Cardiopulmonary Arrest and Cardiac Emergencies - Essay Example

The Author’s Name] [The Professor’s Name] [The Course Title] [Date] Cardiopulmonary Arrest And Cardiac Emergencies Introduction The frequency and quality of emergency resuscitation training in the UK have improved during the past 20 years (Colquhoun et al 2004). During this period resuscitation guidelines have been reviewed and updated, most recently in 2005 (Deakin et al 2005, Soar and Spearpoint 2005). However, despite perceived progress, discharge outcomes from in-hospital resuscitation remain poor at 17% (Tunstall-Pedoe et al 1992, p. 1347-1351, Gwinnutt et al 2000, p. 125-135, Peberdy et al 2003, p. 297-308). Poor resuscitation skills were evident among nurses in 1987 (Wynne et al 1987, p. 1198-1199) and there was little evidence of improvement 20 years later (Kramer-Johansen et al 2007a, p. 406-417). This paper considers the management of a cardiac patient in emergency department and how the current resuscitation guidelines (Deakin et al 2005, Soar and Spearpoint 2005) inform and direct resuscitation practice, concentrating on those resuscitation skills that are most likely to be provided by nurses. It also considers important policy and guidance developments on preventing cardiac arrest and the emerging clinical interventions aimed at improving quality of survival at the immediate post-resuscitation phase of care. The paper ends with an overview of current policy and guidance on end-of-life decisions. Prevention of cardiac arrest Cardiac arrest is considered preventable for many in-hospital patients. Of those patients who experience in-hospital cardiac arrest, 79%display basic signs of physiological deterioration before collapse (Kause et al 2004, p. 275-282). Consequently early identification of a patient at risk of cardiac arrest is important. Prevention of cardiac arrest features prominently in the most recent in-hospital resuscitation guidelines (Smith 2005, Soar and Spearpoint 2005) and has become an important component of the Resuscitation Council (UK) (RC(UK)) advanced life support (ALS) provider course (Nolan et al 2008) and the RC(UK) immediate life support (ILS) course (Soar et al 2003, p. 21-26). After the development of critical care outreach services (Department of Health (DH) 2000a) and early warning/patient-at-risk systems, prediction and prevention of in-hospital cardiac arrest have become widely adopted strategies (Rowan 2007). Recent evidence indicates that there are variations in how acute NHS trusts have set up track and trigger systems and RRTs (Rowan and arrison 2007, p. 1165-1166). While improvements in patient outcomes have been predicted (Kenward et al2004, p. 257-263 Smith et al 2006), limited success in reducing cardiac arrest rates has been reported (Gold hill et al 1999, p. 853-860, Ball et al 2003, p. 1014-1017 Priestley et al2004, Buist et al 2007, p. 1210-1212). Buist et al (2007) suggested that the formation and placement of medical emergency teams is only part of the story. Success took six years and required the provision of a committed educational strategy, accompanied by a supportive team to ensure acceptance of the concept, including removal of the fear (particularly among nurses) of calling the RRT to patients not yet in cardiac arrest. The importance of reflective audit and the influence on staff behaviour following the introduction of a new approach to detecting and preventing cardiac arrest were additional and significant contributors to the success of the medical emergency team (Buist et al2007, p. 1210-1212). Rowan and Harrison (2007) suggested that the presence of a committed champion was fundamental to successful implementation of this and other prevention systems. A large cluster randomised trial did not demonstrate significant reductions in unplanned intensive care unit admissions and cardiac arrest mortality despite the introduction of track and trigger/medical emergency team systems (Hillman et al 2005, p. 2091-2097). McGaughey et al (2007) critically reviewed outreach and early warning scoring systems and concluded that further research was required before the widespread promotion of outreach could be recommended. However, it is important to put the evidence into context. Nursing Role In The Initial Assessment Of A Collapsed Patient On discovery of a collapsed patient, it is important to summon immediate assistance by shouting for help and/or using the emergency alarm. Assessment of the patient should be conducted as described in the RC (UK) in-hospital resuscitation guidelines (Soar and Spearpoint2005), which recommend an Airway, Breathing, Circulation, Disability and Exposure (ABCDE) system. When the patient is in arrest the cardiac arrest team should be called (following local procedure, usually 2222), stating cardiac arrest and the hospital/ward/clinical area. Unresponsive, lifeless patients should be placed on their backs, preferably with their head and shoulders resting on a single pillow, to aid airway opening. In most circumstances the airway can be opened (and the tongue removed as an obstruction) by gently lifting the chin and tilting the head, however consideration must be given to patients with head and neck trauma or with conditions where movement of the head and neck should be avoided. In these situations a jaw thrust manoeuvre should be conducted to maintain head and cervical spine alignment while the airway is being opened and assistance may be necessary. The presence of vomit, blood, loose-fitting dentures and other debris in the mouth will require immediate removal, which can be performed with gloved fingers, oral suctioning or (rarely) instrumentation with forceps (Jevon 2008, p. 35-37).Once the airway has been opened and cleared the patient should be assessed for signs of life by looking at the chest for movement, while listening and feeling for breathing over the patient’s mouth and nose. Although not essential, attempts at feeling for a pulse at the carotid artery can be conducted while assessing breathing. This assessment should be completed in ten seconds. During the early stages of cardiac arrest some patients make an occasional gasp for breath; however these agonal respirations are not effective and must be regarded as a sign of arrest. A member of staff would usually need to leave the scene of the incident to call the cardiac arrest team and retrieve the resuscitation trolley, while those who remain commence chest compressions and ventilation. In unusual circumstances where only a single member of staff is present, that person must leave the scene to summon the cardiac arrest team before returning to commence resuscitation on the patient. Commencing cardiopulmonary resuscitation More than 70% of cardiac arrests occurring in hospital are witnessed by a healthcare worker, many of whom are nurses, and witnessed cardiac arrest is an important predictor of survival (Gwinnutt et al 2000, p. 125-135, van Walraven et al 2001, p. 35-40 Peters and Boyde 2007, p. 240-246). Early commencement of chest compressions and ventilations is linked to meaningful recovery (Gwinnutt et al 2000, p. 125-135). When indicated, CPR at a ratio of 30compressions followed by 2 ventilations must be commenced in accordance with current guidelines (Deakin et al 2005, p. S25-S37, Soar and Spearpoint 2005). To conduct optimal chest compressions the heel of one hand should be placed in the centre of the patient’s chest. Sufficient pressure should then be applied to depress the sternum by 4-5cm. The chest should then be fully released, the aim being to spend an equal amount of time in both the compression and relaxation phase. Compressions should continue steadily and rhythmically, until30 have been delivered, at a rate of approximately100 per minute. (Deakin et al 2005, p. S25-S37) Effective, efficient compression technique involves ensuring that arms are held straight and perpendicular to the patient’s chest, using the bodyweight to provide the necessary movement to depress the sternum (RC (UK) 2001).During this time preparations should be made to provide ventilation to the patient’s lungs. (Deakin et al 2005, p. S25-S37) The availability of equipment, such as a simple pocket mask, bag-valve-mask device and other airway management devices, depends on experience, education, practice and local policy. Where there is a delay in accessing equipment mouth-to-mouth technique can be used, however most people continue to remain reluctant to use this technique on patients, or when vomit or blood is present(Soar and Spearpoint 2005). In such circumstances it is recommended that continuous chest compressions are conducted until a pocket mask or resuscitation bag-valve-mask device has been setup and applied to the patient. Buck-Barrett and Squire (2004) and Spearpoint (2007) suggest that bag-valve-mask ventilation is used widely during in-hospital resuscitation, while mouth-to-mouth ventilation and pocket mask ventilation are rarely used. The pocket mask offers several advantages: it is often more readily available and can be easily and effectively used by a single rescuer by lifting the chin and jaw, providing a seal between the cuff and the patient’s face and blowing steadily through the one-way valve. The same handling technique is used with the bag-valve-mask device to provide the seal between the cuff and the patient’s face. However, this technique requires a second person to squeeze the bag to ventilate the patient’s lungs. Either device should be connected to an oxygen source, via a flow regulator, set at a minimum flow of 10l/min. The two ventilations should be delivered steadily, taking no more than a couple of seconds to deliver, before quickly restarting chest compressions. While it is useful to observe that the patient’s chest rises with ventilation, chest compressions must not be delayed to see the chest fall following the second ventilation.CPR should be continued until a defibrillator is attached to the patient; in most hospitals the cardiac arrest team will arrive in a few minutes. Attention should be paid to limit the period of providing continuous chest compressions to a maximum of two minutes. Cardiac monitoring Traditionally, manual defibrillators have been used for in-hospital resuscitation, but in recent years the use of automated external defibrillators (AEDs) has become more widespread. Many hospitals have adopted two-tier systems, placing AEDs in wards and departments, and manual defibrillators in critical care facilities. This strategy has received support from the NPSA (Lilford et al 2005). In recent years, manufacturers have produced dual-function defibrillators incorporating a semi-automated mode of operation alongside standard manual functions The key function of AEDs is automated electrocardiogram (ECG) recognition and appropriate prompting of the operator to deliver the direct current (DC) shock to the patient and to recommence CPR. Manual defibrillators rely on human ECG interpretation, manual interaction and decision making, including energy selection before delivery of the shock. There are advantages and disadvantages to each approach. (Deakin et al 2005, p. S25-S37) Monitoring the patient’s ECG using an AED or hands-free manual defibrillator requires attaching large adhesive electrode pads to the patient’s bare chest. Following removal from the packaging and peeling off the backing, each individual pad should be carefully placed and smoothed over quickly and firmly with a hand to ensure that it is in full contact with the patient’s skin. (Nolan et al 2008) One pad should be placed below the right clavicle adjacent to the sternum with the second pad placed long ways in the mid-auxiliary line. Three-lead ECG monitoring with a cable should be connected to the patient using standard ECG electrodes placed on the right shoulder, left shoulder and left abdomen when using a monitoring defibrillator that has hand-held paddles . (Spearpoint et al 2000, Gombotz et al 2006, p. 416-422). If the patient’s chest is hairy the area for pad or paddle placement might need to be shaved, and this should be done as quickly as possible. If a razor is not immediately available, attempts at defibrillation must be made following pad or paddle placement. In circumstances where blood, vomit or other fluids are present on the chest, it should be dried with a towel before applying electrodes, defibrillator pads or paddles. (Nolan et al 2008). If a patient requires cardio version or pacing it is usually necessary to obtain a good quality ECG signal from three-lead monitoring, which supplements the DC shock delivery (cardio version) or pacing current passing through the hands-free electrode pads. (Spearpoint et al 2000, Gombotz et al 2006, p. 416-422). Defibrillation The time from collapse to the delivery of the first shock is critical to survival (Spearpoint et al 2000, Gombotz et al 2006, p. 416-422). The use of defibrillators by nurses as first responders before the arrival of the cardiac arrest team is now considered an extension of basic resuscitation and has resulted in improvements in survival (Spearpoint et al 2000, 2006, Gombotz et al 2006, p. 416-422). An AED that detects VF or pulseless VT will charge automatically and prompt the operator to press the shock button to deliver the DC shock. A manual defibrillator requires the operator to recognise the ECG, select the energy, charge the defibrillator and then press the shock button(s). Evidence suggests that manual defibrillators are slightly faster, but significantly more ECG diagnostic errors are made (Kramer-Johansen et al 2007b, p. 212-220). While the defibrillator is charging, attention must be paid to safety before shock delivery. The operator of the defibrillator should shout ‘Stand clear’ and ensure that everyone (including the operator) is clear of the patient, equipment and associated furniture. When attempting defibrillation, oxygen masks, nasal cannulae, pocket masks or bag-valve-mask devices connected to an oxygen source must be removed and placed at least one metre away from the patient’s chest area, to avoid the risk of fire. At the culmination of the two-minute CPR sequence, and in the absence of any overt signs of life, the ECG should be re-analysed. If the patient remains in a shockable rhythm then a second shock should be delivered, followed by a further two-minute sequence of CPR. If the rhythm is no longer shockable and the monitor displays an organised ECG then an assessment of the ABC should be conducted for no longer than ten seconds. In the absence of signs of life the patient has now developed pulseless electrical activity (PEA). This is characterised by the presence of a normal or near normal ECG in a patient with the clinical signs of cardiac arrest (Nolan et al 2008). Absence of any electrical activity indicates that systole has developed, which should be confirmed by checking the ECG electrodes and their connections (advanced practitioners may check all three ECG views). In either situation CPR should be restarted for two minutes during which preparations for ALS interventions can be made. (Nolan et al 2008) If signs of life, including return of a palpable pulse, are evident successful resuscitation has occurred (at least temporarily) and post-resuscitation care can begin. Advanced life support Deakin et al (2005) include an ALS treatment algorithm that outlines the recommended care pathways in a manner that is taught easily, readily understood and able to be practically applied in an organised, systematic way. Implementation of the guidelines is achieved largely through resuscitation training. The RC (UK) ILS course is centered on developing core resuscitation skills most likely to result in survival and is most relevant for nurses. The RC (UK) ALS provider course contains additional advanced sections and is designed to develop cardiac arrest team leaders. Most cardiac arrest team leaders will have received ALS training at some stage and would be considered the best people to lead hospital resuscitation teams. As the arrest team assembles, staff already engaged in resuscitation should continue to conduct CPR calmly and efficiently. (Behringer et al 2007, p. 848-884) Such an approach will convey a positive, controlled and reassuring atmosphere, allowing the arrest team valuable moments to orientate to the situation and begin to gather relevant information. In the early stages of the event nurses are often well placed to provide important information about the patient and the circumstances of the collapse. The common elements contained in the treatment algorithm (Deakin et al 2005) for ALS occur during the two-minute sequences of CPR. Continuation of CPR is the priority, but consideration must be given to ensuring that the patient has functional intravenous (IV) access. Existing IV catheters can be used provided they are relatively proximal to the heart and of a suitable gauge to enable rapid drug administration (14, 16 or 18 gauge cannulae) (Nolan et al 2008). On the arrival of an anesthetist, airway management should be handed over and the anesthetist will often secure the patient’s airway. Post-resuscitation care Return of spontaneous circulation rates for in-hospital resuscitation appear variable at 44-62% (Gwinnutt et al 2000, p. 125-135, Peberdy et al 2003, p. 297-308, Spearpoint 2007). The immediate post-resuscitation phase presents care providers with a significant challenge to establish stability and many patients re-arrest. Those who respond to a short-period of CPR tend to do better, particularly those who have endured a shockable cardiac arrest (Gwinnutt et al 2000, p. 125-135). In some circumstances, patients receive ‘do not attempt resuscitation’ (DNAR) orders in the early post-resuscitation period (Spearpoint 2007) and often remain on the ward or department. Those who spontaneously breathe and regain consciousness might also remain on the ward, but most are transferred to a level 2 facility, such as a coronary care unit, pending further investigations and treatment. In post-arrest situations where the patient remains unconscious and requires advanced airway management, an intensive care referral will be necessary. Immediate post-resuscitation care should include an ABCDE assessment with the recording of vital signs, a 12-lead ECG, chest X-ray and a full blood screen. (Behringer et al 2007, p. 848-884) Additional specific investigations can be necessitated by the patient’s condition. Therapeutic hypothermia is a guideline recommendation for patients who remain unconscious and require advanced airway management (Nolan et al 2005, p. S39-S86). As increasing evidence supports the intervention as an adjunct to cerebral recovery (Behringer et al 2007, p. 848-884), more centres are likely to adopt this strategy. Although there are a number of relative contraindications, for example terminal disease, coagulopathy, life-threatening arrhythmias, severe cardiogenic shock, sepsis and pregnancy, many centres have begun to apply therapeutic hypothermia to all patients who remain unconscious post-arrest. Liaison between hospital, patient and family and friends is another important nursing role in the post-resuscitation phase. Nursing skills are important in helping loved ones to understand and come to terms with such a dramatic event. Similarly, the conscious, recovering patient may need help in understanding what has happened to them, the immediate consequences and their future. Nurses are often the providers of skilful, appropriate care and support to patients. End-of-life decisions In providing holistic care nurses are often the protagonists in discussing end-of-life issues for patients, often in challenging situations. While recognising that nurses are professionally obliged to work collaboratively, Wood and Wainwright (2007) emphasise the legal responsibility and individual accountability facing nurses with respect to their clinical decision to commence or withhold CPR, irrespective of any medical decision. It is therefore imperative that nurses acquire and apply appropriate legal knowledge to enable good nursing practice. It is also important that nurses are demonstrably supported by policy and national guidance alongside that offered by their professional and advisory bodies. The Human Rights Act 2000, the Mental Capacity Act 2005 and Decisions Relating to Cardiopulmonary Resuscitation (British Medical Association (BMA) et al 2007) are pertinent here. The implications for nursing contained in the latter document are considerable. Section six states: ‘The responsibility for making the decision rests with the most senior clinician currently in charge of the patient’s care, although they may delegate the task to another person who is competent to carry it out.’ The most senior clinician could be a consultant, GP or suitably experienced nurse. Organisations will need to establish their own criteria for what constitutes a suitably experienced nurse and develop robust DNAR policies. (British Medical Association, Resuscitation Council, 2007) Conclusion Nurses are often the first healthcare professionals to identify and respond to a critically ill or arrested patient, and need the appropriate knowledge and skills as well as being able to demonstrate competence in performing those skills. Nurses are increasingly becoming involved in end-of-life discussions and DNAR decisions, and should have a good understanding of the law. References Ball C, Kirkby M, Williams S (2003) Effect of the critical care outreach team on patient survival to discharge from hospital and readmission to critical care: non-randomised population based study. British Medical Journal. 327, 7422, 1014-1017. Behringer W, Bernard S, Holzer M, Polderman K, Roine R, Tiainen M (2007) Prevention of postresuscitation neurologic dysfunction and injury by the use of therapeutic mild hypothermia. In Paradis NA, Halperin HR, Kern KB, Wenzel V, Chamberlain DA (Eds) Cardiac Arrest: The Science and Practice of Resuscitation Medicine. Second edition. Cambridge University Press, Cambridge, 848-884. Berg RA, Sanders AB, Kern KB et al (2001) Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 104, 20, 2465-2470. British Medical Association, Resuscitation Council (UK) and Royal College of Nursing (2007) Decisions Relating to Cardiopulmonary Resuscitation. A Joint Statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. BMA, London. Buck-Barrett I, Squire I (2004) The use of basic life support skills by hospital staff; what skills should be taught? Resuscitation.60, 1, 39-44. Buist M, Harrison J, Abaloz E, Van Dyke S (2007) Six year audit of cardiac arrests and medical emergency team calls in an Australian outer metropolitan teaching hospital. British Medical Journal. 335, 7631, 1210-1212. Colquhoun MC, Chamberlain DA, Newcombe RG et al (2008) A national scheme for public access defibrillation in England and Wales: early results. Resuscitation. 78, 3, 275-280. Colquhoun MC, Handley AJ, Evans TR (Eds) (2004) ABC of Resuscitation. Fifth edition. BMJ Books, London. Deakin CD, Nolan JP (2005) European Resuscitation Council guidelines for resuscitation 2005.Section 3. Electrical therapies: automated external defibrillators, defibrillation, cardioversion and pacing. Resuscitation. 67, Suppl 1, S25-S37. Department of Health (2000) Comprehensive Critical Care: a Review of Adult Critical Care Services. The Stationery Office, London. Goldhill DR, Worthington L, Mulcahy A, Tarling M, Sumner A (1999) The patient-at-risk team: identifying and managing seriously ill ward patients. Anaesthesia. 54, 9, 853-860. Gombotz H, Weh B, Mitterndorfer W, Rehak P (2006) In-hospital cardiac resuscitation outside the ICU by nursing staff equipped with automated external defibrillators - the first 500 cases. Resuscitation. 70, 3, 416-422. Gwinnutt CL, Columb M, Harris R (2000) Outcome after cardiac arrest in adults in UK hospitals: effect of the 1997 guidelines. Resuscitation. 47, 2, 125-135. Hillman K, Chen J, Cretikos M et al (2005) Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. The Lancet. 365, 9477, 2091-2097. Jevon P (2008) Maintaining an airway. Nursing Standard. 22, 26, 35-37. Kause J, Smith G, Prytherch D, Parr M, Flabouris A, Hillman K (2004) A comparison of antecedents to cardiac arrests, deaths and emergency intensive care admissions in Australia and New Zealand, and the United Kingdom – the ACADEMIA study. Resuscitation. 62, 3, 275-282. Kenward G, Castle N, Hodgetts T, Shaikh L (2004) Evaluation of a medical emergency team one year after implementation. Resuscitation.61, 3, 257-263. Kramer-Johansen J, Edelson DP, Losert H, Köhler K, Abella BS (2007a) Uniform reporting of measured quality of cardiopulmonary resuscitation (CPR). Resuscitation. 74, 3, 406-417. Kramer-Johansen J, Edelson DP, Abella BS, Becker LB, Wik L, Steen PA (2007b) Pauses in chest compression and inappropriate shocks: a comparison of manual and semi-automatic defibrillation attempts. Resuscitation. 73, 2, 212-220. Lilford R, Barach P, Bentham L et al (2005) Teaching Life Support and Resuscitation Competencies in Health Care – Current Practices and Strategies for Future Research. ww.pcpoh.bham.ac.uk/publichealth/ psrp/documents/PS015_Final_ Report_Lilford.pdf McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M (2007) Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards. Cochrane Database of Systematic Reviews. Issue 3. National Institute for Health and Clinical Excellence (2007) Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in Adults in Hospital. Clinical Guideline 50. NICE, London. National Patient Safety Agency (2007) Recognising and Responding Appropriately to Early Signs of Deterioration in Hospitalised Patients. NPSA, London. Nolan J, Soar J, Lockey A et al (2008) Advanced Life Support. Fifth edition. Resuscitation Council (UK), London. Nolan JP, Deakin CD, Soar J, Böttiger BW, Smith G (2005) European Resuscitation Council guidelines for resuscitation 2005. Section 4. Adult advanced life support. Resuscitation. 67, Suppl 1, S39-S86. Peberdy MA, Kaye W, Ornato JP et al (2003) Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation. 58, 3, 297-308. Perkins GD, Roberts C, Gao F (2002) Delays in defibrillation: influence of different monitoring techniques. British Journal of Anaesthesia. 89, 3, 405-408. Peters R, Boyde M (2007) Improving survival after in-hospital cardiac arrest: the Australian experience. American Journal of Critical Care. 16, 3, 240-246. Priestley G, Watson W, Resuscitation Council (UK) (2001) Guidance for Safer Handling During Resuscitation in Hospitals. RCUK, London. Project SDO/74/2004. www.sdo.nihr.ac.uk/files/project/ 74-final-report.pdf Rowan K (2007) Evaluation of Outreach Services in Critical Care – Rowan KM, Harrison DA (2007) Recognising and responding to acute illness in patients in hospital. British Medical Journal. 335, 7631, 1165-1166. Smith G (2005) Prevention of In hospital Cardiac Arrest and Decisions about Cardiopulmonary Resuscitation. www.resus.org.uk/ pages/poihca.pdf Smith GB, Prytherch DR, Schmidt P et al (2006) Hospital-wide physiological surveillance – a new approach to the early identification and management of the sick patient. Resuscitation. 71, 1, 19-28. Soar J, Perkins GD, Harris S, Nolan J (2003) The immediate life support course. Resuscitation. 57, 1, 21-26. Soar J, Spearpoint K (2005) In-Hospital Resuscitation. www.resus.org.uk/pages/inhresus.pdf. Spearpoint K (2007) Annual Report to Patient Safety Committee. Hammersmith Hospitals NHS Trust, London. Spearpoint KG, McLean CP, Steen S, Liao Q, Pierre L, Paskevicius A, Sjöberg T (2003) The critical importance of minimal delay between chest compressions and subsequent defibrillation: a haemodynamic explanation. Resuscitation. 58, 3, 249-258. Tunstall-Pedoe H, Bailey L, Chamberlain DA, Marsden AK, Ward ME, Zideman DA (1992) Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results. British Medical Journal. 304, 6838, 1347-1351. van Walraven C, Forster AJ, Wood J, Wainwright P (2007) Cardiopulmonary resuscitation: nurses and the law. Nursing Standard. 22, 4, 35-40. Wood J, Wainwright P (2007) Cardiopulmonary resuscitation: nurses and the law. Nursing Standard. 22, 4, 35-40. Wynne G, Marteau TM, Johnston M, Whiteley CA, Evans TR (1987) Inability of trained nurses to perform basic life support. British Medical Journal. 294, 6581, 1198-1199. Read More