Set of protocolized maneuvers aimed at reversing the situation of cardiorespiratory arrest, replacing and attempting to resume spontaneous breathing and circulation.
Objectives:
– To urgently provide the necessary care to recover the patient’s brain functions completely. – To maintain the patient’s life support. – To decrease the anxiety of the family.
Equipment:
– Crash cart. – Equipment necessary for oxygen therapy. – Equipment necessary for secretion aspiration. – Equipment necessary for electrocardiogram. – Sphygmomanometer. – Stethoscope. – Stop table. – Defibrillator.
Material:
– Non-sterile gloves. – Sterile compresses and gauze. – Specific medication. – Necessary material for oxygen therapy. – Necessary material for secretion aspiration. – Necessary material for the establishment of fluid therapy. – Necessary material for obtaining venous and arterial blood samples. – Necessary material for the Peripheral Catheter insertion technique. – Nursing records.
Procedure:
– Assess the patient’s situation and condition: (see figure 1). 1. Assess the patient’s state of consciousness: gently shake the patient and ask him/her out loud how he/she is feeling. If the patient responds, assess clinical changes and notify the physician if necessary. If the patient does not respond, assess respiration (SEE, HEAR and FEEL). 2. Assess ventilation: bring your face close to the patient’s mouth, observing if there are thoracic movements and if you notice air coming out of the nose or mouth, for no more than 10 seconds. If breathing, place the patient in the lateral safety position. If not breathing, assess circulation.
– The decision to start CPR is made when the patient is unresponsive and not breathing normally. – Note the time of onset of arrest. – Call for help and notify the physician. – Preserve the patient’s privacy. – Move the crash cart with the patient. – Place the patient in the supine position on the crash cart.
Start external cardiac massage if there is no pulse:
1. Locate compression point: center of chest. 2. Place the base of the hand on that point and the base of the other hand on top of it. With the fingers interlocked without contact with the chest. Keep the arms perpendicular to the compression point and load the weight of the body on them without bending the elbows. 4. Compression will depress the sternum 4-5 cm (one third of the anterior-posterior diameter) and the rate will be at least 100 compressions per minute. Compression and decompression should have the same duration.
Permeabilize the airway:
1. Clean the mouth of secretions, food, dental prostheses…
2. Manually elevate the mandible and tilt the forehead backwards (forehead-chin maneuver). If cervical injury is suspected, elevate the jaw without mobilizing the neck. – Ventilate the patient: 1. Connect ambu to the oxygen source at the highest possible concentration. 2. – Synchronize cardiac massage with ventilation: every 2 breaths 30 compressions independently of one or two resuscitators. – If a defibrillator monitor is available, monitor the patient and if in ventricular fibrillation or supraparoxysmal ventricular tachycardia: select voltage Monophasic 360 J and Biphasic 200 J, apply conductive paste to the paddles to perform defibrillation, and instruct all personnel to move away from the patient’s bed. One paddle is placed to the right of the sternum below the clavicle and the other at the level of the cardiac apex (usually to the left of the left nipple) 5th-6th intercostal space left mid-axillary line. – Maintain 1-2 thick venous lines, cannulate peripheral line if the patient does not have one. – Administer fluids and drugs prescribed by the physician. – Prepare material and assist the physician in endotracheal intubation if indicated. – Interrupt resuscitation maneuvers when ordered by the physician. – Prepare everything necessary for transfer to ICU, if required. – Collect the material used and clean it. – Replenish used equipment from the crash cart, leaving it ready for reuse when needed. – Record in the nursing documentation: start time of resuscitation maneuvers and duration, medication administered, procedures performed, time of transfer to ICU, incidents, constants.
Observations:
Due to its degree of complexity, this procedure needs to be adapted to each of the hospitals in the Valencian Community. The recommendations made in this procedure are based on the latest recommendations published by the European Resuscitation Council in 2005 (1,2). The precordial thump is only indicated in the first 30 seconds of a cardiac arrest witnessed with the patient monitored to determine whether the patient is in VF or PSVT.
Considerations in pediatrics:
1. compression point for massage: – Infants: If there is 1 rescuer, 1 finger below the intermammary line, use the middle and ring fingers of the hand. If there are two resuscitators: circle the thorax with both hands and press on the same place with the thumbs, depressing the thorax one third of the anteroposterior diameter.
– Young children: 2 fingers above the xiphoid appendage only using the base of one hand. – Children > 8 years old: 2 fingers above the xiphoid appendage. Frequency of compression: – Infants: 100-120 compressions/minute. – Children: 100 compressions/minute. 3. Depth of compression. – Infants: one third of the anteroposterior diameter. – Children: one third of the anteroposterior diameter. 4. Ventilation volume: Ventilation should be performed with extreme care to avoid barotrauma. Insufflate until the thorax is seen to rise. 5. Ventilation frequency: – Infants: 20-25/minute. – Children: 15-20/minute. 6. Sequence of compression/ventilation: start with 5 resuscitation ventilations: 30:2 single resuscitator 15:2 2 resuscitators. 3:1 newborns in delivery room. 7. In case of airway obstruction by foreign bodies in unconscious children or infants, attempt 5 insufflations and in the absence of response proceed with chest compressions without checking circulation.
Considerations in pregnant women: CPR in the pregnant woman has the same sequence as CPR in a non-pregnant woman. The differences lie in the correct position of the pregnant woman, mode of airway clearance and location of the chest compression point (3).
POSITION: Supine decubitus on a flat, hard surface and proceed to move the uterus to the left. Place a wedge under the flank of the right hip approximately 15-30º. The thighs of the second rescuer can also act as a wedge. If there is suspicion of vertebral injury, manually move the uterus to the left, pushing the abdomen with the hands. AIRWAY: in case of airway obstruction, the Heilich maneuver is NOT indicated; perform 6 chest compressions on the mid-sternal area, about 2 seconds apart.
VENTILATION: the pregnant woman has a higher risk of gastroesophageal reflux and consequently of bronchoaspiration.
COMPRESSIONS: Start cardiac massage on the thorax, depressing it 2-5 cm. at a rate of 80 times per minute. The sequence will be 15:2 independently of 1 or 2 resuscitators.
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