
compression minimizing interruptions in
compressions, and avoiding excessive ventilation).
Bsc.Nsg 4th year 30 4/6/2013

31. To initiate chest compressions before giving rescue
breaths (C-A-B rather than A-B-C).
Compression rate should be at least 100/min (rather
than “approximately” 100/min).
Compression depth for adults has been changed
from the range of 1½ to 2 inches to at least 2 inches (5
cm).
Bsc.Nsg 4th year 31 4/6/2013

32. BLS only provides 15 to 20% of normal cardiac output and
should be regarded as “buying time” until the
commencement of ALS.
If there is more than one rescuer present , another should
take over the CPR every 1 to 2 minute to prevent fatigue.
Bsc.Nsg 4th year 32 4/6/2013

33. ADVANCED LIFE SUPPORT
Advanced life support (ALS) includes use of adjunctive
equipment and techniques for
 assisting ventilation and circulation
 ECG monitoring with dysrrhythmia recognition and
defibrillation
 establishment of I.V. access and pharmacologic
therapy in addition to BLS skills.
Bsc.Nsg 4th year 33 4/6/2013

34. ALS ALGORITHM
Bsc.Nsg 4th year 34 4/6/2013

35. ALS includes:
 Circulation by cardiac compression
Airway management by equipments
 Breathing by advanced techniques
 Defibrillation by manual defibrillator
 Drugs.
Bsc.Nsg 4th year 35 4/6/2013

36. Circulation
Chest compression:
- rate- 100/min
- Place- mid of sternum
- Depth- at least 5 cm
(2inches)
- or 1/3rd of AP diameter of chest
- No synchrony with respiration
Bsc.Nsg 4th year 36 4/6/2013

37. Precordial Thump
• The precordial thump should not be used for
unwitnessed out-of-hospital cardiac arrest.
• The precordial thump may be considered for patients
with witnessed, monitored, unstable VT (including
pulseless VT) if a defibrillator is not immediately ready
for use, but it should not delay CPR and shock
delivery.
Bsc.Nsg 4th year 37 4/6/2013

38. A. Airway management
1) Guedel’s airways- Most commonly used
Bsc.Nsg 4th year 38 4/6/2013

39. Airway management
2) Laryngeal Mask Airways
Bsc.Nsg 4th year 39 4/6/2013

40. Airway management
3) Endotracheal tube
Bsc.Nsg 4th year 40 4/6/2013

41. B. Breathing:
Breathing can be accomplished by
1.Bag and mask ventilation
2.Ventilation by advanced method:
a.ET tube: Intubation is most definitive
and best method for ventilation.
b.LMA
c.Tracheostomy tube
3. Ventilation by automatic ventilators.
Bsc.Nsg 4th year 41 4/6/2013

42. Bag and Mask Ventillation
Bsc.Nsg 4th year 42 4/6/2013

43. Artificial Manual Breathing
Unit(AMBU)
It consists of self inflating bag made up of
rubber or silicon, connector, safety valve,
mouth piece.100% oxygen can be delivered by
AMBU bag by attaching oxygen source and
oxygen reservoir.
Bsc.Nsg 4th year 43 4/6/2013

44. Defibrillation
These are the treatment for tachydysrhythmias.
Defibrillation depolarize the critical mass of
myocardial cell at once. When they repolarize the
sinus node recapture its role as the pacemaker .
Is treatment of choice for pulseless VT/VF.
Bsc.Nsg 4th year 4/6/2013

45. Ventricular tachycardia
Bsc.Nsg 4th year 45 4/6/2013

46. Ventricular fibrillation
Bsc.Nsg 4th year 46 4/6/2013

47. Defibrillator
Defibrillators can be classified as :
Monophasic(delivers current of
one polarity only and
Biphasic (deliver current of 2 polarity)
Bsc.Nsg 4th year 47 4/6/2013

48. Position of defibrillator paddle:
1st paddle - on the
right side of the
chest just below the
clavicle
2nd at precordial,
region.
Paddle should be
applied with pressure
equivalent to 10 kg.
Bsc.Nsg 4th year 48 4/6/2013

49. Paddle size
Adult: 13cm
Children:8cm
Infants:4.5cm
Latest Recommendation for shock protocol ;
Previous recommendation of 3 successive shock
(200,300,360J)
Now a days only single shock is recommended .i.e.
360J by monophasic
150-200J by biphasic
Bsc.Nsg 4th year 49 4/6/2013

50. Nurses role while performing
defibrillation
Apply conducting jelly between the paddle and the
skin.
Place the paddle so that they don't touch patient’s
clothing and bed linen and aren't near medication
and direct oxygen flow.
Ensure that defibrillator is not in synchronized mode.
Don't charge the device until ready to shock; then
keep the thumbs and fingers off discharge button
until paddle are on the chest.
Bsc.Nsg 4th year 50 4/6/2013

51. Nurses role in defibrillation
Before pressing the discharge button call “ all clear” 3
times
1st clear: Ensures you aren’t touching patient,bed,
equipment
2nd clear: Ensures no one is touching patient, bed ,
equipment
3rd clear: Ensures you and everyone else are clear off
the patient and anything touching the patient.
Bsc.Nsg 4th year 51 4/6/2013

52. Nurses role in defibrillation
Record the delivered energy and the
results (cardiac rhythm and pulse).
After the event is complete inspect the
skin under the pads and paddles for burns ,
and if any detected consult about the
treatment.
Bsc.Nsg 4th year 52 4/6/2013

53. DRUGS
1. Adrenaline(all types of cardiac arrest)- 1mg every
3-5 mins
2. Amidarone(VF,VT)- 1st dose:300mg IV bolus, 2nd
dose 150 mg
3. Lidocaine(If Amidarone isn’t available)
4. Sodium bicarbonate(only if cardiac arrest is
associated with hyperkalemia or tricyclic anti-
depressent overdose)
5. Calcium gluconate
Bsc.Nsg 4th year 53 4/6/2013

54. Adrenaline (Epinephrine):
Class : Adrenergic
MOA : Causes Cardiac stimulation
Indication : cardiac arrest
Dose : Adults – 0.5-1 mg IV
- repeat every 5min
- Children – 10 mcg/kg
Adverse reaction : nervousness , tremor,
headache, drowsiness , palpitation , tachycardia
, dyspnea .
Bsc.Nsg 4th year 54 4/6/2013

55. Amiodarone:
Class : Ventricular antiarrhythmic
MOA : abolishes ventricular arrhythmia
Indication : recurrent VF , unstable VT , atrial
fibrillation
Dose : 300mg IV ; further 150mg may be given ,
followed by an infusion of 900mg for 24 hour.
Bsc.Nsg 4th year 55 4/6/2013

56. FLOWCHART OF ACLS
Bsc.Nsg 4th year 56 4/6/2013

57. Unresponsive
Call for
help(monitor/defribillator)
Start BLS algorithm
Attach monitor & defibrillator
when available
Check rhythm
Bsc.Nsg 4th year 57 4/6/2013

58. Rythm
Non-
Shockable
shockable
VT Asystole
VF PEA
Bsc.Nsg 4th year 58 4/6/2013

59. VF and VT
Bsc.Nsg 4th year 59 4/6/2013

60. Asystole and PEA
Bsc.Nsg 4th year 60 4/6/2013

61. SHOCKABLE(pulseless VF/VT)
1stShock (150-200 biphasic, 360 monophasic)
CPR 30:2(2min)
If VF,VT persists
2nd Shock( 150-360 biphasic, 360 monophasic)
CPR30:2(2 min)
Bsc.Nsg 4th year 61 4/6/2013

62. Check monitor(if VT,VF
persists)
Adrenaline 1mg IV
every 3-5min
3rd
Shock
CPR 30:2(2 min)
Check monitor(if VT,VF
persists)
Amidarone(300 mgIV)
4th Shock
CPR 30:2 (2 min)
Bsc.Nsg 4th year 62 4/6/2013
Adrenaline 1mg IV

63. 5th shock
Further shock after each 2
min period of CPR
If organised electrical
activity seen,check for
pulse
If pulse present:start post resuscitation care
If no pulse and asystole seen :continue CPR and switch
Bsc.Nsg 4th year on to non shockable rhythm
63 4/6/2013

64. Management of Asystole and PEA
Start CPR 30:2
Give adrenaline 1mg as soon as intravascular access is
achieved.
Continue CPR 30:2 until the airway is secured, then
continue chest compressions without pausing during
ventilation
Consider possible reversible causes and correct any
that are identified
Bsc.Nsg 4th year 64 4/6/2013

65. Management of Asystole and PEA
Recheck the patient after 2 min:
If there is still no pulse and no change in the ECG
appearance:
- Continue CPR.
- Recheck the patient after 2 min and proceed accordingly.
- Give further adrenaline 1 mg every 3-5 min (alternate loops).
- If VF/VT, change to the shockable rhythm algorithm.
- If a pulse is present, start post-resuscitation care.
Bsc.Nsg 4th year 65 4/6/2013

66. WHEN TO STOP RESUSCITATION
Bsc.Nsg 4th year 66 4/6/2013

67. POST RESUSCITATION CARE
Optimizing vital organ perfusion
Maintain o2 saturation more than or equal to 94%
Transport to comprehensive post arrest system of care
Emergent coronary reperfusion for high suspicion of
STEMI or AMI
Temperature control
Aniticipation, treatment and prevention of multi organ
dysfunction
Bsc.Nsg 4th year 67 4/6/2013

68. Bsc.Nsg 4th year 68 4/6/2013

69. References:
American Heart Association “Guidelines for CPR
and ECC, 2010”
Aitkenhead AR, Rowbotham DJ, Smith G. Textbook
of Anesthesia, 4th Edition Churchill
Livingstone:2001;748-757
Barash PG, Cullen BF, Stoclting RK, Clinical
Anesthesia, 5th Edition, Lippincott, Williams and
Wilkins:2006; 1390-1404
Stoclting Rk, Miler RD. Basics of Anesthesia, 4th
Edition, Churchill Lvingstone:2000479-492
Harrison's, Principle of internal medicine, 16th
Bsc.Nsg 4th year 69 4/6/2013
Edition, Vol II, 1621-1622.