Cardiopulmonary resuscitation

Chapter 8 Cardiopulmonary resuscitation



Fiona Clements



CHAPTER CONTENTS


Introduction 94
Learning outcomes 95

Rationale 95

Factors to note 95

Basic paediatric life support 96
Method 96

Dos and don’ts 98

Advanced paediatric life support 98
The emergency trolley 98

Maintenance of airway 98
Equipment 98

Method 98

Vascular access 100
Equipment 100

Method 100

Drugs and fluid therapy 100
Drug therapy 101

Defibrillation 101
Dos and don’ts 102

Summary 102


INTRODUCTION


While few resuscitation situations involving children arise without warning, it remains imperative that children’s nurses are skilled in the area of basic life support (Simpson 1994, Carter & Dearmun 1995). Paediatric basic life support (BLS) is described as the provision of cardiopulmonary resuscitation (CPR) with no devices or with bag-valve-mask ventilation or barrier devices, until advanced life support (ALS) can be provided (International Guidelines 2000). However, ‘if basic life support is not effectively delivered to the child, attempts at advanced life support are likely to prove futile’ (Simpson 1994, p 39).


As accidents remain the commonest cause of death in children and as the life expectancy of children with a variety of chronic illnesses is increasing, the need for parents, and also other members of the general public, to learn basic paediatric life support is becoming increasingly important (Carter & Dearmun 1995, Whitton 1995).


It is important to recognise that practising CPR using a baby or child manikin is the most effective way of ensuring that children’s nurses have appropriate skills to help an infant or child in need. In addition, these skills, in order to be fresh, require to be updated regularly.


All nurses must be aware of the emergency call telephone number and procedure for their individual clinical areas.


Sudden cardiac arrest is a rare event in the paediatric population; most children will show signs of physiological deterioration, sometimes hours prior to the event (Tibballs et al 2005). As outcome from cardiac arrest is poor, it is important that deteriorating patients are recognised and appropriate interventions made. A number of early warning systems to detect clinical deterioration have been developed and are now used within adult medicine (Parr et al 2001, Hodgetts et al 2002). Early warning systems are now being developed throughout paediatric medicine (Tibballs et al 2005, Duncan et al 2006, McCabe et al 2009). Most paediatric hospitals are now using or developing early warning systems, it is important that the nurse is familiar with their format and use.



LEARNING OUTCOMES


By the end of this section, and following further reading and simulated practice, the nurse should be able to:


• Assess responsiveness in infants and children

• Use appropriate airway opening techniques

• Assess respiration by looking, listening and feeling for expired breath

• Provide rescue breathing using both mouth-to-mouth techniques and use of a bag-valve-mask system

• Pulse check using appropriate sites

• Provide chest compressions

• Identify priorities in advanced life support.


RATIONALE


Commentators on both sides of the Atlantic acknowledge the importance of resuscitation as a nursing skill (AHA 2000, Resuscitation Council (UK) 2005).


Cardiac arrest in children is often the terminal event of progressive shock or respiratory failure; early signs of shock or respiratory failure must be recognised and treated to prevent cardiac arrest (International Guidelines 2000, Resuscitation Council (UK) 2005).


Many children die or suffer permanent neurological impairment each year because of respiratory failure, sudden infant death syndrome, sepsis or trauma (CDC at: www.cdc.gov/injury/wisqars/index.html). Appropriate prompt action can help avoid many of them.


Advanced life support will be futile if basic life support is not delivered effectively.



FACTORS TO NOTE


Babies and children differ from adults in a number of ways:


• The causes of their cardiopulmonary arrest are different, with adults tending to suffer from primary cardiac arrest, whereas children, who predominantly have healthy hearts, tend to have secondary cardiac arrest following a period of hypoxia, often associated with an airway or breathing emergency. This fact suggests that cardiac arrest in children may be preventable if appropriate measures are taken to deal with the airway or breathing problem. The presence of hypoxia also explains why children fare so poorly following cardiopulmonary arrest. If the heart is deprived of oxygen to the point where it can no longer function, then similar effects must be seen in the brain and other vital organs (Hampson-Evans & Bingham 1998).

• Respiratory infection and sepsis are the primary causes of cardiopulmonary arrest in children under 5 years of age, with trauma being the major cause in the 5- to 14-year age group (Williams 1994).

• Babies and children differ from each other in resuscitation terms. The term ‘infant’ refers to the under 1-year-old, including the neonatal period; the term ‘child’ is defined as being from the age of 1 year through to puberty (ERC 2005, Resuscitation Council (UK) 2005, AHA 2005).

• The paediatric larynx is funnel shaped, not cylindrical. This renders the larynx more susceptible to impaction of foreign objects.

• The larynx of the child is soft and the trachea is short. The tongue of the infant or child is large in comparison and, as such, increases airway obstruction and obscures the view of the glottis (Williams 1994, Bishop-Kurylo & Masiello 1995).

• Infants have poorly developed accessory muscles and an immature bronchial tree, the diaphragm being the major muscle of respiration (Hazinski 1992).

• Chest compressions should be initiated in children if the pulse is absent or the heart rate is less than 60 beats/min, with signs of poor perfusion (ERC 2005, Resuscitation Council (UK) 2005)

• Basic life support should be initiated before the administration of any drugs, or other intervention, is considered.

• Cardiac arrest is defined as the absence of palpable central pulses. Four cardiac arrest rhythms may be identified on electrocardiograph (ECG) monitoring in children: asystole, pulseless electrical activity (PEA), ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT).

• The presenting rhythm in most paediatric cardiac arrests is asystole or extreme bradycardia (Sirbaugh et al 1999, Young & Seidel 1999).

• Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) has been reported in 10–20% of paediatric cardiac arrests (Mogeyzel et al 1995, Young & Seidel 1999). It is most likely to occur in children who are hypothermic, have structural cardiac disease or have taken an overdose of tricyclic antidepressants.

• Defibrillation takes precedence in the treatment of VF and VT. One shock at 4 J/kg should be delivered every 2 min in VF/VT cardiopulmonary arrest. Paediatric paddles should be used in children below 10 kg (ERC 2005, Resuscitation Council (UK) 2005).


BASIC PAEDIATRIC LIFE SUPPORT



METHOD


If the lone rescuer has been taught adult basic life support then they may use the adult sequence with the addition of providing five initial breaths and performing 1 min of basic life support prior to going for help (Resuscitation Council (UK) 2005).


The following recommendations should be used by those who have a duty of care to respond to paediatric emergencies.


1. Ensure that both the rescuer and child are in a safe environment leaving the child in the position you find him unless he would be in further danger.

2. Assess the level of responsiveness by gently shaking or pinching the child’s fingers or toes. Tactile and verbal stimulation should be used. Do not shake children with suspected spinal injuries.

3. If the child is unresponsive, call for help but do not leave the child alone. It is possible that this unconsciousness may cause airway obstruction. Opening of the airway may be the only resuscitative action that is required.


Opening the airway



• The airway can be opened in either of two ways:
– Head tilt/chin lift – one hand is placed on the child’s forehead, and a finger of the other hand is placed on the bony tip of the chin. The head is then tilted back and the chin lifted upwards and forward (Fig. 8.1). It is important to avoid overextension of the neck and compression of the soft tissues under the chin as either of these can cause obstruction of the air passages.

– Jaw thrust – this technique is the preferred choice where neck injury is suspected as it allows the airway to be opened without moving the neck. In this instance the index fingers of both hands are placed behind the angles of the jaw and the mandible is lifted upwards carrying the tongue forward. This manoeuvre may close the mouth, if so the thumbs should be placed on the tip of the chin to open the mouth (Hampson-Evans & Bingham 1998).

• If impaction of the airway by a foreign body is suspected or witnessed, and is visible in the mouth, it should be removed.

• Once the airway is open, assess breathing.

• Assess breathing by looking for the rise and fall of the chest, listening for breath sounds at the child’s mouth and nose, and feeling for evidence of expired breath with your cheek, taking no more than 10 seconds. Care should be taken to differentiate effective breathing from ineffective gasping respiratory effort (Poets et al 1999).

• If there is no breathing, artificial ventilation should be commenced without delay.

• For infants, place the head in the neutral position and deliver breaths by covering the mouth and nose. It has been suggested that in some infants it is not possible for an adult to effectively cover both mouth and nose for ventilation (Tonkin et al 1995). If the nose and mouth cannot be covered by the rescuer’s mouth, breaths could be delivered by covering either the nose or the mouth (if the nose is used, the mouth should be closed to prevent air escaping) (ERC 2005, AHA 2005).

• For the child, breathing should be by the mouth-to-mouth route using a head tilt, chin lift.

• Maintain the airway in an open position throughout ventilation.

• Deliver breaths slowly, 1–1½ seconds each, to minimise the possibility of gastric distension and optimise filling of lungs (McCrory & Downs 1990, Resuscitation Council (UK) 2005).

• Observe the chest during rescue breathing to ensure that it rises and falls. This movement confirms the patency of the airway.

• Deliver five initial rescue breaths (ERC 2005, Resuscitation Council (UK) 2005). If chest movement is not witnessed, reposition the airway. If this is unsuccessful, the possibility of a foreign body should be considered.

image

Figure 8.1 Airway opening: head tilt/chin lift.



Checking the pulse



• Assess circulation by palpation of the pulse and observing for any other signs of life, e.g. swallowing, moving, breathing (Resuscitation Council (UK) 2005).

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Mar 7, 2017 | Posted by in NURSING | Comments Off on Cardiopulmonary resuscitation

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