The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [392]
4 Lie patient flat on a firm surface/bed. If on a chair, lower the patient to the floor, ensuring that the head is supported. Effective external cardiac massage can be performed only on a hard surface (Resuscitation Council 2010b, C).
5 If patient is in bed, remove bed head and ensure adequate space between back of bed and wall. To allow easy access to patient’s head in order to facilitate intubation. E
6 Ensure a clear airway. If cervical spine injury is excluded, extend, not hyperextend, the neck (thus lifting the tongue off the posterior wall of the pharynx). This is best achieved by lifting the chin forwards with the finger and thumb of one hand while pressing the forehead backwards with the heel of the other hand (see Figure 10.26). If this fails to establish an airway, there may be obstruction by a foreign body. Try to remove the obstruction if visible. Insert oropharyngeal Guedel airway if you have appropriate training. see Figures 10.37-10.40
Do not remove well-fitted dentures. To establish and maintain airway, thus facilitating ventilation (Resuscitation Council 2010b, C).
They help to create a mouth-to-mask seal during ventilation. E
7 Place the heel of one hand in the centre of the sternum and place the other on top, ensuring that the hands are located between the middle and the lower half of the sternum. Ensure that only the heel of the dominant hand is touching the sternum.
Place the other hand on top, straighten the elbows and make sure shoulders are directly over the patient’s chest.
The sternum should be depressed sharply by 5–6 cm. The cardiac compressions should be forceful, and sustained at a rate of 100–120 per minute. To ensure accuracy of external cardiac compression and reduced delay in commencing cardiac compressions (Resuscitation Council 2010b, C).
This produces a cardiac output by applying direct downward force and compression (Smith 2000. R3).
8 Apply facemask with Ambu-bag over nose and mouth. Compress bag in a rhythmical fashion: the bag should be attached to an oxygen source, 12–15 litres. In order to deliver +85% oxygen, a reservoir may be attached to the Ambu-bag. If, however, oxygen is not immediately available, the Ambu-bag will deliver ambient air. Room air contains only 21% oxygen. In shock, a low cardiac output, together with ventilation/perfusion mismatch, results in severe hypoxaemia. The importance of providing a high oxygen gradient from mouth to vital cells cannot be exaggerated and so oxygen should be added during CPR as soon as it is available (80–100% is desirable) (Simmons 2002, R3).
9 Maintain cardiac compression and ventilation at a ratio of 30:2. This rate can be achieved effectively by counting out loud ‘one and two’, and so on. There should be a slight pause to ensure that the delivered breath is sufficient to cause the patient’s chest to rise. This must continue until cardiac output returns and the patient has a palpable blood pressure. Counting aloud will ensure co-ordination of ventilation and compression ratio. To maintain circulation and oxygenation, thus reducing risk of damage to vital organs. E
10 When the cardiac arrest team arrives, it will assume responsibility for the arrest in liaison with the ward staff. To ensure an effective expert team co-ordinates the resuscitation (Resuscitation Council 2010b, C).
11 Attach patient to ECG monitor using three electrodes or defibrillation patches/paddles. To obtain adequate ECG signal. Accurate recording of cardiac rhythm will determine the appropriate treatment to be initiated. E
Intubation in CPR
12 Continue to ventilate and oxygenate the patient before intubation. The risks of cardiac arrhythmias due to hypoxia are decreased (Resuscitation Council 2010b, C).
13 Equipment for intubation should be checked before handing to appropriate medical/nursing