CHAPTER 6 CARDIOPULMONARY RESUSCITATION TECHNIQUES
PRETEST QUESTIONS
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?
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?
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?
4. Which of the following drugs is used to treat ventricular fibrillation during CPR?
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?
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?
REVIEW
I. CARDIOPULMONARY RESUSCITATION
CRT Exam Content Matrix: IB2a, IIIG4d, III I1a-d
RRT Exam Content Matrix: IB2a, IIIG4a, III I1a-c
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.
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.
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.)
5. Determine breathlessness: place ear over the patient’s mouth, then look, listen, and feel for air movement.
8. If there is still no air movement, straddle the patient’s thighs and perform up to five abdominal thrusts.
5. Determine breathlessness: place ear over the patient’s mouth, then look, listen, and feel for air movement.
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.
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.
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.
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.
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.
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
b. Volume expanders are administered to increase vascular fluid volume to reverse relative hypovolemia. They include
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.
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
The adult’s cardiopulmonary status should be reassessed after five cycles, and the infant or child’s status should be reassessed after 20 cycles.1. Adult: 
to 2 inches with two hands stacked and the heel of one hand on the lower half of the patient’s sternum
to 2 inches with two hands stacked and the heel of one hand on the lower half of the patient’s sternum2. 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.
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.
1. Rib fractures (especially in infants and elderly persons) may lead to pneumothorax or lacerated liver.
2. Fat embolism may result from microfractures of the ribs or sternum. Fat leaks from bone marrow and enters the venous circulation.
3. Gastric distention results from air entering the stomach from rescue breathing. This air should be removed from the stomach with a nasogastric (NG) tube because a distended abdomen interferes with lung expansion.
RRT Exam Content Matrix: None listed
1. A non-rebreathing valve with a standard universal adapter consists of a 22-mm OD that fits standard resuscitation masks and a 15-mm ID that connects to standard ET or tracheostomy tubes.
2. The non-rebreathing valve also houses the exhalation valve and ports, which prevent the rebreathing of exhaled air.
3. The resuscitators use self-inflating bags by means of a bag intake valve. (The bag may still be used to ventilate, even without gas flowing to it.)
4. A reservoir attachment should be connected to the bag intake valve so that, as the bag reinflates, it fills with supplemental oxygen instead of room air. This ensures that higher oxygen levels (approaching 100%) will be delivered to the patient.
5. Most resuscitator bags have pressure-relief devices that open to the atmosphere at a pressure of 40 cm H2O so that excessive pressures are not delivered to the patient’s lungs.
6. Some resuscitators come equipped with PEEP valves for patients who are being manually ventilated. This is very beneficial because it has been shown that stopping PEEP in patients who need a bag-mask causes drastic reductions in their PaO2 if they receive ventilation without PEEP.
c. Use the longest possible bag refill time (meaning a slower ventilation rate). Allow the bag to fully refill before the next breath. A faster ventilation rate decreases the percentage of delivered O2.
d. Do not use large stroke volumes (i.e., the volume squeezed from the bag), if possible. High volumes delivered from the bag result in more room air being entrained, thus lowering levels of O2. (This is not significant if a reservoir attachment is used.)
1. Leaks during inspiration caused by improperly fitted face mask or inadequately filled ET tube cuff
2. Equipment malfunction caused by sticking valves, missing parts, improper assembly, or dirty valve mechanisms
Exam Note
5. Volume delivery decreases if the pressure needed to ventilate the patient’s lungs is higher than the capacity of the unit.
6. The unit is powered from a 50-psi O2 wall outlet. If the diaphragm in the unit breaks, the patient’s airway could be exposed to this high pressure.
1. This method of ventilation provides an option to mouth-to-mouth ventilation, which should be avoided unless there is no other means of ventilating the patient’s lungs.
2. Mouth-to-valve mask rescue breathing involves placing one end of the one-way valve on a mask. The other end has a mouthpiece attached. The rescue breather may manually ventilate the patient’s lungs through the mouthpiece; the patient’s exhaled air passes around the exhalation ports to the outside.
3. This one-way valve system for rescue breathing protects the breather from cross-contamination from the patient’s exhaled air.
V. PHARMACOLOGIC INTERVENTION DURING CPR
CRT Exam Content Matrix: IIID5c, IIIG4d, III I1a-d, III I3d
RRT Exam Content Matrix: IIID5c, IIIG4a, III I1a-c, III I3d
1. A central venous line (central line) is the ideal route, if available. It is inserted into the vena cava from the subclavian, jugular, or femoral vein.
3. Intraosseous infusion (IO) may be used when IV cannulation is unsuccessful or is taking too long. IO infusion is the infusion of medications, blood products, and fluids into the bone marrow cavity; from there, the infusion will then be delivered to the venous circulation. Any drug given IV may be administered IO.
4. ET tube: drugs such lidocaine, epinephrine, atropine, vasopressin, and naloxone hydrochloride may be instilled directly into the tracheobronchial tree via the ET tube for rapid absorption.
The instilling of these drugs through the ET tube may be permissible if the IV or IO route is not available, but it is not preferred. Recent studies indicate that giving resuscitation drugs through the ET tube results in lower blood concentrations than if the same dose is given IV. The recommended dose of drugs that are administered endotracheally are generally two to three times the IV dose, but the optimal endotracheal drug dose of most drugs is not known.5. Intracardiac: Epinephrine is the only drug that may be injected directly into the heart but only when the ET tube or IV route is not available or when administration via those routes has failed to elicit a response.
c. Dosage: 1-mg/kg IV bolus followed by additional boluses of 0.5 to 1.5 mg/kg every 3 to 5 min, up to a total of 3 mg/kg, or 2 to 3 mg/kg through the ET tube. Continuous infusion (drip) may be started at a rate of 2.0 to 4.0 mg/min when perfusion is restored after ventricular fibrillation.
c. Dosage: 40 units IV push (one-time dose); may be used in place of first or second dose of epinephrine in cardiac arrest
d. Pharmacologic actions: vasoconstriction of peripheral, pulmonary, cerebral, and coronary blood vessels
The use of sodium bicarbonate (NaHCO3) is no longer recommended during CPR. It has been found to cause adverse effects, including a shift of the HbO2 curve to the left (decreased release of O2 by Hb), depression of cerebral and myocardial function, and deactivation of catecholamines (e.g., isoproterenol and epinephrine) used during the resuscitative effort.
A rapid response team (RRT), also called the medical emergency team (MET) is often activated when a critically ill patient is deteriorating. The team is called to help prevent the development of a cardiac arrest and improve the patient’s medical outcome. The team generally comprises a physician, nurse, and respiratory therapist with critical care training who are available at all times. The team will be notified by other hospital staff based on well-defined guidelines for activation of the team.VI. DEFIBRILLATION AND CARDIOVERSION
CRT Exam Content Matrix: IIIJ7
RRT Exam Content Matrix: IIIJ8
1. Defibrillation is a nonsynchronized current of electricity delivered to the heart during ventricular fibrillation.
2. It is administered by means of paddles placed on specific areas of the chest. After conducting gel is applied to the paddles, one paddle is placed below the clavicle and to the right of the upper part of the sternum. The other paddle is placed on the midaxillary line just to the left of the left nipple.
3. The initial electric current delivered should be 200 J (W/s) for adults using a biphasic defibrillator and 360 J for a monophasic defibrillator and 2 J/kg of body weight in infants and children. If this level is not effective in restoring normal ventricular activity, it may be increased to no more than 360 J for adults or 4 J/kg in infants and children.
4. This high charge of electricity delivered to the myocardium is intended to reverse life-threatening ventricular arrhythmias by causing complete depolarization of the cardiac muscle, thereby disrupting the electrical circuits in the heart that are causing the ventricular fibrillation.
5. Lidocaine and epinephrine may be administered because they improve the success of defibrillation.
6. It is essential that appropriate levels of electric current be used to prevent myocardial damage and cardiac arrhythmias.
7. The precordial thump, a sharp, quick blow delivered to the midportion of the sternum by the fleshy part of the fist, is recommended for a witnessed cardiac arrest when a defibrillator is not available.
1. Cardioversion is a synchronized current of electricity delivered to the heart during ventricular depolarization (QRS complex).
3. Cardioversion delivers a lower energy level than does defibrillation. Normal levels for cardioversion are a charge of 25 to 100 J to restore normal cardiac rhythm in adults and 0.2 to 1.0 J/kg in infants and children.
4. The respiratory therapist’s duties in assisting with this procedure should include the following.
d. Have manual resuscitator and intubation equipment readily available (See Chapter 9 on cardiac monitoring for further information on ECGs and specific arrhythmias).
CRT Exam Content Matrix: IA1, IB5f
RRT Exam Content Matrix: IA1, IB5e
A. An advance directive is a written document stating a person’s decisions regarding medical treatment that is to be initiated (or not initiated) should the person not have the physical or mental capacities to communicate their wishes.
B. A living will is a type of advance directive that patients put in writing regarding their wishes about medical treatment if they become terminally ill and not capable of making decisions about their medical care. A living will directs physicians to either withhold or withdraw “death-delaying” treatments. This does not include hydration and nutrition. The directives in a living will apply only to patients who have a terminal illness.
C. A durable power of attorney for health care is another type of advance directive in which a legal guardian is appointed to make the medical decisions for a patient who cannot make those decisions on their own. The withdrawal of hydration and nutrition by feeding tube is permissible with this type of directive.
D. Do-not-resuscitate (DNR) protocols are often part of the advance directive. If no documentation for DNR protocols is present, resuscitation is generally begun while, at the same time, attempting to obtain orders from the physician.
E. DNR protocols may vary from state to state, but generally if the patient is in full cardiac or respiratory arrest, EMS personnel will follow these protocols
F. If the patient is not in full respiratory or cardiac arrest but the patient’s breathing and pulse rate is inadequate, resuscitation should not be administered; however, the following is generally allowed
As mentioned previously, protocols vary from state to state. The above protocols are offered only as an example. Health care professionals should be familiar with the protocols in their area.VIII. TRANSPORTING THE CRITICALLY ILL PATIENT
CRT Exam Content Matrix: III I3a-b
RRT Exam Content Matrix: III I3a-b
Exam Note
Questions relating to transporting patients via land or air appear on the RRT examination only.
b. The practitioner should hold the ET tube with one hand and the bag with the other. This better stabilizes the tube and helps avoid inadvertent extubation.
d. Special attention must be given to monitoring lines that could become dislodged during transport.
g. During transport in an unpressurized aircraft, rapid increases in altitude result in decreased atmospheric pressure and PO2. This may be managed by increasing delivered O2 concentrations.
h. Higher altitudes (lower atmospheric pressure) may increase the size of an untreated pneumothorax and increase ET tube cuff pressure, which may decrease capillary perfusion to the trachea.
k. Heated humidity or aerosol for ventilators or masks during transport is not necessary for such short-term use.
IX. PARTICIPATING IN DISASTER MANAGEMENT
CRT Exam Content Matrix: III I3c
RRT Exam Content Matrix: III I3c
A. No one will ever forget the tragedy that took place in New York City on September 11, 2001. After that terrible event, anthrax mailings occurred throughout the country. Even more recently, the threat of influenza in pandemic proportions has been a real concern.
B. Because of the potential for an event resulting in mass casualties, the U.S. medical community has taken steps to ensure that mechanical ventilators are available for the possibly thousands of individuals who may require life support.
C. To make sure an adequate number of ventilators are available should a mass disaster occur, the U.S. Centers for Disease Control and Prevention’s Strategic National Stockpile program has more than 6000 ventilators at their disposal.
D. Planning at the local level for such an event is essential. Because respiratory therapists are responsible for setting up and maintaining mechanical ventilators, they must be actively involved in disaster management planning, training, and implementation.
E. A reliable triage system must be implemented during a mass casualty event so that patients who require ventilator support can be identified.
F. Because critical care respiratory therapists may be in short supply, noncritical care therapists who have been trained in critical care situations such as this will be called on to assist in patient care.
G. Because infants and children will also be victims, the ventilators must also be capable of maintaining this age group.
I. The respiratory therapist must play a key role in training caregivers in the use of the mechanical ventilator.
POSTCHAPTER STUDY QUESTIONS
1. List three medications that are commonly instilled directly down the ET tube.
2. What is the major indication for the administration of dopamine?
3. List two indications for lidocaine.
4. Sodium nitroprusside (Nipride) is indicated for the treatment of what condition?
5. Describe the proper airway management of a postterm neonate in whom meconium aspiration is suspected.
6. When resuscitating a neonate immediately after delivery, what is the proper ventilation rate and peak inspiratory pressure for manual ventilation?
7. List four criteria that aid in delivering the highest O2 concentration with a manual resuscitator.
8. What is the initial current delivered during defibrillation of an adult with a monophasic defibrillator? With a biphasic defibrillator?
9. What is the maximum current used to defibrillate an adult?
10. List two drugs that may be administered to improve the success of defibrillation.
11. List five arrhythmias that cardioversion is used to terminate.
12. How many joules are delivered to the patient during cardioversion?
13. List three potential consequences that could affect a patient during an air transport at high altitude.
Aehlert B. ACLS quick review study guide, ed 3. St Louis: Mosby; 2007.
American Heart Association, CPR guidelines, Dallas, 2005.
Hess DR, Respiratory care principles and practice, ed 1, Philadelphia, Saunders, 2002.
Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9. St Louis: Mosby; 2009.
