Cardio pulmonary resuscitation

• Gordon –artificial ventilation
• Elam and Safar-rescue breathing
• Beck and Zoll-AC defibrillator
• Lown-DC defibrillator
• Kouwenhoven Knickerboker,jude-chest
compressions
• CPR endorsed-1963
• CPR guidelines-1966, 1973, 1979, 1985, 1992,
2000, 2005,2010

 Actions linking the adult victim of sudden
cardiac arrest with survival are called the adult
Chain of Survival.

 Epidemiology and Recognition of
Cardiac Arrest-most common victim is a
man between 50 and 75 years of age –with r/f
 Incidence of cardiac arrest is lowest during
sleep and begins to rise rapidly soon after
awakening

 Greater than 80% of patients -initiating event
is a ventricular tachyarrhythmia (ventricular
tachycardia) degenerating rapidly to
ventricular fibrillation in 62% of cases,
torsades de pointes in 13%, and primary
ventricular fibrillation in 8%

 Most important determinant of survival from
sudden cardiac arrest is the presence of a
trained lay rescuer who is ready, willing, and
able to act.
 As a rule of thumb, the American Heart
Association recommends that at least 20%
of the adult population should be trained in
basic CPR to reduce mortality from out-of-
hospital cardiac arrest

 Each minute that a patient remains in
ventricular fibrillation, the odds of survival
decrease by 7% to 10%

 Survival is highest when CPR is started
within the first 4 minutes of arrest and
advanced cardiac life support (ACLS),
including defibrillation and drug therapy, is
started within the first 8 minutes

• Rescuers should begin CPR if an adult is
unresponsive and not breathing normally
• Do not delay in an attempt to recognise a
pulse
• Pulse Check-lay rescuers ,even healthcare
providers perceived a pulse when it was
nonexistent
• Breathing Assessment- agonal gasps are
mistaken for regular breathing
• Circulatory assessment-non specific

 Combination of absent breathing with
unresponsiveness
 Pulse alone not a good criterion
 Agonal gasps should not be mistaken for
breathing

 For lay rescuers, interrupting chest
compressions to perform a pulse check is
not recommended.
 For healthcare professionals, it is
reasonable to check a pulse if an organized
rhythm is visible on the monitor at the next
rhythm check

 Attempt to shorten the delay to first chest
compressions for adult victims, experts came
to the consensus that rescuers may consider
starting CPR with chest compressions rather
than ventilations (the sequence will then be
“CAB”).

 major determinant of neurologically intact
survival from prolonged cardiac arrest because
of VF -perfusion pressures generated by chest
compressions rather than the blood gas
composition, acid base balance, or the
frequency or strength of defibrillation shocks

 With sudden unexpected cardiac collapse
from VF, the pulmonary veins, the left heart
and the entire arterial system are filled with
oxygenated blood and the recommended
two ventilations do not increase arterial
saturation

 if chest compressions are initiated early and
continued, many of these patients will continue
to gasp, thereby providing physiologic
ventilation that facilitates both oxygenation and
venous return to the chest

• 241 patients randomly assigned to receive chest
compression alone and 279 assigned to chest
compression plus mouth-to-mouth ventilation
• Survival to hospital discharge was better among
patients assigned to chest compression alone
than among those assigned to chest compression
plus mouth-to-mouth ventilation (14.6% vs.
10.4%), but the difference was not statistically
significant (p = .18).

 outcome after CPR with chest compression
alone is similar to that after chest
compression with mouth-to-mouth
ventilation, and chest compression alone
may be the preferred approach for
bystanders

 40% of 445 out-of-hospital cardiac arrests
 46% of arrests caused by a cardiac etiology
compared with 32% in other etiologies
 Fifty-five percent of witnessed arrest patients
had agonal activity compared with 16% of
unwitnessed arrest patients

 Agonal respirations occurred in 56% of
arrests due to ventricular fibrillation
compared with 34% of cases with a non
ventricular fibrillation rhythm
 Twenty-seven percent of patients with agonal
respirations were discharged alive compared
to 9% without them (p < .001).
 Associated with increased survival

 overall survival of out-of-hospital cardiac
arrest ;
 2.2 percent for those who were not
receiving bystander CPR when the EMS
arrived
 4.2 percent for those who were receiving
chest compressions plus mouth-to-mouth
breathing
 6.2 percent for those receiving chest-
compression-only bystander CPR

 Technique of closed-chest "cardiac massage"
for cardiac arrest was first published in 1960-
kouwenhoven, jude, and knickerbocker

 Two models-
 Cardiac pump-younger,earlier stages,normal
chest walls,better survival
 Thoracic pump-older,barrel chest,poorer
survival

 Hand position:
 The rescuer should compress the lower half
of the victim’s sternum-2005 guidelines
 simplified way-Place the heel of your hand in
the center of the chest with the other hand
on top
 Inter nipple line is not a relaible landmark.

 chest compression rates 80/min were
associated with ROSC in some studies.
 chest compressions for adults at a rate of at
least 100 compressions per minute.
 There is insufficient evidence to
recommend a specific upper limit for
compression rate.
 Pauses should be minimized to maximize
the number of compressions delivered per
minute

 Chest Compression Depth
 measured compression depth during adult
human resuscitation is often less than 4 cm
(1.5 inches)
 Conflicting evidence regarding the utility of
increasing depth of compression.
 No improvement of myocardial blood flow
with increased compression depth from 4
cm to 5 cm, although coronary perfusion
pressure (CPP) improved from 7 to 14 mm
Hg

 Recommendation-reasonable to compress
the sternum at least 2 inches/5 cm for all
adult cardiac arrest victims
 Insufficient evidence to recommend a
specific upper limit for chest compression
depth.

• Incomplete recoil during compressions is
associated with reductions in mean arterial
pressure, coronary perfusion pressure, cardiac
output(LOE 4)
• Recommendation:allowing complete recoil of the
chest after each compression may improve
circulation, there is insufficient evidence to
determine the optimal method to achieve the goal

 Cough CPR:may be possible for a conscious,
responsive person to cough forcefully and
maintain enough blood flow to the brain to
remain conscious for a few seconds until
the arrhythmia disappears or is treated.
 Blood flow is maintained by increased
pressure in the chest that occurs during
forceful coughs.

• Limited benefit of cough CPR during the initial
seconds to minutes of cardiac arrest in patients
who remained conscious in a controlled,
monitored setting of electrophysiology testing
• Recommendation:only for patients maintaining
consciousness during the initial seconds to
minutes of VF or pulseless VT cardiac arrest in
a witnessed, monitored, hospital setting (such
as a cardiac catheterization laboratory).

• 3 prospective case series of VT in the
electrophysiology laboratory-precordialthump
by experienced cardiologists was of limited use
(1.3% ROSC).
• Rhythm deterioration following precordial
thump occurred in 3% of patients and was
observed predominantly in patients with
prolonged ischemia or digitalis-induced toxicity.

 Precordial thump is ineffective for VF, and it
should not be used for unwitnessed OHCA
 Considered for patients with monitored,
unstable VT if a defibrillator is not immediately
available
 Use of the precordial thump for witnessed
onset of asystole –evidence equivocal

 For patients in cardiac arrest, percussion
(fist) pacing is not recommended

• Air way:head tilt– chin lift maneuver is
feasible, safe, and effective
• Studies about jaw thrust are equivocal while
studies about jaw lift with thumb in mouth are
negative
• Recommendation:reasonable to open the
airway using the head tilt– chin lift maneuver
when assessing breathing or giving
ventilations.

 Each breath to be administered within 1
second, and delivered with enough volume to
cause a visible rise in the anterior chest wall.
 Administration of the two rescue breaths
should be completed quickly, interrupting chest
compression for only 10 seconds

 Bystander reluctance
 inordinately long interruptions of essential
chest compressions
 Increases intrathoracic pressures, thereby
reducing the return of venous blood to the
chest.

 Compressions Only and
Compressions Plus Ventilations:
 Chest compressions alone -recommended
for untrained laypersons
 Chest compressions alone - trained
laypersons if they are incapable of delivering
airway and breathing maneuvers
 Chest compressions with ventilations
-trained laypersons who are capable of
giving CPR with ventilations to cardiac arrest
victims

 Study based on 2005 guidelines-30:2 showed
improvement of survival compared to survival
with use of the previous 15:2 ratio

 Animal studies (LOE 5) showed improved
survival with a compression-ventilation ratio
above 30:2
 ratio of more than 100:2 was associated with a
low ROSC rate and reduced arterial partial
pressure of oxygen
 Recommendation-ratio should be 30:2

 Legitimate reasons for the interruption -
 Need to ventilate
 Need to assess the rhythm or to assess ROSC

Need to defibrillate.
RECOMMENDATION:minimize interruptions of
chest compressions during the entire
resuscitation attempt

 Only an average of 5-15% of patients treated
with standard CPR survive cardiac arrest and it
is widely agreed that increasing the blood flow
generated by chest compression will improve
survival
 Often done incorrectly, and incorrect chest
compression can compromise survival.

 Potentially better compression
 High quality chest compressions in a moving
ambulance
 Reduction in the number of emergency medical
systems (EMS) personnel needed to perform
resuscitation

• Mimic intraaortic balloon counterpulsation.
• Two rescuers are needed to perform this
technique: one compresses the sternum and
the other interposes abdominal compressions
between each pair of chest compressions
• Recommends -in-hospital resuscitation as an
alternative to standard CPR whenever sufficient
personnel trained in the technique are
available

• maximize the force applied to the chest during
compression
• By encircling the chest force can distributed over
the chest, thereby reducing local stresses on the
chest wall and allowing high forces to be safely
applied.
• This distributed compression allows for large
increases in intrathoracic pressure without the
trauma inherent in applying force to a single point,
as with standard chest compression

 Typical inflation pressure is 250 mm Hg, and
the chest compression rate is 60/minute.

 Insufficient evidence to support or refute the
use of IAC-CPR/ACD-CPR/Open chest-
CPR/piston CPR
 LUCAS/LDB-maintain continuous chest
compression while undergoing CT scan or
similar diagnostic studies, when provision of
manual CPR would be difficult

 BLS-CAB
 3 GROUPS-
 VT/VF/PULSELESS ARREST
 BRADYASYSTOLE
 TACHYCARDIA WITH PULSES
 POST RESUCITATION CARE

1. Electrical, phase of VF, lasts for about 4 to 5
minutes-defibrillation most effective in
restoring rhythm
2. Circulatory, phase of untreated VF lasts for a
variable period of time, but typically from
about 5 to 15 minutes -defibrillation first
during this "circulatory" phase –pulseless
electrical activity

 Metabolic phase of VF follows the circulatory
phase-raely succseeful

 Theoretical rationale for CPR before shock
delivery is to improve coronary perfusion and
thereby the chances of achieving sustained
return of spontaneous circulation
 Improvements in ROSC, survival to hospital
discharge, neurologic outcome, and 1-year
survival

 Most crucial intervention -restoring
myocardial blood flow by the generation of
adequate coronary perfusion pressure with
chest compressions prior to and immediately
after defibrillation attempts
 Chest compressions-improve the chances of
restoring a perfusing rhythm following
defibrillation

 Recommendation:inconsistent evidence to
support or refute delay in defibrillation to
provide a period of CPR (90 seconds to 3
minutes) for patients in non EMS witnessed
VF/pulseless VT cardiac arrest

 Electrode-Patient Inter face
 For both defibrillation and AF cardioversion,
when using biphasic defibrillators, self-
adhesive defibrillation pads are safe and
effective and are an acceptable alternative
to standard defibrillation paddles
 In AF cardioversion using monophasic
defibrillators, hand-held paddles are
preferable.

 Reasonable to place paddles/pads on the
exposed chest in an anterior-lateral position

 The defibrillator paddle/pad should be placed
on the chest wall ideally at least 8 cm from the
generator position.
 The anterior-posterior and anterior-lateral
paddle/pad placements on the chest are
acceptable in patients with a permanent
pacemaker or icd

 Reasonable to use a paddle/pad size 8 cm

 Biphasic waveforms are more effective in
terminating VF when compared with
monophasic waveforms.
 There is insufficient evidence to recommend
any specific biphasic waveform.
 In the absence of biphasic defibrillators,
monophasic defibrillators are acceptable

 It is reasonable to start at a selected energy
level of 150 J to 200 J for a BTE waveform for
defibrillation of pulseless VT/VF cardiac arrest.
 monophasic defibrillation, initial and
subsequent shocks using this waveform should
be at 360 J.

 For second and subsequent biphasic shocks
the same initial energy level is acceptable.
 It is reasonable to increase the energy level
when possible

• Atrial fibrillation 100-200 (monophasic waveform)
100-120 (biphasic waveform)
Stepwise increase for subsequent shocks
• Atrial flutter 50-100
• Supraventricular tachycardia due to reentry- 50-100
• Ventricular tachycardia (VT) (monomorphic) 100
• VT (polymorphic) 360 unsynchronized shock

• When defibrillation is required, a single shock
should be provided with immediate resumption
of chest compressions after the shock.
• Chest compressions should not be delayed for
rhythm reanalysis or pulse check immediately
after a shock.
• CPR should not be interrupted until rhythm
reanalysis is undertaken.

 High first-shock success rate of new
defibrillators
 Intervening chest compressions may
improve oxygen and substrate delivery to the
myocardium, making the subsequent shock
more likely to result in defibrillation

 Organised activity without effective circulation
 Poor prognosis
 Treat reversible causes-
hypovolemia,pneumothorax
 Neck vein examination is helpful
 Proper CPR,
 Open massage in case of penetrating trauma

 Epinephrine:vasopressor of choice for use
during resuscitation
 improve cerebral blood flow by preventing
arterial collapse and by increasing peripheral
vasoconstriction
 enhances coronary perfusion pressure, which
is the major determinant of the ROSC after
cardiac arrest

 dose - 1 mg (10 mL of a 1:10,000 solution)
every 3 to 5 minutes during resuscitation in
adults
 Continous infusion-1 mg of epinephrine
hydrochloride to 250 mL of normal saline or
dextrose 5% in water (D5W) to run at 1
µg/minute and increased to 3 to 4
µg/minute

 Intracardiac injections increase the risk of
coronary artery laceration, cardiac
tamponade, and pneumothorax and cause
interruption of external chest compression
and ventilation-not advisable
 Trials with doses of epinephrine >5mg
showed no significant benefit

 Vasopressin: recommended dose is 40 units
IV in place of the first or second dose of
epinephrine in the pulseless ventricular
tachycardia/ventricular fibrillation algorithm.
 last approximately 10 to 20 minutes
 No recommendation on optimal dose

 Anoxic arrest of the heart causes a progressive
increase in the concentration of PCO2 inside
heart muscle cells that may reach very high
levels (90 to 475 Torr)
 Above an intramyocardial PCO2 of approximately
475 Torr, pulseless electrical activity is present
and the heart cannot be resuscitated

 Severe arterial acidosis –inadequate
ventilation
 Correct the inadequacy of CPR technique.
 Soda bicarb-if given will increase intracellular
Co2 and will cause further deterioration.
 Can be given in cases of pre existing metabolic
acidosis,renal failure,hyperkalemia

 Amiodarone may be considered for those who
have refractory VT/VF, defined as VT/VF not
terminated by defibrillation, or VT/VF
recurrence in out-of-hospital cardiac arrest or
in-hospital cardiac arrest.
 There is inadequate evidence to support or
refute the use of lidocaine in the same settings

 Monomorphic VT-w/o CHF/MI-procainamide
 With MI/CHF-amiodarone
 Sotalol can be considered in setting of MI

 Amiodarone reduced the frequency of
recurrent arrhythmias.
 Magnesium –torsades de pointes

 Vagal maneuvers, IV adenosine, verapamil, and
diltiazem are recommended as first-line
treatment strategies in the termination of
narrow-complex tachycardias

 Refers to a cardiac rhythm that has a
ventricular rate below 60 beats per minute in
adults and/or periods of absent heart rhythm
(asystole)
 Survival is poor (generally 1% to 3% or less)

• 1-mg dose of atropine IV and is repeated every
3 to 5 minutes if asystole persists.
• Three milligrams (0.04 mg/kg) given IV is a fully
vagolytic dose in most patients
• The administration of a total vagolytic dose of
atropine should be reserved for patients with
bradyasystolic cardiac arrest.
• Endotracheal atropine produces a rapid onset
of action similar to that observed with IV
injection. The recommended adult dose of
atropine for endotracheal administration is 1.0
to 2.0 mg diluted in 10 mL of sterile water

 If not effective, then consider epinephrine (2 to
10 g/min) or dopamine (2 to 10 g/kg/min).

 Cardiac transplant, theophylline 100 to 200
mg slow injection IV(maximum 250 mg) may be
given.

 Use of pacing (eg, TC, TV, and needle) in
cardiac arrest (in- or out-of-hospital) did not
improve ROSC or survival.
 no apparent benefit related to the time at
which pacing was initiated (early or delayed in
established asystole), location of arrest (out-of-
hospital or in-hospital), or primary cardiac
rhythm (asystole or PEA

 Airway-
 Maintained by endo tracheal intubation
 Supraglottic airway is an alternative
 End tidal Pco2 is an useful adjunct

 Percentage of carbon dioxide contained in the
last few milliliters of gasexhaled from the lungs
with each breath -end-tidal carbon dioxide
concentration (PetCO2)
 Measured by capnography-infrared
device/colorimetry
 Useful information on the anatomic location of
an airway device

 normal respiration and circulation, the
PetCO2 averages 4% to 5%.
 normal or elevated levels of cardiac output,
ventilation is the rate-limiting factor
 At low levels of cardiac output-ventilation is
fixed -reflects change in cardiac output

 Ventilation through an ET tube that has been
properly inserted in the trachea yields a
PetCO2 of 4% to 5% in a patient with a normal
cardiac output and no significant
ventilation/perfusion gradient
 ventilation through an ET tube that has been
inadvertently inserted into the esophagus
results in a PetCO2 of less than 0.5%

 Dramatic change from a low to a high
PetCO2 due to venous carbon dioxide
washout is often the first clinical indicator
that ROSC has occurred
 PetCO2 typically returns to normal (4% to
5%) within 2 to 5 minutes after ROSC if the
patient maintains a good cardiac output.

• Resternotomy for patients with cardiac arrest
following cardiac surgery should be considered
in an appropriately staffed and equipped ICU
• Chest compressions should not be withheld
while preparing for emergency resternotomy.
• Mechanical circulatory support may be
considered in the setting of cardiac arrest
following cardiac surgery.

 Return of spontaneous circulation (ROSC) does
not mean full recovery for the victim or even
survival.
 Postresuscitation deaths are highest in the first
24 hours after ROSC; therefore,
postresuscitation care is critical for survival.

Assess adequacy of ventilation
Titarate doses of medication-ionotropes
Repeat echo and ECG
Assess for factors that could have led to arrest
CAD-early revascularisation

 Avoid hyperthermia
 Seizure control
 Tight glucose control
 Organ specific evaluation and support

• 5 clinical signs that were found to strongly predict death or
poor neurologic outcome, with 4 of the 5 predictors
detectable at 24 hours after resuscitation:
• ● Absent corneal reflex at 24 hours
• ● Absent pupillary response at 24 hours
• ● Absent withdrawal response to pain at 24 hours
• ● No motor response at 24 hours
• ● No motor response at 72 hours
• An electroencephalogram performed 24 to 48 hours after
resuscitation has also been shown to provide useful
predictive information and can help define prognosis

 resuscitation efforts should be continued until
"reliable criteria indicating irreversible death
are present.”
 This position leaves more latitude for the
judgment of the medical personnel involved,
but is more difficult to apply uniformly in
practice.

 CPR 2010 guidelines promote adherence to
chain of survival principles
 Importance of maintaining circulation by
compressions is given priority changing the well
known ABC to CAB.
 Interruption of compressions to be minimised
even for acts like pulse check,rescue
breaths,rhythm analysis

 Utility of 90 second CPR before defibrillation is
not proven beyond doubt
 End tidal CO2 is auseful guide for positioning
ET tube as well as predicting success of CPR
 Mechanical devices and alternate techniques
can only be recommended in special situations
 Induced hypothermia should be considered in
comatose patients,especially post VF.

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