A Review of The Effectiveness of CPR in a Case Scenario Based on Anzcor Guidelines

Cardiac arrest refers to the sudden loss of heart function due to a fault in the electrical transmission system. It interrupts the pumping mechanism of the heart and consequently, the body is deprived off blood and oxygen. This condition is usually accompanied by cessation of breathing and loss of consciousness. It is an extremely fatal situation with a very high mortality rate. In Australia, for example, only 10% of the approximate 20,000 individuals who have cardiac arrest every year survive. This is according to research conducted by the Victor Chong Cardiac Research Institute. To avoid death and further morbidity, immediate and appropriate emergency care is essential. Proper and timely cardiopulmonary resuscitation, comprising prompt defibrillation and quality care after the arrest leads to higher survival rates and better neural results. I reviewed the video on YouTube and compared the resuscitation done to the ANZCOR guidelines as covered in our coursework. Evidently, the team had several strengths and weaknesses. In this paper, I will explore their practice based on the standard guidelines and existing research.

The video begins with a nurse walking into a ward to administer medication to a patient. She calls him and as she walks closer, she discovers the patient is not responding. She calls him again and declares that he is not breathing. She further stimulates the patient by touching him to ascertain that he is unconscious and not simply sleeping. Possible dangers are addressed when she looks at the patient to determine any obvious cause of the unconsciousness. According to the 2016 ANZCOR guidelines on basic life support, she got the first steps right by assessing immediate danger to the patient and confirming unconsciousness (Grantham and Christiansen, 2016).

The first mistake comes when the nurse determines whether the patient is breathing instead of calling for help first. According to the national guidelines, calling for help is considered paramount in both trained and untrained personnel before beginning CPR. This is because the exercise involves plenty of activities which cannot be performed effectively by one individual. Nehme and Andrew conducted a study and found out that there was improved outcomes when the first individual at the scene calls for help without delay. The nurse does not check the airway before assessing for breathing. She should have checked for any solids in the mouth or visible secretions, remove them and then proceed to open the airway using the head-tilt chin-lift maneuver. According to Newel, this simple maneuver can make the airway patent again and help remove any present impediment. It further facilitates the return of natural circulation. After opening the airway, breathing assessment should follow.

The nurse uses the wrong technique to check for breathing. She simply looks at him and touches his neck before concluding that there is absence of breathing. Contrary to what she did, one should look, listen and feel for breathing signs as recommended by Kaihula and Sawe (Kaihula et al., 2018). This is usually done with the ear closer to the nose and eyes looking at the chest for chest rises. It should be noted that gasping and labored breathing should not be considered as effective breathing. These are present in patients still in the initial phases of cardiac arrest.

In the absence of normal breathing, cardiopulmonary resuscitation should begin immediately. Unfortunately, in the video, the first nurse goes to get her team instead of beginning the appropriate procedures. After they arrive, one of the nurses checks for the radial pulse while another one takes the BVM and gives six breathes before taking a break. They do not give chest compressions at any point their resuscitation attempt. The recommended approach to CPR is initiating chest compressions and breaths in the ratio 30:2 once inadequacy of breathing has been established. According to recent protocols, checking of pulse is skipped. This is because studies conducted by Johnson and Pearson revealed that it is difficult both for a layperson and a trained medic to certainly identify a pulse in the resuscitation process (Johnson et al., 2018). It is therefore recommended that rescuers should proceed to chest compressions and giving breaths rather than wasting time looking for a pulse.

Research has shown that chest compressions are the most important component of the CPR procedure. They mimic the pumping mechanism of the heart by increasing intrathoracic pressure, therefore, pushing the remaining oxygenated blood to the tissues for oxygen delivery. Effective compressions are performed with the rescuer on the right side of the patient (if he is right-handed) and the compressing hands on the sternum, preferably, at the middle of the nipple line. They should be hard and fast with the aim of 100-120 compressions per minute but allowing the chest wall to recoil before giving successive compressions. The depth of the compressions should be a minimum of 2 inches with minimum interruptions (Ewy, 2016). After every 30 compressions, two rescue breaths should be given by a different member of the team using bag-valve-mask equipment. The adequacy of the ventilation should be assessed by looking for chest rise when air is pumped in. If no rising occurs, patency of the airway should be re-evaluated. This compression breath cycle should continue minimal interruptions with the maximum lasting not more than 10 seconds.

I noted that this particular team mainly relies on defibrillation for the resuscitation of the patient. After arrival, one of them brings the machine and they immediately analyze the rhythm. Ideally, defibrillation comes into play after the first cycle of CPR. Compressions are stopped and pads placed on the chest to analyze the rhythm of the heart as recommended by the latest guidelines. In this case, it came after the first six breaths were given. They, however, correctly analyzed rhythm and identified the appropriate time for a shock. They proceed to make another mistake of analyzing and shocking for a second and third time immediately after the first one. The pads are taken back then brought again after a brief moment of in-effective practice. The correct practice is, after the first defibrillation, CPR should continue for another two minutes before analysis and shock are done again. These should alternate until the patient recovers.

There is also wrongful use of drugs in the video. An unknown amount of epinephrine is given after the fourth shock is given. This is a wrong timing according to the national guidelines. Nolan states that the first dose of adrenalin should be given after successful first defibrillation and a second set of CPR. The correct dose is 1mg but the leader does not mention it. If they had used adrenalin consistently, the second dose should have been given after two successful cycles of CPR. They further make a mistake of giving amiodarone immediately after the adrenalin dose. Amiodarone is an acceptable drug in the resuscitation scenario. Actually, they gave the correct dose 300mg as approved by the European Resuscitation Council. Also, it’s given when the heart rhythm is shockable, like in this patient. However, they did not consider that fact that it’s given after three sets of defibrillation with good CPR and not concurrently with adrenalin. Nonetheless, the routes of administration were correct.

The response team makes no attempt to determine the probable cause of cardiac arrest in the patient. It is a protocol that the etiology of the arrest be established in order to manage it and avert future encounters. Jimenez states that the first step should be to evaluate whether the reason for admission is the cause of the cardiac arrest then other factors considered. The body temperature is checked to rule out hypothermia and a bedside glucose test conducted because hypoglycemia is a known culprit in arrest cases. Pulse oximetry should also be conducted to ensure that the partial pressure of oxygen is above 90 and also analyze other gases in the arteries. Chest conditions that may trigger a patient to go into cardiac arrest are evaluated by listening to lung breath sounds and also observing the symmetry of chest rising during the ventilations. Naloxone, an opioid antagonist is given to patients to reverse the condition in case it was caused by opioid toxins in the body. Potassium imbalance should have been evaluated by doing a blood electrolyte test.

Due to the poor nature of the procedure, the team does not get to post-resuscitation care. The only thing I see them re-evaluating is the pulse of the patient, which is absent at the end of the video. With effective CPR and defibrillation, a pulse is usually obtained after a number of cycles. The adequacy of the pulse is checked and a further re-evaluation of the airway and spontaneous breathing. In most cases, the patient is put on oxygen and moved to the intensive care unit. ICU care in post-cardiac arrest patients has shown to significantly improve patient outcomes. In the ICU, the physiological status of the heart is monitored using a 12 lead electrocardiogram. In addition, blood oxygen levels are kept above 94% and constant monitoring of CO2 levels. Room temperature and blood glucose are also closely regulated.

There is poor leadership in the team and hence the disorder witnessed in the video. Team members have no clearly defined roles on the site. This makes some to stand idly and hinder movement as other members are working. At an instance, two individuals want to do defibrillation at the same time. There is poor communication in the team. This is seen when more than one person is talking with a particular anxious nurse disrupting everything. At some point, one of them decides to leave the scene before the patient is stabilized. No one is keeping a record of the events and drugs being administered. This is a group of individuals who don’t know their guidelines and have never been involved in teambuilding exercises. Poor coordination of resuscitation increases the chances of deviating from the standard guidelines and produces a bad patient outcome as seen in the video.

In conclusion, cardio-pulmonary resuscitation is a life-saving practice when performed correctly. This applies to both lay people and health care professionals in the hospitals. It not only prevents death but also, it avoids other conditions that are associated with oxygen deprivation during the period of the arrest. Due to its significance, the practice ought to be regulated by guidelines which provide the best procedures on how to go about it. These procedures should be taught to the entire population and emphasized in medical practitioners for effective emergency care. Furthermore, the skills should be enhanced through simulations, leadership and team building exercises since they positively influence the quality of resuscitation.

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