continuing education activity
Cardiopulmonary resuscitation (CPR) is a group of procedures performed to provide oxygen and circulation to the body during cardiac arrest. The most widely used CPR guidelines in North America are issued by the American Heart Association (AHA). These are published every 5 years after the meeting of the International Liaison Committee on Resuscitation (ILCOR). This activity describes the assessment and management of patients who may need CPR and highlights the role of the interprofessional team in improving the care of affected individuals.
Explain the steps for detecting an out-of-hospital cardiac arrest.
Explain with a rescuer how CPR is performed on a victim of an out-of-hospital cardiac arrest.
Explain how CPR is performed on infants and children.
Explain the importance of improving coordination between the interprofessional team to improve the care of patients requiring CPR.
Cardiopulmonary resuscitation (CPR) is a series of procedures performed to provide oxygen and circulation to the body during cardiac arrest. Our current modern approach to this process grew out of the work of a handful of physicians in the 1950s and has now evolved into the process further discussed here. The most widely accepted guidelines in North America are those of the American Heart Association (AHA). These are published every 5 years after the meeting of the International Liaison Committee on Resuscitation (ILCOR).
Nearly 350,000 Americans die from heart disease each year. Half of them die suddenly outside a hospital due to a sudden disruption in spontaneously organized heart function. The most common cause of sudden cardiac arrest in adults is ventricular fibrillation. While advances in emergency cardiac care continue to improve survival, sudden cardiac arrest remains a leading cause of death in many parts of the world. As of 2016, heart disease remains the leading cause of death in the United States.
Seventy percent of cardiac arrests that occur outside of a hospital occur at home. Half of these cardiac arrests go unnoticed. Despite advances in rescue services, the survival rate remains low. Adult victims of non-traumatic cardiac arrest who are resuscitated by emergency services have a hospital discharge survival rate of only 10.8%. In comparison, adult patients suffering cardiac arrest in a hospital have survival rates to hospital discharge of up to 25.5%.
The definitive treatment for ventricular fibrillation is electrical defibrillation. This is most commonly done with an automated external defibrillator (AED). If an AED is not available for defibrillation, brain death is likely to occur in less than 10 minutes. CPR is a means of providing artificial circulation and ventilation until defibrillation can be performed. Traditional manual CPR, which combines chest compressions with ventilation, can provide up to 33% of normal cardiac output and oxygenation when performed properly.
story and body
Patients requiring CPR are unconscious and unresponsive with missing pulses. There is a prognostic advantage in determining the last time the patient was seen normally, or better yet, when pulses were lost. In addition, the accompanying medical history of bystanders, family, friends and the general practitioner can be helpful in the etiological assessment.
There are no specific physical examination findings, but signs of cyanosis and decreased peripheral blood flow may suggest a cause for the arrest.
The absence of a palpable pulse in an unresponsive patient indicates the need for CPR.
Treatment / Administration
Note: The technique described here is intended for use by healthcare professionals who, with a rescuer, are performing CPR on an adult casualty outside of a hospital setting. Modifications for children, infants, and in-hospital CPR are listed below. These recommendations have been updated from the 2015 updated American Heart Association guidelines for CPR and emergency cardiac care.
Immediate detection of cardiac arrest is essential to initiate emergency medical services (EMS) response and begin CPR as soon as possible. In this age of ubiquitous cell phone availability, it is now possible to call 911 while staying with the victim. Make sure the scene is safe and ask for help. Simultaneously, initiate CPR by first giving chest compressions (C), followed by opening the airway (A) and delivering rescue breaths (B) (the CAB sequence versus the previous ABC sequence). The hands are placed on the lower half of the sternum and chest compressions are begun at a rate of 100 to 120 compressions per minute. The goal is to compress the sternum to a depth of at least two inches while avoiding excessive depth of compression. The chest wall must fully recoil on the upstroke to maintain coronary artery perfusion pressure.Thirty compressions are given, followed by a short pause for two breaths. Because of the critical contribution of chest compressions to coronary artery perfusion, interruptions in chest compressions should be minimized and any interruptions should be kept to a minimum when necessary.
After 30 chest compressions, the rescuer performs a head tilt/chin-up maneuver to open the airway (assuming no cervical spine injury is suspected). If a cervical spine injury is suspected, the airway is opened with the jaw thrust maneuver without straightening the head. Two breaths are given: The rescuer takes a “normal” breath (not deep or excessive) and delivers a breath lasting about one second, which should be just long enough for the chest to rise. The process is repeated for a second breath before chest compressions are resumed.
Ideally, a healthcare professional wishing to intervene outside of the hospital as a first responder should have immediate access to a barrier device such as a rescue mask. However, this is not always the case. Mouth-to-mouth resuscitation was the alternative, which many untrained rescuers are reluctant to perform, particularly in the case of an unknown victim. This is a decision healthcare professionals must make for themselves. Only compression CPR was accepted as appropriate for untrained lay rescuers. If extenuating circumstances prohibit a healthcare provider in an out-of-hospital setting from performing rescue ventilation without a barrier device, compression-only CPR should be performed until emergency medical services arrive.
The cycle of 30 alternating chest compressions with two rescue breaths continues until an AED is available or until additional help arrives. When an AED arrives, its pads should be placed on the front and back of the patient, taking care to minimize delays in resuming chest compressions. Most modern devices verbalize more instructions—once attached to the patient, AEDs detect the current heart rhythm and tell the patient if they should be defibrillated. If the AED advises a shock, stop chest compressions and stand away from the patient until defibrillation is complete. After defibrillation is complete, or if a shock is not advised, immediately resume cycles of chest compressions and ventilations following the CAB sequence until further help arrives.
A quick physical exam, focusing on the palpable pulse and mental status, is important because drug overdose, including heavy alcohol use, can sometimes mimic cardiac arrest.
According to 2015 AHA data, survival to discharge from hospital remains low at 10.6% for patients with an out-of-hospital cardiac arrest. 8.3% of patients with out-of-hospital cardiac arrest are discharged with good neurological function. Observed cardiac arrests in patients receiving quality CPR have a better prognosis, with 25.5% of patients surviving to hospital discharge.
Cardiac arrest has a grim prognosis—most patients don't survive. For those who survive, their hospitalization may be complicated by varying degrees of neurological damage from hypoxic encephalopathy. All organ systems can suffer ischemic damage. Chest compressions, when performed correctly, can cause rib fractures, which can be complicated by a pneumothorax.
Warning and patient information
In the event of cardiac arrest, the patient's family and/or his or her representative or surrogate must be notified. It is important to verify patient code status and all previous instructions must be followed if proper documentation can be obtained under the laws of the local jurisdiction.
Pearls and Other Issues
By definition, infant CPR is for patients less than one year old. CPR in infants applies to patients from one year of age through puberty. Adult CPR guidelines apply after puberty. Modifications for infant and child CPR are listed below. All other aspects of CPR follow adult guidelines, including beginning the process with the Compression First (CAB) sequence and compression rate of 100 to 120 per minute. The sternum should be depressed to a depth of about one-third the anteroposterior diameter of the chest; that's about two inches for a toddler and 1.5 inches for a baby.
CPR modifications in infants
Chest compressions in children are performed by placing the heels of one or two hands (depending on the child's size) on the lower half of the breastbone. The chest is compressed at a rate of 100 to 120 per minute to a depth of approximately two inches. After 30 compressions, deliver two consecutive breaths and return to chest compressions. Continue the cycle of 30 compressions for two breaths until help arrives.
CPR modifications in infants
Chest compressions on an infant are performed by placing two fingers on the breastbone just below the nipple line. The baby's chest is squeezed at a rate of 100 to 120 per minute to a depth of about 1.5 inches. After 30 compressions, deliver two consecutive breaths and return to chest compressions. Continue the cycle of 30 compressions for two breaths until help arrives.
RCP not a hospital
There are usually multiple rescuers available in the hospital, and ventilation is usually provided with a bag-valve-mask (BVM) device. BVM ventilation must be performed by a professional qualified for its use. If the patient is not intubated, CPR is performed by one provider providing chest compressions while the second provider provides BMV breaths. The compressions to breaths ratio in this situation changes to 15 compressions to two breaths. Once the patient is intubated, there is no need to cycle compressions and ventilations - chest compressions are performed continuously while ventilator breaths are delivered independently via BVM at a rate of 10 per minute (one breath every six seconds). Beginners often tend to deliver BVM breaths at a higher rate.
Improving health team outcomes
All healthcare professionals, including nurses and pharmacists, should know how to perform CPR. In fact, many hospitals now require healthcare professionals to have a valid CPR certificate in order to work. When done quickly and correctly, CPR can save lives.
- (Video) CPR for Infants (Newborn to 1 Year)
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