Cardiopulmonary resuscitationIntervention

CPR being performed on a mannequin

ICD-9: 99.60 (http://icd9cm.chrisendres.com/index.php?srchtype=procs&srchtext=99.60&Submit=Search&action=search)

MeSH D016887

OPS-301 code:

8-771 (http://ops.icd-code.de/ops/code/8-771.html)

Cardiopulmonary resuscitationFrom Wikipedia, the free encyclopedia

Cardiopulmonary resuscitation(CPR) is an emergency procedurewhich is performed in an effort tomanually preserve intact brainfunction until further measures aretaken to restore spontaneous bloodcirculation and breathing in a personin cardiac arrest. It is indicated inthose who are unresponsive with nobreathing or abnormal breathing, forexample agonal respirations. It maybe performed both in and outside ofa hospital.

CPR involves chest compressions atleast 5 cm deep and at a rate of atleast 100 per minute in an effort tocreate artificial circulation bymanually pumping blood throughthe heart. In addition, the rescuermay provide breaths by eitherexhaling into the subject's mouth orutilizing a device that pushes air intothe subject's lungs. This process of externally providing ventilation is termed artificial respiration. Currentrecommendations place emphasis on high-quality chest compressions over artificial respiration; a simplifiedCPR method involving chest compressions only is recommended for untrained rescuers.

CPR alone is unlikely to restart the heart; its main purpose is to restore partial flow of oxygenated blood to thebrain and heart. The objective is to delay tissue death and to extend the brief window of opportunity for asuccessful resuscitation without permanent brain damage. Administration of an electric shock to the subject'sheart, termed defibrillation, is usually needed in order to restore a viable or "perfusing" heart rhythm.Defibrillation is only effective for certain heart rhythms, namely ventricular fibrillation or pulseless ventriculartachycardia, rather than asystole or pulseless electrical activity. CPR may succeed in inducing a heart rhythmwhich maybe shockable. CPR is generally continued until the subject regains return of spontaneous circulation(ROSC) or is declared dead.

Contents1 Medical uses2 Methods

2.1 Standard2.2 Compression only2.3 In pregnancy

CPR training: CPR is beingadministered while a second rescuerprepares for defibrillation.

2.4 Other3 Effectiveness4 Pathophysiology5 Adjunct devices

5.1 Timing devices5.2 Manual assist devices5.3 Automatic devices

6 Prevalence6.1 Chance of receiving CPR6.2 Chance of receiving CPR in time

7 Society and culture7.1 Portrayed effectiveness7.2 Stage CPR7.3 Self-CPR hoax7.4 CPR learned from movies and television

8 History9 In other animals10 References11 External links

Medical usesCPR is indicated for any person who is unresponsive with no breathing, or who is only breathing inoccasional agonal gasps, as it is most likely that they are in cardiac arrest.[1]:S643 If a person still has a pulse,but is not breathing (respiratory arrest), artificial respirations may be more appropriate, but due to the difficultypeople have in accurately assessing the presence or absence of a pulse, CPR guidelines recommend that laypersons should not be instructed to check the pulse, while giving health care professionals the option to checka pulse.[2] In those with cardiac arrest due to trauma CPR is considered futile but still recommended.[3]

MethodsIn 2010, the American Heart Association and International LiaisonCommittee on Resuscitation updated their CPR guidelines.[1]:S640[4]

The importance of high quality CPR (sufficient rate and depth withoutexcessively ventilating) was emphasized.[1]:S640 The order ofinterventions was changed for all age groups except newborns fromairway, breathing, chest compressions (ABC) to chest compressions,airway, breathing (CAB).[1]:S642 An exception to thisrecommendation is for those who are believed to be in a respiratoryarrest (drowning, etc.).[1]:S642

Standard

A universal compression to ventilation ratio of 30:2 is recommended for adult and in children and infant if

Type of Arrest ROSC Survival Source48% 22% [14]

only a single rescuer is present.[5]:8 If at least 2 rescuers are present a ratio of 15:2 is preferred in children andinfants.[5]:8 In newborns a rate of 3:1 is recommended unless a cardiac cause is known in which case a 15:2ratio is reasonable.[1]:S647 If an advanced airway such as an endotracheal tube or laryngeal mask airway is inplace delivery of respirations should occur without pauses in compressions at a rate of 8-10 per minute.[6] Therecommended order of interventions is chest compressions, airway, breathing or CAB in mostsituations.[1]:S642 With a compression rate of at least 100 per minute in all groups.[5]:8 Recommendedcompression depth in adults and children is about 5 cm (2 inches) and in infants it is 4 cm (1.5 inches.[5]:8 Asof 2010 the Resuscitation Council (UK) still recommends ABC for children.[7] As it can be difficult todetermine the presence or absence of a pulse the pulse check has been removed for lay providers and shouldnot be performed for more than 10 seconds by health care providers.[5]:8 In adults rescuers should use twohands for the chest compressions, while in children they should use one, and with infants two fingers (indexand middle fingers).[8]

Compression only

Compression only (hands-only or cardiocerebral resuscitation) CPR is a technique that involves chestcompressions without artificial respiration.[1]:S643 It is recommended as the method of choice for the untrainedrescuer or those who are not proficient as it is easier to perform and instructions are easier to give over thephone.[1]:S643[5]:8[9] In adults with out-of-hospital cardiac arrest, compression-only CPR by the lay public hasa higher success rate than standard CPR.[9] The exceptions are cases of drownings, drug overdose, and arrestin children. Children who receive compression only CPR have the same outcomes as those who received noCPR.[1]:S646 The method of delivering chest compressions remains the same, as does the rate (at least 100 perminute). It is hoped that the use of compression only delivery will increase the chances of the lay publicdelivering CPR.[10] For those with non cardiac arrest and people less than 20 years of age standard CPR issuperior to compression only CPR.[11][12]

In pregnancy

During pregnancy when a women is lying on her back the uterus may compress the inferior vena cava andthus decrease venous return.[3] It is recommended for this reason that the uterus be pushed to the persons leftand if this is not effective either role the person 30°s or consider emergency cesarean section.[3]

Other

Interposed abdominal compressions may be beneficial in the in hospital environment.[13] There is however noevidence of benefit pre hospital or in children.[13] Internal cardiac massage is manual squeezing of the heartcarried out through a surgical incision into the chest cavity. This may be carried out if the chest is already openfor cardiac surgery.

EffectivenessUsed alone, CPR will result in fewcomplete recoveries, and thosewho do survive often develop

Witnessed In-Hospital Cardiac ArrestUnwitnessed In-Hospital Cardiac Arrest 21% 1% [14]

Bystander Cardiocerebral Resuscitation 40% 6% [15]

Bystander Cardiopulmonary Resuscitation 40% 4% [15]

No Bystander CPR (Ambulance CPR) 15% 2% [15]

Defibrillation within 3–5 minutes 74% 30% [16][17]

serious complications. Estimatesvary, but many organizationsstress that CPR does not "bringanyone back," it simply preservesthe body for defibrillation andadvanced life support.[16]

However, in the case of "non-shockable" rhythms such asPulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. Onaverage, only 5–10% of people who receive CPR survive.[18] The purpose of CPR is not to "start" the heart,but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation)can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, thecurrent consensus is to perform CPR on a patient who is not breathing.

Studies have shown the importance of immediate CPR followed by defibrillation within 3–5 minutes ofsudden VF cardiac arrest improve survival. In cities such as Seattle where CPR training is widespread anddefibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as NewYork, without those advantages, the survival rate is only 1–2 percent.[17]

In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous Circulation(ROSC), where their heart starts to beat on its own again, than ultimately survive to be discharged fromhospital (see table below). This is due to medical staff either being ultimately unable to address the cause of thearrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravelyill in more than one way.

Compression-only CPR is less effective in children than in adults, as cardiac arrest in children is more likely tohave a non-cardiac cause. In a 2010 prospective study of cardiac arrest in children (age 1–17), for arrests witha non-cardiac cause provision by bystanders of conventional CPR with rescue breathing yielded a favorableneurological outcome at one month more often that did compression-only CPR (OR 5.54; 95% confidenceinterval 2.52–16.99). For arrests with a cardiac cause in this cohort, there was no difference between the twotechniques (OR 1.20; 95% confidence interval 0.55–2.66).[19] This is consistent with American HeartAssociation guidelines for parents.[20]

PathophysiologyCPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keepvital organs alive. Blood circulation and oxygenation are required to transport oxygen to the tissues. The brainmay sustain damage after blood flow has been stopped for about four minutes and irreversible damage afterabout seven minutes.[21][22][23][24][25] Typically if blood flow ceases for one to two hours, the cells of thebody die. Because of that CPR is generally only effective if performed within seven minutes of the stoppageof blood flow.[26] The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperaturesas sometimes seen in near-drownings prolong the time the brain survives. Following cardiac arrest, effectiveCPR enables enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsiveto defibrillation attempts.

Adjunct devices

While several adjunctive devices are available none other than defibrillation as of 2010 have consistently beenfound to be better than standard CPR for out of hospital cardiac arrest.[1]:S644 These devices can be split in tothree broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especiallydepth and speed of compressions, and those which take over the process completely.

Timing devices

They can feature a metronome (an item carried by many ambulance crews) in order to assist the rescuer ingetting the correct rate. Some units can also give timing reminders for performing compressions, breathing andchanging operators.[27]

Manual assist devices

Mechanical devices have not been found to have greater benefit than harm and thus are not currentlyrecommended for widespread use.[28]

Audible and visual prompting may improve the quality of CPR and prevent the decrease of compression rateand depth that naturally occurs with fatigue,[29][30][31][32][33][34] and to address this potential improvement, anumber of devices have been developed to help improve CPR technique.

These items can be devices to placed on top of the chest, with the rescuers hands going over the device, and adisplay or audio feedback giving information on depth, force or rate,[35] or in a wearable format such as aglove.[36] Several published evaluations show that these devices can improve the performance of chestcompressions.[37][38]

As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the devicewith them, these devices can also be used as part of training programs to improve basic skills in performingcorrect chest compressions.[39]

Automatic devices

There are also some automated devices available which take over the chest compressions for the rescuer.These have several advantages: they allow rescuers to focus on performing other interventions; they do notfatigue and begin to perform less effective compressions, as humans do; and they are able to perform effectivecompressions in limited-space environments such as air ambulances, where manual compressions are difficult.These devices use either pneumatic (high-pressure gas) or electrical power sources to drive a compressing padon to the chest of the patient. One such device, known as the LUCAS, was developed at the UniversityHospital of Lund, is powered by the compressed oxygen supplies already standard in ambulances andhospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusionpressure[40] and return of spontaneous circulation.[41]

Another system called the AutoPulse is electrically powered and uses a large band around the patients chestwhich contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studiesshowing increased successful return of spontaneous circulation.[42][43]

Prevalence

Chance of receiving CPR

Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attemptCPR in between 14%[44] and 45%[45] of the time, with a median of 32%. This indicates that around a third ofout-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable,and the studies suggest only around half of bystander CPR is performed correctly.[46][47]

There is a clear correlation between age and the chance of CPR being commenced, with younger people beingfar more likely to have CPR attempted on them prior to the arrival of emergency medical services.[44][48] Itwas also found that CPR was more commonly given by a bystander in public than when an arrest occurred inthe patient's home, although health care professionals are responsible for more than half of out-of-hospitalresuscitation attempts.[45] This is supported by further research, which suggests that people with no connectionto the victim are more likely to perform CPR than a member of their family.[49] This is likely because of theshock experienced by finding a family member in need of CPR; it is easier to remain calm - and think clearly -when the person in need of CPR is a complete stranger, as in this case one will not be as frightened.

There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Laypersons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medicalcause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.[49]

Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told toonly perform the chest compression element of the resuscitation.[10]

Chance of receiving CPR in time

CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,[50] becausepermanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of thebrain become dormant in as little as 4–6 minutes in an oxygen deprived environment and the cells are unableto survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic bloodinfusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methodsachieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determinewhat role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this newknowledge[51] A notable exception is cardiac arrest occurring in conjunction with exposure to very coldtemperatures. Hypothermia seems to protect by slowing down metabolic and physiologic processes, greatlydecreasing the tissues' need for oxygen.[52] There are cases where CPR, defibrillation, and advanced warmingtechniques have revived victims after substantial periods of hypothermia.[53]

Society and culture

Portrayed effectiveness

CPR is often severely misrepresented in movies and television as being highly effective in resuscitating aperson who is not breathing and has no circulation. A 1996 study published in the New England Journal ofMedicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67%survival to discharge.[54][55] This gives members of the public an unrealistic expectation of a successfuloutcome.[54] When educated on the actual survival rates, the proportion of patients over 60 years of age

desiring CPR should they suffer a cardiac arrest drops from 41% to 22%.[56]

Stage CPR

Chest compressions are capable of causing significant local blunt trauma, including bruising or fracture of thesternum or ribs.[57] Performing CPR on a healthy person may or may not disrupt normal heart rhythm, butregardless the technique should not be performed on a healthy person because of the risk of trauma.

The portrayal of CPR technique on television and film often is purposely incorrect. Actors simulating theperformance of CPR may bend their elbows while appearing to compress, to prevent force from reaching thechest of the actor portraying the victim. Other techniques, such as substituting a mannequin torso for the"victim" in some shots, may also be used to avoid harming actors.

Self-CPR hoax

A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survivea Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source ofthe technique. Rochester General Hospital has denied any connection with the technique.[58][59]

Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored patients. Oneresearcher has recommended that it be taught broadly to the public.[60][61]

However, “cough CPR” cannot be used outside the hospital because the first symptom of cardiac arrest isunconsciousness[62] in which case coughing is impossible, although myocardial infarction (heart attack) mayoccur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vastmajority of people suffering chest pain from a heart attack will not be in cardiac arrest and CPR is not needed.In these cases attempting “cough CPR” will increase the workload on the heart and may be harmful. Whencoughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90seconds.[63]

The American Heart Association (AHA) and other resuscitation bodies[63] do not endorse "Cough CPR",which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimateuse of the coughing technique: "This coughing technique to maintain blood flow during brief arrhythmias hasbeen useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG ismonitored continuously, and a physician is present."[64]

CPR learned from movies and television

In at least one case, it has been claimed that CPR allegedly learned from a movie was used to save a person'slife. In April 2011, it was claimed that nine-year-old Tristin Saghin saved his sister's life by administering CPRon her after she fell into a swimming pool, using only the knowledge of CPR that he had gleaned from amotion picture, Black Hawk Down.[65]

HistoryMain article: History of CPR

Sign showing old Silvester andHolger-Nielsen methods ofresuscitation

In the 19th century, Doctor H. R. Silvester described a method (TheSilvester Method) of artificial respiration in which the patient is laid ontheir back, and their arms are raised above their head to aid inhalationand then pressed against their chest to aid exhalation.[66] Theprocedure is repeated sixteen times per minute. This type of artificialrespiration is occasionally seen in films made in the early part of the20th century.

A second technique, called the Holger Neilson technique, described inthe first edition of the Boy Scout Handbook in the United States in1911, described a form of artificial respiration where the person waslaid on their front, with their head to the side, resting on the palms ofboth hands. Upward pressure applied at the patient’s elbows raised theupper body while pressure on their back forced air into the lungs,essentially the Silvester Method with the patient flipped over. Thisform is seen well into the 1950s (it is used in an episode of Lassieduring the Jeff Miller era), and was often used, sometimes for comediceffect, in theatrical cartoons of the time (see Tom and Jerry's "The Catand the Mermouse"). This method would continue to be shown, for historical purposes, side-by-side withmodern CPR in the Boy Scout Handbook until its ninth edition in 1979. The technique was later banned fromfirst-aid manuals in the UK.

However, it was not until the middle of the 20th century that the wider medical community started torecognize and promote artificial respiration combined with chest compressions as a key part of resuscitationfollowing cardiac arrest. The combination was first seen in a 1962 training video called "The Pulse of Life"created by James Jude, Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with WilliamKouwenhoven and Joseph S. Redding had recently discovered the method of external chest compressions,whereas Safar had worked with Redding and James Elam to prove the effectiveness of artificial respiration. Itwas at Johns Hopkins University where the technique of CPR was originally developed. The first effort attesting the technique was performed on a dog by Redding, Safar and JW Perason. Soon afterward, thetechnique was used to save the life of a child.[67] Their combined findings were presented at annual MarylandMedical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptanceover the following decade, helped by the video and speaking tour they undertook. Peter Safar wrote the bookABC of resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the1970s.[68]

Artificial respiration was combined with chest compressions based on the assumption that active ventilation isnecessary to keep circulating blood oxygenated, and the combination was accepted without comparing itseffectiveness with chest compressions alone. However, research over the past decade has shown thatassumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressionsalone (see Cardiocerebral resuscitation in this article).[69]

In other animalsIt is feasible to perform CPR on animals, including cats and dogs. The principles and practices are virtuallyidentical to CPR for humans. One difference is that resuscitation is usually done through the animal's nose, notthe mouth. One is cautioned to only perform CPR on unconscious animals to avoid the risk of being bitten and

that animals, depending on species, have a lower bone density than humans, causing bones to becomeweakened after CPR is performed.[70]

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External linksThe Center for Resuscitation Science at the Hospital of the University of Pennsylvania(http://www.med.upenn.edu/resuscitation/)2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and EmergencyCardiovascular Care (http://circ.ahajournals.org/content/vol112/24_suppl/)ERC European Resuscitation Council (http://www.erc.edu/)Learn CPR - University of Washington (http://depts.washington.edu/learncpr/)Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine (http://www.sjtrem.com/)How Stuff Works - CPR (http://health.howstuffworks.com/cpr.htm)CPR (http://www.nhs.uk/conditions/accidents-and-first-aid/pages/cpr.aspx) : NHS ChoicesHow to resuscitate a child (http://www.nhs.uk/Planners/birthtofive/Pages/Howtorescusitate.aspx) : NHSChoicesSarver Heart Center's Continuous Chest Compression CPR on YouTube(http://medicine.arizona.edu/spotlight/learn-sarver-heart-centers-continuous-chest-compression-cpr)

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