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Why is it important for every nurse practitioner to learn Cardiopulmonary Resuscitation (CPR)?

“Nurse saves doctor after he collapses during a run.”

“Nurse saves gym-goer who collapsed after a heart attack.”

“An off-duty nurse was in the right place at the right time Sunday when a man suffered a medical emergency at a gymnastics event.”

The stories are endless and often go unnoticed how nurses save lives every day. But the question is, is it so easy to do so? Ever wondered how will you react if someone collapses in front of you? The quick response of any medical professional is “START CPR”.

But as a health professional how do you know whether the situation really needs you to start CPR or not. As nurses we are often the first responders to any emergency that happens in a hospital setting. As simple it sounds, if you do not know what and how to assess in a victim your brain could throw you off with many questions.

  • Is it really an arrest?
  • Does the victim really need CPR?
  • What if I am not assessing the victim carefully and he is just asleep?
  • What if I don’t perform CPR properly?
  • Should I call a senior /Doctor first?

As scary it might sound, you do have very limited time to manage a collapsed victim and the more time one wastes, less are the chances of a survival. As per The Centers of Disease Control and Prevention (CDC), heart disease is the leading cause of death among men and women. We will address common misconceptions about CPR in this blog post.

Why should you learn CPR?

Nurses are the first responders– In a hospital, nurses need to manage an emergency before the team arrives.

CPR saves lives– Cardiopulmonary Resuscitation is a simple life skills that not only save lives but also prevents long term complications such brain damage. According to American Heart Association (AHA), those victims who were treated by emergency medical services (EMS), 10.6% survived. Among the bystander witnessed cases in which individuals had a heart rhythm that could be treated effectively with a defibrillator, 31.4 % survived. The data reflects the importance of quick action taken by bystanders to save a life.

See link: https://www.sca-aware.org/sca-news/aha-releases-2015-heart-and-stroke-statistics

CPR-heart and stroke statistics

Source: https://www.sca-aware.org/sca-news/aha-releases-2015-heart-and-stroke-statistics

Increases your chances at a job- many job requirements specify nurses to be trained to perform and be certified as ‘CPR provider’. See the links below.

/product/cardio-pulmonary-resuscitation-cpr-adult/

Train others- Often nurses educators need to train others on essential skill of performing CPR. Nurse educators can go for higher certification and be trained as a trainer.

Quality patient care- It is evident that if the nurses are well prepared to deal with the arrest situation in hospital and community, the patient care is bound to be better as they manage the situation effectively. American Heart Association stats that CPR, especially if administered immediately after cardiac arrest, can double or triple a person’s chance of survival. See more here:

https://cpr.heart.org/AHAECC/CPRAndECC/AboutCPRECC/CPRFactsAndStats/UCM_475748_CPR-Facts-and-Stats.jsp

When should be CPR performed?

Cardiopulmonary Resuscitation should be performed when someone is not breathing or when the heart stops beating. In many situations the victim might not be a cardiac patient or have a history of cardiac disease. One should know that there may be other situations as well where a victim might experience cardiac arrest or stop breathing, this include the following conditions.

  • Stroke or tumor
  • Choking
  • Allergic reaction
  • Traumatic injury (head/neck)
  • Electric shocks
  • Drowning

So, CPR must be performed in any situation when a person in not breathing or has no pulse.

What is the difference between CPR and First aid?

First aid refers to the initial action taken by the responders in case of an emergency situation.

So how is CPR different from first aid?

First aid teaches the res-ponders to recognize a variety of emergency situations such as head injuries, neck injuries, burns, traumatic injuries whereas CPR is a ‘step’ while providing first aid in case a victim suffered cardiac arrest, near drowning situations or when the victim is not breathing.

Read more about CPR and First Aid courses here:

Steps of First aid during arrest situation include:

1. Call for help- Call on emergency number.

2. Provide First aid- There can be a number of reasons if the person stops breathing or the heart stops. For example traumatic injury or choking. If the victim has suffered an arrest situation, the rescuer must provide initial first aid such as performing Heimlich maneuver or removing the victim from the danger zone. See the link to know more about Heimlich maneuver here.

Choking Management- Adults

Choking Management- Infant

3. Start CPR- Start CPR as soon as possible as time to avoid complications of injuries to get worsen.

CPR-first aid

Source: http://boostafosterfamily.org/wp-content/

Methods of performing CPR

1. CPR by trained health professionals- It is recommended that trained health professionals should check for pulse and start CPR if no pulse can be felt within 10 seconds starting with chest compression. Start 30 chest compressions followed by 2 rescue breaths.

Learn about CPR for health professionals here:

Cardio Pulmonary Resuscitation (CPR)-Adult

Cardio Pulmonary Resuscitation (CPR)-Infant

2. Hands only CPR/CPR without ventilation- If you are not trained in performing CPR or you have not renewed your certification within two years, it is suggested that one must perform hands only CPR that is provide chest compressions only. The rescuer only provides chest compression without giving ventilation to the victim.

What are the steps of CPR?

The steps of CPR were revised and changed from ‘A-B-C’ to ‘C-A-B’. The evidence suggest that chest compressions is the most important step during CPR than opening airway and breathing in adults. Thus, it is recommended that the rescuer must begin performing chest compression and then focus on airway and breathing.

C stands for Chest Compression

A stands for Airway

B stands for Breathing

CPR-C-A-B

Source: https://medictests.com/abc-vs-cab-correct/

CPR using Automated External Defibrillator (AED)

CPR is crucial for the survival of an individual who has suffered an arrest, but often use of AED is equally emphasized. Automated External Defibrillator or AED is a device suggested to be used as soon as it is available. AED are placed in public places and are meant to be used if an arrest situation happens at a public place. AED can identify the abnormal heart rhythm and decides whether shock needs to be given or not. An AED gives instructions from pushing the button to connecting the pads. The purpose of AED is that, even a layman or untrained professional can give shock to the victim saving a life without causing damage. It has been proven that early shock increases the chances of survival of a victim. Learn more about how to use an AED here.

Automated External Defibrillator

Automated external defibrilator

Source: https://i1.wp.com/scrubbing.in/wp-content/uploads/2013/09/AED.png?resize=556%2C266

CPR with defibrillator

Defibrillator is device that gives shock to the heart when life threatening arrhythmia such as Ventricular tachycardia and Ventricular fibrillation occurs. These are the only two conditions where a defibrillator is used. Health professionals must use a defibrillator as soon as it is available. It is preferred to use a manual defibrillator than AED if both are available.

In case you are unsure of the dose of defibrillator remember the following practical points:

  • Know your defibrillator- Check what type of defibrillator is available in your unit. For example if it says ‘Monophasic’ then the amount of energy requirement is more (360 J). If the defibrillator is ‘Biphasic’, you can start with lower energy (120 J, 150 J).
  • Be consistent- This means if you started at a dose of 150 J give the next shock with same amount of energy.
  • Increase the energy with each shock- You can either choose to give same amount of energy with each shock or you must increase the dosage with each shock (120 J, 150 J and 200 J).

Learn more about using defibrillator on the following links:

CPR without defibrillator

Do you always need a defibrillator when resuscitating a victim? The answer is No.

You don’t always need a defibrillator during an arrest situation. While providing first aid to a person who has collapsed, the most important thing is to start CPR. By providing chest compressions, you are manually trying to pump the blood from the heart to the other organs of the body. This act ensures that the vital organs are still getting oxygen through blood. Defibrillator temporarily stops the heart rhythm and allows the heart to resume back the normal rhythm. There are certain conditions where you do not need a defibrillator during CPR which include Pulse-less electric activity and asystole. In these conditions, the heart has ‘no rhythm’, so giving a shock will not be of any benefit. Only thing that can save life in such conditions is CPR.

If you are using an AED it will instruct you to continue CPR and not give any shock but if you are using a manual defibrillator you need to recognize these conditions on your own.

Steps to be a confident CPR provider

1. Learn the basics- Pay attention to important steps and principles behind them for example C-A-B sequence, chest compression quality and pulse check. Learn more about the basics here: Bodhi Link

2. Know the medications- Nurses are expected to provide IV medication during resuscitation. Read about medications and recommended dosage in various arrest situations. For example epinephrine is the drug of choice irrespective of the heart rhythm during a cardiac arrest.

3. What not to give- Be updated what actions or drugs not to give during resuscitation. For example atropine is no more used during arrest situation. American Heart Association stopped recommending atropine during cardiac arrest since the guidelines released in 2010. Learn more about the changes here: http://www.heart.org/idc/groups/heart-public/@wcm/@ecc/documents/downloadable/ucm_317350.pdf

4. Orient yourself to emergency equipment- Keep yourself updated with the emergency or crash cart to understand the placement of drugs, equipment like ET tube, defibrillator, laryngoscope which are used during resuscitation.

Learn more about what items to expect in a crash cart here:

5. Refresh knowledge and skills- Participate in BLS and ACLS courses after a minimum duration of two years to renew your knowledge and skills of performing CPR.

CPR courses for nursing professionals

Nurses can undergo variety of certificate courses based on their area of placement and professional requirements.

Cardio Pulmonary Resuscitation (CPR)-Adult in English

CPR-Adult in Hindi

Cardio Pulmonary Resuscitation (CPR)-Infant in English

CPR-Infant in Hindi

American Heart Association Advance Cardiac Life Support-

https://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/AdvancedCardiovascularLifeSupportACLS/UCM_473186_Advanced-Cardiovascular-Life-Support-ACLS.jsp

American Heart Association Pediatric Life Support-

https://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/Pediatric/UCM_473190_Pediatric.jsp

CPR certification Vs Re-certification

CPR certification lasts for a duration of two years. Researches indicate that there is deterioration of knowledge and skills of performing resuscitation with time. American Heart Association suggests that the health professionals must undergo re-certification to refresh the knowledge and skills of performing CPR every two years. Re-certification might take lesser time compared to the initial certification depending upon the organization you choose to certify yourself with.

You can choose to go for a blended learning and e-learning. See link:

https://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/BasicLifeSupportBLS/UCM_481711_BLS—Instructor-Led-Training.jsp

https://www.redcross.org/take-a-class/cpr/cpr-training/cpr-renewal

NOTE: Make sure the certification you choose to undergo is recognized by your employer.

Conclusion

In many organizations and units where nurses work, CPR is an essential skill which they must be trained in such as emergency department and critical care units. It is a crucial skill which nurses must learn and encourage others as well to learn, as it not only helps them at the professional front but also empower them to be ready for adverse events that might happen at home and other social settings. See more inspiring stories here and learn more about CPR heroes:

https://www.bhf.org.uk/how-you-can-help/how-to-save-a-life/what-is-cpr/everyday-heroes

“Take Action- Learn CPR”

Orthodontics in growing children

In today’s world of selfies and smartphones, a beautiful smile is desired by all. People have become more aesthetically conscious and have begun to seek orthodontic treatment to correct the malocclusion in their dentition and improve aesthetics. A beautiful smile is a pleasure to the eyes and orthodontics is the branch of dentistry which provides people with the smile they want.

In the growing age, children encounter a variety of dento-facial abnormalities and malocclusion. It is important to identify the malocclusion and correct it at the right age for proper development of the dento- facial structures. Malocclusions hamper the aesthetics of a person as well. Thus, it is necessary that the abnormality is addressed on time.

There are certain deleterious oral habits which the children acquire at an early age and this leads to malocclusions.
It is important to intercept these habits at the earliest.
Proper oral hygiene habits should be instilled in children at an early age to avoid dental caries and periodontal diseases. Dental caries and periodontal diseases can lead to premature loss of deciduous as well as permanent teeth leading to malocclusions.

Here are a few points which will improve our understanding about orthodontics and the oral habits in growing children.

The need for the correction of malocclusion:

An incorrect bite can lead to:

  • Interference with normal growth and development of jaws
  • Impaired chewing
  • Difficulty swallowing
  • Speech defects
  • Malocclusion makes the person more susceptible to cavities and periodontal problems
  • Poor esthetics
  • Deleterious oral habits in growing children:

The American Academy of Pediatric Dentistry (AAPD) recognizes that an infant’s, child’s, or adolescent’s well-being is affected by oral habits and encourages health practitioners to take an individualized approach in the management of these habits.
Frequently, children acquire certain habits that may either temporarily or permanently be harmful to dental occlusion and to tooth supporting structures.
The different deleterious oral habits and their treatment is discussed below:

Thumb and digit sucking:

  • Placement of thumb or one or more fingers in varying depths into the mouth.
  • One of the most commonly seen habits.
  • The presence of this habit is considered quite normal till 3.5 to 4 yrs of age.

Clinical features

Proclination of maxillary anterior
Increased over jet
Anterior open bite
Narrow maxillary arch: The muscles contract during thumb sucking leading to a narrow maxillary arch

(Photograph of an eight year old patient with thumb sucking habit.)

Diagnosis: Presence of clean nails and callus on the finger is commonly associated with thumb sucking

Management: There are three approaches in the management of thumb sucking.

  • Psychological
  • Mechanical
  • Chemical

1. Psychological: Thumb sucking is said to be attributed to lack of love, parental care and affection.
The parents should be counselled to provide the child with adequate love and care. The attention of the child should be diverted to other things such as games and toys.

Dunlop beta hypothesis: Dunlop put forward a theory that states the best way to break a habit is by its conscious, purposeful repetition. Dunlop suggests that the child should be asked to sit in front of a large mirror and asked to suck his thumb observing himself.

2. Mechanical: They are reminding appliances that help the child quit the habit.
They can be removable or fixed.

Palatal crib Palatal crib              blue grass appliance blue grass appliance

3. Chemical: Placing bitter tasting preparations on the thumb that is sucked can make the habit distasteful.

  • Pepper dissolved in a volatile medium
  • Quinine
  • Asfoetida
  • Femite

Tongue thrust habit

Condition in which the tongue makes contact with any teeth anterior to the molars during swallowing.

Clinical features

  • Proclination of anterior teeth
  • Anterior open bite
  • Bomaxillary protrusion
  • Posterior open bite in case of lateral tongue thrust
  • Posterior cross bite

Management of tongue thrust

Habit interception:

1. Habit breaker appliances – fixed or removable cribs and rakes

2. The child is taught the correct method of swallowing

3. Various muscle exercises of the tongue :

The hold pull exercise: The tip of the tongue and the midpoint are made to contact the palate and the mandible is gradually opened. This helps in stretching the lingual frenum.

Mouth breathing habit

Mouth breathing can result in altered jaw and tongue posture, which could alter the oro-facial equilibrium thereby leading to malocclusion.

Types of mouth breathers:

  • Obstructive
  • Habitual
  • Anatomic

1. Obstructive: Complete or partial obstruction of the nasal passage can result in the mouth breathing. Some causes of nasal obstruction are:

  • Deviated nasal septum
  • Nasal polyps
  • Chronic inflammation of nasal mucosa
  • Localized benign tumors
  • Obstructive adenoids

2. Habitual: A habitual mouth breather is one who continues to breathe through his mouth even though the nasal obstruction is removed.

3. Anatomic: An anatomic mouth breather is one whose lip morphology does not permit complete closure of the mouth such as patient having short upper lip.

Clinical features

  • Long and narrow face
  • Narrow nose and nasal passage
  • Short and flaccid upper lip
  • Contracted upper arch with possibility of posterior cross bite
  • Increased over jet as a result if flaring of upper incisors
  • Anterior marginal gingivitis can occur due to drying of the gingiva
  • Dry mouth predisposing to caries
  • Anterior open bite

 

Patient with mouth breathing exhibiting marginal gingivitis

Patient with mouth breathing exhibiting marginal gingivitis.

( source: textbook of orthodontics by S.I BHALAJI )

Management

1. Removal of the nasal or pharyngeal obstruction

2. Interception of the habit: use of vestibular screen

3. Rapid maxillary expansion: patients with narrow, constricted maxillary arches benefit from expansion procedures aimed at widening the arch. It has been found to increase the nasal airflow and decrease the nasal air resistance.

Bruxism

Bruxism can be defined as the grinding of teeth for non functional purposes. Some authors refer to nocturnal grinding as bruxism and bruxomania is the term given for grinding during day time. Psychological and emotional stresses have been attributed as one if the major causes in bruxism.

Clinical features

  • Oclussal wear facets.
  • Fractures of teeth and restorations.
  • Tenderness and hypertrophy of masticatory muscles.
  • Headache and pain in the facial muscles when the patient wakes up in the morning.

Management

  • As stress is the major factor, appropriate counseling by a psychiatrist maybe initiated.
  • Hypnosis, meditation and relaxing exercises can help in relieving muscle tension.
  • If occlusal prematurities are present , occlusal adjustments can be made.
  • Night guards help in eliminating occlusal interference and prevent occlusal wear.

Lip biting

Lip biting and lip sucking sometimes appear after forced discontinuation of thumb or finger sucking. It most often involves the lower lip that is turned inwards and pressure exerted on the lingual surface of the maxillary anterior.
Clinical features

  • Proclined upper anteriors and retroclined lower anteriors
  • Hypertrophic and redundant lower lip
  • Cracking of lips

Management

This habit can be intercepted using lip bumpers.

The different malocclusions occurring in children are of a number of types.

To make our understanding easier they can be broadly divided into: intra-arch , inter arch and skeletal.

1. Intra-arch: The malocclusions occurring within the same arch either the maxilla or mandible

Intra-arch

  • Distal tipping
  • Mesial tipping
  • Lingual tipping
  • Buccal tipping
  • Spacing between teeth

Spacing between teeth

  • Crowding : Lack of space leads to crowding and ectopic eruption the teeth

crowding teeth

  • Rotations

rotation

2. Inter-arch: When there is discrepancy in the relationship between the maxillary and mandibular teeth.

  • Deep bite: It is a condition in which there is excessive vertical overlap between the maxillary and mandibular anteriors.

inter arch-Deep bite

  • Open bite : A condition in which there is no overlap between the maxillary and mandibular anteriors.

inter arch-open bite

 

  • Cross bite which can be anterior or posterior : It is the abnormal transverse relationship between upper and lower arches.

inter arch-cross bite

 

3. Skeletal: Skeletal malocclusions that involve abnormalities in the maxilla or mandible. The defects can be in size, position or relationship between the jaws. The maxilla or mandible can either be deficient or excessive in its size.

When is the best time for orthodontic treatment?

  • The jaws of pre–teens and teens are still growing. Therefore, it is easier to shift teeth at this age.
  • Sometimes two separate phases of braces are necessary.
  • Phase 1 : when patients are 6 -7 years of age to amle room for the permanent teeth
  • Phase 2 : at age 12 (when all the permanent teeth have erupted) second round of braces are applied to straighten the teeth and correct the bite.
  • We are living in a world where people are conscious and concerned about their appearance and specially their smile. As a result more and more adults also seek orthodontic treatment. The treatment may take a longer time in adults.

As we discuss the different malocclusions and the best time for the treatment, it might occur to us what can cause malocclusion in the first place.

What causes malocclusion?

  1. Genetics: One may inherit a small jaw from the mother and large teeth size from the father.
  2. Nutritional deficiencies: Malnutrition can restrict the growth of the jaws
  3. Bad oral habits can cause a shift in the normal position of the teeth or can cause them to erupt abnormally. The various deleterious habits have been discussed later.
  4. Tooth loss: If a tooth is lost either due to trauma, caries or periodontal disease, the rest of the teeth may shift. Premature loss or prolonged retention can also lead to a deviation in the path of eruption of the succedaneous tooth.
  • While some forms of malocclusion are inherited and unavoidable, a variety of malocclusions can also be prevented by taking the right measures at an early age and intercepting the deleterious oral habits. It is also true that whatever may be the type of malocclusion or abnormality in the dentition, it can be treated by an orthodontist.
  • Along with intercepting the deleterious oral habits, it is also essential to inculcate good oral hygiene habits in children at a young age.
    1. Brush twice daily: In the morning and at night before going to bed
    2. Rinse your mouth after every meal
    3. Decrease the frequency of sugary foods
    4. Children should floss at least once a day. Young children will need supervision from the parents
    5. Regular dental check ups every 6 months.

Take home message: Malocclusion can affect the growing children and lead to aesthetic as well as functional abnormalities. It is very important to seek orthodontic treatment at an early age to gain best results. The parents should pay attention to any oral habits that the child may acquire and seek help of a dentist to get rid of them. Parents should instill good oral hygiene habits in the children and should understand the importance of regular dental checkups. Remember, a smile is valuable.

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