CARDIOPULMONARY RESUSCITATION (CPR)

UPDATED: JUL 29, 2013

 

 

Presented by Dr. Muhammad Mobarock Hossain

MD(card) Final partBSMMU, Dhaka.

Date: Sunday,17 th November,2013

Practice essentials

Cardiopulmonary resuscitation (CPR) consists of the use of chest compressions and artificial ventilation to maintain circulatory flow and oxygenation during cardiac arrest.

Although survival rates and neurologic outcomes are poor for patients with cardiac arrest, early appropriate resuscitation-involving early defibrillation and appropriate implementation of post-cardiac arrest care lead to improved survival and neurologic outcomes.

Essential update: A drug combination to improve CPR outcome

In a randomized trial involving 268 patients with in-hospital cardiac arrest, treatment with a combination of vasopressin, steroids, and epinephrine (VSE) during CPR followed by treatment of survivors with daily steroids was associated with a greater likelihood of being discharged with a neurologically favorable outcome compared with standard care with epinephrine alone.

VSE patients also had improved hemodynamics and central venous oxygen saturation, as well as less organ dysfunction.

Cont…

Patients were randomly assigned to combination treatment with vasopressin (20 IU/CPR cycle) plus epinephrine (VSE group) or saline placebo plus epinephrine (control group) for the first 5 CPR cycles after randomization.

During the first CPR cycle, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo.

VSE patients who were successfully resuscitated but still hemodynamically unstable were treated with an intravenous infusion of hydrocortisone (300 mg daily for 7 days), while control patients were given saline placebo.

Cont…

Patients in the VSE group had a significantly higher probability of return of spontaneous circulation of 20 minutes or longer after CPR (83.9% of patients vs 65.9% in the control group) and a higher chance of survival to hospital discharge with a neurologically favorable outcome (13.9% vs. 5.1%).

Among patients surviving after CPR but with post-resuscitation shock, those in the VSE group had a higher probability of survival to hospital discharge with a favorable neurologic outcome.

Indications

CPR should be performed immediately on any person who has become unconscious and is found to be pulseless.

The most common nonperfusing arrhythmias are…

Ventricular fibrillation (VF) Pulseless ventricular tachycardia (VT) Pulseless electrical activity (PEA) Asystole Pulseless bradycardia

NB:CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established.

Contraindications

The only absolute contraindication to CPR is a

do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire not to be resuscitated in the event of cardiac arrest.

A relative contraindication to performing CPR is if a clinician justifiably feels that the intervention would be medically futile(useless).

Equipment

CPR, in its most basic form, can be performed anywhere without the need for specialized equipment. Universal precautions (ie, gloves, mask, gown) should be taken.

However, CPR is delivered without such protections in the vast majority of patients who are resuscitated in the out-of-hospital setting, and no cases of disease transmission via CPR delivery have been reported.

Some hospitals and EMS systems employ devices to provide mechanical chest compressions.

A cardiac defibrillator or AED provides an electrical shock to the heart via 2 electrodes placed on the patient’s torso and may restore the heart into a normal perfusing rhythm.

Technique

Cardiopulmonary resuscitation (CPR) comprises 3 steps (CAB) :

Chest compressions,

Airway, and

Breathing

Lay rescuers should perform compression-only CPR (COCPR).

Healthcare providers, however, should perform all 3 components of CPR (chest compressions, airway, and breathing).

Positioning for CPR :

CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface, which allows effective compression of the sternum .

Delivery of CPR on a mattress or other soft material is generally less effective.

The person giving compressions should be positioned high enough above the patient to achieve sufficient leverage, so that he or she can use body weight to adequately compress the chest .

For an unconscious adult:

Give 30 chest compressions.

Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing.

Before beginning ventilations, look in the patient’s mouth for a foreign body blocking the airway.

Please watch the Video of

Assessment of a patient

Ventilation

If the patient is not breathing

2 ventilations are given via the provider’s mouth or a bag-Valve-mask (BVM). If available, a barrier device (pocket mask or face shield) should be used.

To perform the BVM or invasive airway technique, the provider does the following:

Ensure a tight seal between the mask and the patient’s face

Squeeze the bag with one hand for approximately 1 second, forcing at least 500 mL of air into the patient’s lungs.

Next, the provider checks for a carotid or femoral pulse. If the patient has no pulse, chest compressions are begun.

device (pocket mask or face shield) should be used.

Bag-valve-musk(BVM)

Pocket musk

Mouth-to-mouth technique:

To perform, the provider does the following: Pinch the patient’s nostrils closed to assist with an

airtight seal Put the mouth completely over the patient’s mouth After 30 chest compression, give 2 breaths (the

30:2 cycle of CPR) Give each breath for approximately 1 second with

enough force to make the patient’s chest rise. Failure to observe chest rise indicates an

inadequate mouth seal or airway occlusion After giving the 2 breaths, resume the CPR cycle

Please watch the Video of

Mouth to mouth breathing

Chest compression

Chest compression

The provider should do the following:

Place the heel of one hand on the patient’s sternum and the other hand on top of the first, fingers interlaced.

Extend the elbows and the provider leans directly over the patient .

Press down, compressing the chest at least 2 inches. Release the chest and allow it to recoil completely The compression depth for adults should be at least 2 inches

(instead of up to 2 inches, as in the past) The compression rate should be at least 100/min The key phrase for chest compression is, “Push hard and fast”.

NB: Untrained bystanders should perform chest compression–only CPR (COCPR)

Cont…

After 30 compressions, 2 breaths are given;

however, an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute.

This entire process is repeated until a pulse returns or the patient is transferred to definitive care

To prevent provider fatigue or injury, new providers should intervene every 2-3 minutes (ie, providers should swap out, giving the chest compressor a rest while another rescuer continues CPR .

Please watch the Video of

Chest compression

Please watch the Video of

Rescuer CPR

Please watch the Video of

Rescuer CPR and use of an AED

(automated external defibrillator)

Please watch the Video of

2 Rescuer CPR

Please watch the Video of

Infant Compression:

Please watch the Video of

Video of infant CPR

Please watch the Video of

Infant 1 rescuer CPR

Please watch the Video of

Child CPR

Post-Procedure

Complications:

Performing chest compressions may result in the fracturing of ribs or the sternum, though the incidence of such fractures is widely considered to be low.

Artificial respiration using noninvasive ventilation methods (eg, mouth-to-mouth, bag-valve-mask [BVM]) can often result in gastric insufflation. This can lead to vomiting, which can further lead to airway compromise or aspiration. The problem is eliminated by inserting an invasive airway, which prevents air from entering the esophagus.