CARDIOPULMONARY RESUSCITATION TECHNIQUES

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CHAPTER 6 CARDIOPULMONARY RESUSCITATION TECHNIQUES

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. You enter a patient’s room to give a treatment and observe the patient is unconscious and not breathing. After calling for help, your first action should be which of the following?

A. Deliver two breaths.
B. Begin chest compressions.
C. Perform abdominal thrusts.
D. Open the airway.

2. After 10 min of CPR, an infant’s pulse returns but no ventilatory effort is present. The respiratory therapist should do which of the following?

A. Continue compressions and rescue breathing at a ratio of 15 : 2.
B. Stop compressions and deliver one breath every 6 s.
C. Deliver five back blows, until breathing resumes.
D. Stop compressions and deliver one breath every 3 s.

3. A patient has been intubated, and CPR is being performed. The patient’s ECG strip indicates asystole, and the physician is unable to start an intravenous (IV) line. The respiratory therapist should recommend which of the following immediately?

A. Instill sodium bicarbonate directly down the ET tube.
B. Continue to attempt to start an IV in a peripheral vein.
C. Instill epinephrine directly down the ET tube.
D. Inject epinephrine directly into the myocardium.

4. Which of the following drugs is used to treat ventricular fibrillation during CPR?

1. Epinephrine
2. Lidocaine
3. Atropine sulfate
A. 1 only
B. 2 only
C. 1 and 2 only
D. 2 and 3 only

5. During CPR, the patient’s ECG strip indicates ventricular fibrillation. The patient has been defibrillated with 200 J using a biphasic defibrillator with no change in the ECG reading. The respiratory therapist should recommend which of the following?

A. Repeat defibrillation with 300 J.
B. Repeat defibrillation with 450 J.
C. Instill sodium bicarbonate directly down the ET tube.
D. Continue two-rescuer CPR with a compression/ventilation ratio of 5 : 2.

6. A patient’s ECG strip indicates atrial fibrillation and cardioversion should be attempted. The defibrillator should be set at what level to return the heart to normal function?

A. 50 J
B. 150 J
C. 250 J
D. 400 J

See answers and rationales at the back of the text.

REVIEW

I. CARDIOPULMONARY RESUSCITATION

CRT Exam Content Matrix: IB2a, IIIG4d, III I1a-d

RRT Exam Content Matrix: IB2a, IIIG4a, III I1a-c

A. Obstructed Airway (in a Conscious Adult)
1. Determine whether there is an airway obstruction by asking the patient if he or she is choking and if he or she can speak or cough.
2. Perform abdominal thrusts until the foreign body is expelled or the patient loses consciousness.
3. If the patient loses consciousness, place the patient on his or her back and call for help.
4. Use the tongue/jaw lift to open the mouth. If an object is visible perform a finger sweep with the patient’s head turned to the side.
5. Open the airway by using the head tilt/chin lift method.
6. Give two breaths.
7. If the ventilation attempts fail (determined by observing the chest not rising or difficulty in expelling air into the patient), reposition the airway and perform ventilation again. If there is still no air movement, straddle the patient’s thighs and perform up to five abdominal thrusts. (Perform chest thrusts in pregnant or obese victims.)
8. Again, perform a finger sweep, if an object is visible, and reattempt ventilations.
9. Repeat this sequence until the airway is cleared.
B. Obstructed Airway (in an Unconscious Adult)
1. Determine unresponsiveness.
2. Activate emergency medical service (EMS) or code team.
3. Position the patient on his or her back.
4. Open the airway using the head tilt/chin lift method.
5. Determine breathlessness: place ear over the patient’s mouth, then look, listen, and feel for air movement.
6. Attempt ventilation.
7. If there is no air movement, reposition the airway and reattempt ventilation.
8. If there is still no air movement, straddle the patient’s thighs and perform up to five abdominal thrusts.
9. Perform a finger sweep, if an object is visible, with the patient’s head turned to the side.
10. Attempt ventilation.
11. Repeat the sequence until the airway is cleared.
C. One-Rescuer CPR (Adult Patient)
1. Determine unresponsiveness.
2. Call for help. Activate EMS.
3. Position patient on his or her back.
4. Open the airway using the head tilt/chin lift method.
5. Determine breathlessness: place ear over the patient’s mouth, then look, listen, and feel for air movement.
6. Give two breaths while observing chest rise. (Allow lungs to deflate between breaths.)
7. Determine pulselessness by palpating the carotid artery. (Palpate brachial artery in an infant.)
8. Begin chest compressions at a rate of 100/min (30 compressions to two breaths).
9. Continue until patient responds, help arrives, or you can physically no longer continue.
D. Two-Rescuer CPR (Adult Patient)
1. When a second rescuer arrives, he or she should take over as the new compressor, while the first rescuer gets into position to be the breather. Palpate for a spontaneous pulse at this time.
2. If no pulse is present, continue CPR at a compression/ventilation ratio of 30 : 2.
3. The compressor should pause briefly after the fifteenth compression so the breather can administer a breath.
4. Intubate the patient as soon as possible to provide a more effective airway and to prevent air from entering the stomach during ventilation.
E. Neonatal Resuscitation (Immediately after Delivery)
1. Dry and warm the infant.
2. Suction the nose and mouth with a bulb syringe or DeLee suction catheter.
3. If meconium is seen, intubate the infant and suction the trachea.
4. Provide tactile stimulation to stimulate breathing.
5. If the infant is not breathing or the heart rate is less than 100 beats/min, begin positive pressure ventilation with 100% oxygen with a bag-mask.
a. The initial ventilation rate should be 40/min.
b. The initial ventilation pressure should be 30 to 40 cm H2O, and all the breaths thereafter should be at 15 to 20 cm H2O. (When resuscitating an infant hours after delivery that has respiratory problems resulting in decreased lung compliance, you may need higher pressures for ventilation.)

image The manual resuscitator should have a manometer attached to measure peak inspiratory pressure.

6. After performing ventilation for 15 to 30 s, reassess the pulse; if the heart rate is less than 60 beats/min, then continue ventilation and start chest compressions.
a. The compression rate should be approximately 120/min.
b. Once the heart rate is 60 beats/min or higher, discontinue compressions while maintaining manual ventilation.
c. If the heart rate stays below 60 beats/min, intubate the infant. Continue positive pressure ventilation and chest compressions, and reassess the infant periodically.
7. Drugs used during neonatal resuscitation
a. Epinephrine is a cardiac stimulant that should be administered either via IV drip or directly down an ET tube when the following occurs
(1) If the heart rate remains less than 60 beats/min after 30 s of chest compressions and manual ventilation
(2) If a heart rate cannot be detected
(3) See section on pharmacologic intervention during CPR on p. 80.
b. Volume expanders are administered to increase vascular fluid volume to reverse relative hypovolemia. They include
(1) Whole blood (type O-negative blood cross-matched with mother’s blood)
(2) Normal saline solution
(3) Saline solution with 5% albumin
(4) Ringer’s lactate solution
c. Sodium bicarbonate is indicated in the presence of documented metabolic acidosis, which is caused by increased lactic acid production as a result of prolonged asphyxia.
d. Naloxone hydrochloride (Narcan) is a narcotic antagonist that reverses narcotic-induced respiratory depression. In infants, this most commonly occurs when narcotics are administered to the mother within 4 h of delivery. Naloxone hydrochloride administration is indicated when severe respiratory depression is present and the mother is known to have had narcotics in the past 4 h.

image Naloxone hydrochloride may be administered intravenously, intramuscularly, subcutaneously, or instilled down the ET tube.

II. ADULT, CHILD, AND INFANT CPR MODIFICATIONS

CRT Exam Content Matrix: III I1a-d

RRT Exam Content Matrix: III I1a-c

A. Compression/Ventilation Ratios (for One Rescuer)
1. Adult: compression/ventilation ratio is 30 : 2; 100 compressions/min
2. Child: compression/ventilation ratio is 30 : 2; 100 compressions/min
3. Infant: compression/ventilation ratio is 30 : 2; at least 100 compressions/min
B. Compression/Ventilation Ratios (for Two Rescuers)
1. Adult: compression/ventilation ratio is 30 : 2
2. Child: compression/ventilation ratio is 15 : 2
3. Infant: compression/ventilation ratio is 15 : 2

image The adult’s cardiopulmonary status should be reassessed after five cycles, and the infant or child’s status should be reassessed after 20 cycles.

C. Rescue Breathing for Patients with a Pulse
1. Adult: one breath every 5 to 6 s (10 to 12 breaths/min)
2. Child: one breath every 3 to 5 s (12 to 20 breaths/min)
3. Infant: one breath every 3 s (20 breaths/min)
D. Compression Depth
1. Adult: image to 2 inches with two hands stacked and the heel of one hand on the lower half of the patient’s sternum
2. Child: ⅓ to ½ the AP diameter of the chest with one hand on the lower half of the patient’s sternum
3. Infant: ⅓ to ½ the AP diameter of the chest with two or three fingers a finger’s breadth below the nipple line.

III. CPR: SPECIAL CONSIDERATIONS

CRT Exam Content Matrix: III I1a-d

RRT Exam Content Matrix: III I1a-c

A. Do not hyperextend the neck of an infant to open the airway because this may close off the airway.
B. If a manual resuscitator bag-mask is not available for rescue breathing, use a mask with a one-way valve to prevent contamination from the patient’s exhaled air. Mouth-to-mouth ventilation is used only if no other means is available.
C. Manual compressions achieve only about 25% to 35% of normal cardiac output.
D. On entering a room wherein one-rescuer CPR is being performed, the first step to take before changing to two-rescuer CPR is to establish the presence or absence of a pulse.
E. The best indicator of adequate cerebral blood flow while performing chest compressions is pupillary reaction.
F. Patients with suspected neck injuries should have their airways opened by the jaw-thrust maneuver without head tilt.
G. Hazards of CPR
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