This section consists of five parts:
1 Identifying patients at risk of cardiac arrest in hospital
2 Using the ABCDE approach
3 Confirming cardiac arrest
4 Initiating in-hospital adult cardiopulmonary resuscitation
5 Initiating adult cardiopulmonary resuscitation in a community care environment
(Please note that some publishers and/or organizations use cardiorespiratory in place of cardiopulmonary.)
Within the context of the in-hospital environment, adult resuscitation involves management of the critically ill patient, with acute altered physiology in addition to cardiopulmonary resuscitation (CPR). This chapter will discuss a systematic approach to recognition and management of the ‘at risk’ patient; in-hospital CPR and out-of-hospital CPR for the healthcare provider. The procedures involved in advanced life support (ALS) are outside the remit of this chapter, therefore the focus will be on first responder CPR and use of automated external defibrillators (AED).
Learning outcomes
By the end of this section, you should know how to:
▪ identify patients at risk of cardiac arrest
▪ manage these patients using the ABCDE approach
▪ confirm cardiac arrest
▪ initiate in-hospital cardiopulmonary resuscitation
▪ initiate cardiopulmonary resuscitation in a community setting
▪ identify essential equipment required in a clinical emergency.
Background knowledge required
Revision of the anatomy and physiology of the cardiovascular and respiratory systems
Review of the health authority and trust policy pertaining to the procedure of cardiopulmonary resuscitation.
Indications and rationale for this practice
To maintain function of the vital organs, we require an airway that is open; the ability to breath in oxygen and to obtain adequate gaseous exchange in the lungs; and a pump that can circulate this oxygen to those organs to keep them perfused and alive. Failure at any point in this process will result in reduced oxygen delivery, organ failure and, ultimately, death.
The majority of in-hospital cardiac arrests are not sudden (Jevon 2006), unexpected events and as many as 80% of patients will demonstrate warning signs of altering physiology prior to the event. Close monitoring of the patient may allow early recognition of deteriorating physiology (Table 8.1), provide an opportunity for appropriate treatment and in some cases may prevent cardiac arrest (Resuscitation Council (UK) 2006a).
| *See paragraph titled Disability in Section 2 | |||||||
| Score | 3 | 2 | 1 | 0 | 1 | 2 | 3 |
|---|---|---|---|---|---|---|---|
| Respiration rate | — | < 8 | 9–10 | 11–20 | 21–25 | 26–30 | > 31 |
| Pulse | — | < 4 | 41–50 | 51–100 | 101–110 | 110–130 | > 130 |
| Systolic BP | < 84 | 85–89 | 90–100 | 101–199 | — | > 200 | — |
| GCS/AVPU* | < 8 | 9–13 | 14 | 15 | — | — | — |
| — | — | New agitation/confusion | Alert | Voice | Pain | Unresponsive | |
| Urine | < 10 ml h−1 | < 30 ml h−1 | — | — | — | — | — |
| Temp. (°C) | — | < 35 | 35–35.9 | 36–37.4 | 37.5–38.5 | > 38.6 | — |
| SpO2% | < 87 | 88 –91 | 92–94 | 95–100 | — | — | — |
In hospital the most common cause of cardiac arrest is hypoxaemia due to deteriorating respiratory, circulatory and neurological systems (International Liaison Committee On Resuscitation 2005a). There are common clinical signs evident in the critically ill patient. These are:
▪ tachypnoea in an attempt to breath in more oxygen
▪ tachycardia as the body attempts to circulate oxygen to the vital organs
▪ hypotension as the cardiac output drops, the blood pressure will fall
▪ reduced conscious level as the perfusion of the brain is diminished (Resuscitation Council (UK) 2006a).
Equipment1. Local health authority Early Warning Scoring system (EWSs) chart.
▪ the assessments associated with EWSs must be undertaken as quickly and efficiently as possible to enable the required assistance to be summoned quickly
▪ assess the patient’s respiratory rate (seep. 293) to identify an ‘at risk’ rate
▪ assess the patient’s pulse rate (seep. 279) to identify an ‘at risk’ rate
▪ assess the patient’s blood pressure (seep. 41) to identify an ‘at risk’ systolic pressure
▪ assess the patient’s conscious level using the Glasgow Coma Scale (GCS; seep. 351) to identify an ‘at risk’ GCS score
▪ assess the patient’s hourly urine output if catheterized (seep. 91) or note the time and amount of urine passed by the patient to identify an ‘at risk’ urinary output
▪ assess the patient’s body temperature (seep. 55) to identify an ‘at risk’ temperature
▪ if the patient’s oxygen saturation is being monitored note the percentage (seep. 245) to identify an ‘at risk’ saturation percentage
▪ record the overall score and act immediately as directed by local policy. Some hospitals may function with a medical emergency team, while other hospitals have a cardiac arrest team, which responds to peri-arrest situations. The higher the patient’s score the more ‘at risk’ of cardiac arrest. Identifying patients at risk is often viewed as the first act in the ‘Chain of Survival’, which highlights the actions linking a patient who has a cardiac arrest with survival (Resuscitation Council (UK) 2005).
2. USING THE ABCDE APPROACH
Indications for this nursing practice
A common method used to identify and treat problems is known as the ABCDE approach. This refers to Airway; Breathing; Circulation; Disability; Exposure.
The ABCDE approach is a systematic framework that allows the nurse to identify problems and to act on these without delay. The process is continuous and staff should reassess the casualty at each point where intervention takes place for signs of improvement or deterioration. Nurses should only work to their own level of clinical expertise and should be aware of their limitations. It is essential to call for help as soon as it is required and to acknowledge your limitations.
Airway
▪ the airway should be assessed to determine whether it is patent, partially obstructed or completely obstructed. If a patient can give a verbal response, then it is likely that the airway is patent (Garrioch 2000)
▪ if there is evidence of noise (e.g. stridor or wheeze) then the airway is partially obstructed. Stridor often indicates an upper airway obstruction and wheeze usually indicates a lower obstruction
▪ simple manoeuvres should be used to open the airway (Resuscitation Council (UK) 2006b). If the patient is conscious and assuming there is no neck injury, the patient may attempt to optimise their own airway by sitting upright, if this is clearly not effective and the patient remains conscious, then lifting the chin forward may help. If the patient is unconscious the head-tilt-chin-lift manoeuvre can be used, or if neck injury is suspected, jaw thrust by experienced personnel
▪ if these manoeuvres are ineffective airway adjuncts may be considered (e.g. naso-pharyngeal airway in a conscious patient with a glossopharyngeal reflex or oro-pharyngeal airway in an unconscious casualty without glossopharyngeal reflex). Airway adjuncts should only be used by personnel experienced in their use (Resuscitation Council (UK) 2006b)
▪ if the airway is completely obstructed the patient may develop a ‘see-saw’ pattern of respiration, with a silent chest. See-saw respiratory pattern is confirmed by the abdomen moving in as the chest moves out and vice versa. This is an extreme clinical emergency and will require immediate, advanced airway management; an anaesthetist should be contacted immediately according to local protocol.
Breathing
▪ when assessing breathing, the respiratory rate should be observed and particular attention should be paid to the effort of breathing displayed by the acute patient, tachypnoea and the use of accessory muscles of respiration should be noted and reported immediately. These are worrying signs
▪ other observations of breathing should include listening to the chest with a stethoscope and percussion of the chest by trained personnel. As a guide, it is suggested by early warning scoring systems that if the patient’s respiratory rate is < 5 or > 36 help should be sought
▪ any patient with an acute breathing problem should be administered high-flow oxygen initially (White 2000).
Circulation
▪ the nurse should observe the patient for signs of circulatory failure, an initial observation will determine if the patient is sweaty, clammy, pale, etc.
▪ the patient’s pulse should be assessed and recorded noting the rate, regularity and volume to indicate cardiovascular function (seePractice 34)
▪ a blood pressure recording (seePractice 4) to determine the effectiveness of the cardiovascular system
▪ changes in pulse and blood pressure should be reported to medical staff, according to local policy
▪ if the patient is clearly deteriorating and an adequately experienced clinician is available, the circulation should be accessed with intravenous cannulae to aid quick and easy administration of medications
▪ if the equipment is available, the patient should be monitored with a cardiac monitor and pulse oximetry to provide objective physiological measurements.
Disability
▪ disability relates to the neurological status of the patient
▪ a quick and easy way to determine how well the brain is being perfused is to assess the patient using the AVPU score. This translates to the following (Resuscitation Council (UK) 2006a):
—the patient is Alert
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