Cardiopulmonary resuscitation

CPR being performed on a mannequin during training.

Cardiopulmonary resuscitation (CPR) is an emergency procedure for people in cardiac arrest or, in some circumstances, respiratory arrest.[1] CPR is performed both in hospitals and in pre-hospital settings.[2]

CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling into the patient (or using a device to simulate this) to ventilate the lungs and pass oxygen in to the blood, called artificial respiration.[1][3] Some protocols now downplay the importance of the artificial respirations, and focus on the chest compressions only (CCR).[4][5]

Despite its name, CPR is unlikely to restart the heart; its main purpose is to maintain a flow of oxygenated blood to the brain and the heart, which are both the most essential organs to human life and the most vulnerable to damage from lack of oxygen (hypoxia). Effective CPR helps by delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Advanced life support, including intravenous drugs and defibrillation (the administration of an electric shock to the heart) is usually needed to restore a viable or "perfusing" heart rhythm--one which will support life. This only works for patients in certain heart rhythms, namely ventricular fibrillation or pulseless ventricular tachycardia, rather than the 'flat line' asystolic patient, although CPR can help induce a shockable rhythm in an asystolic patient.

CPR is generally continued, usually in the presence of advanced life support (such as from EMS providers), until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared dead.

Contents

Indications

CPR training: CPR is being administrated while a second rescuer prepares for defibrillation.

The main indication for CPR is cardiac arrest (a condition in which a person's heart has stopped).[6] CPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep vital organs alive.

Blood circulation and oxygenation are absolute requirements in transporting oxygen to the tissues. The brain may sustain damage after blood flow has been stopped for about four minutes and irreversible damage after about seven minutes.[7][8][9][10][11] If blood flow ceases for one to two hours, the cells of the body die unless they get an adequately gradual blood flow, (provided by cooling and gradual warming, rarely, in nature [such as in a cold stream of water] or by an advanced medical team). Because of that CPR is generally only effective if performed within seven minutes of the stoppage of blood flow.[12] The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperatures as sometimes seen in near-drownings prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsive to defibrillation attempts.

If the patient still has a pulse, but is not breathing, this is called respiratory arrest and artificial respiration is more appropriate. However, since people often have difficulty detecting a pulse, CPR may be used in both cases, especially when taught as first aid. For this reason many organizations recommend that non-professionals giving first aid should start CPR if they cannot detect breathing, without checking the pulse[13].

Methods

ILCOR

In 2005, CPR guidelines[14][15] were published by the International Liaison Committee on Resuscitation (ILCOR), agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.[16][17] The primary goal of these changes was to simplify CPR for lay rescuers and health care providers alike, to maximize the potential for early resuscitation. The important changes for 2005 were:[18]

Research[14] has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and cannot accurately discern the absence of pulse in about 10%. The pulse check step has been removed from the CPR procedure completely for lay persons and de-emphasized for health care professionals.

Compression-only resuscitation/cardiocerebral resuscitation (CCR)

The traditional International Liaison Committee on Resuscitation approach described above has been challenged in recent years by advocates for compression-only CPR, also known as cardiocerebral resuscitation (CCR) and as hands-only CPR[22]. This technique is simply chest compressions without artificial respiration. The respiration component of CPR has been a topic of major controversy over the past decade. The CCR method has been championed by the University of Arizona's Sarver Heart Center. A study by the university[23] claimed a 300% greater success rate over standard CPR.[24] The exceptions were in the case of drowning or drug overdose.

In March 2007, a Japanese study in the medical journal The Lancet presented strong evidence that compressing the chest, not mouth-to-mouth (MTM) ventilation, is the key to helping someone recover from cardiac arrest.[25] An editorial by Gordon Ewy MD (a proponent of CCR) in the same issue of The Lancet called for an interim revision of the ILCOR Guidelines based on the results of the Japanese study, but the next scheduled revision of the Guidelines was not until 2010. However, on March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that compression-only CPR works as well as, and sometimes better than, traditional CPR.[26]

The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. It has also been claimed that the use of compression only delivery increases the chances of lay person delivering CPR.[27]

Rhythmic abdominal compressions

Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected to other sites, including the circulation around the heart. Findings published in the September 2007 issue of the American Journal of Emergency Medicine using pigs found that 60 percent more blood was pumped to the heart using rhythmic abdominal compression-CPR than with standard chest compression-CPR, using the same amount of effort. There was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. Avoiding mouth-to-mouth breathing and chest compressions eliminates the risk of rib fractures and transfer of infection.[28]

Internal cardiac massage

Internal cardiac massage is the process of cardiac massage carried out through a surgical incision into the chest cavity.[29] This distinguishes the process from conventional, external cardiac massage, which is carried out by compression near the sternum during cardiopulmonary resuscitation.

Self-CPR hoax

A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survive a Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique.[30][31]

Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored patients. One researcher has recommended that it be taught broadly to the public.[32][33]

However, “cough CPR” cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness[34] in which case coughing is impossible, although myocardial infarction (heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vast majority 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. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds.[35]

The American Heart Association (AHA) and other resuscitation bodies[35] do not endorse "Cough CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimate use of the coughing technique: "This coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG is monitored continuously, and a physician is present."[36]

Effectiveness

Used alone, CPR will result in few complete recoveries, and those who do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for defibrillation and advanced life support.[37] However, in the case of "non-shockable" rhythms such as Pulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 5–10% of people who receive CPR survive.[38] 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, the current 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 of sudden VF cardiac arrest improve survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York, without those advantages, the survival rate is only 1–2 percent.[39]

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 from hospital (see table below). This is due to medical staff either being ultimately unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravely ill in more than one way.

Compression-only CPR is less effective in children than in adults, as cardiac arrest in children is more likely to have a non-cardiac cause. In a 2010 prospective study of cardiac arrest in children (age 1–17), for arrests with a non-cardiac cause provision by bystanders of conventional CPR with rescue breathing yielded a favorable neurological outcome at one month more often that did compression-only CPR (OR 5.54; 95% confidence interval 2.52–16.99). For arrests with a cardiac cause in this cohort, there was no difference between the two techniques (OR 1.20; 95% confidence interval 0.55–2.66).[40] This is consistent with American Heart Association guidelines for parents.[41]

Type of Arrest ROSC Survival Source
Witnessed In-Hospital Cardiac Arrest 48% 22% [42]
Unwitnessed In-Hospital Cardiac Arrest 21% 1% [42]
Bystander Cardiocerebral Resuscitation 40% 6% [43]
Bystander Cardiopulmonary Resuscitation 40% 4% [43]
No Bystander CPR (Ambulance CPR) 15% 2% [43]
Defibrillation within 3–5 minutes 74% 30% [37][39]

Where ROSC means Return of spontaneous circulation.

Chest compression adjuncts

Several devices have become available in order to help facilitate rescuers in getting the chest compressions completed correctly. These devices can be split in to three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth 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 in getting the correct rate. Some units can also give timing reminders for performing compressions, breathing and changing operators.[44]

Manual assist devices

Studies have shown that audible and visual prompting can improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs with fatigue,[45][46][47][48][49][50] and to address this potential improvement, a number 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 a display or audio feedback giving information on depth, force or rate,[51] or in a wearable format such as a glove.[52] Several published evaluations show that these devices can improve the performance of chest compressions.[53][54]

As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the device with them, these devices can also be used as part of training programs to improve basic skills in performing correct chest compressions.[55]

Certain defibrillation pads are capable of performing similar function, in that they may display rate and depth of compressions. Additionally, a certain algorithm may allow them to monitor electrical activity even during CPR.[56]

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 not fatigue and begin to perform less effective compressions, as humans do; and they are able to perform effective compressions 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 pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed oxygen supplies already standard in ambulances and hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure[57] and return of spontaneous circulation.[58]

Another system called the AutoPulse is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation.[59][60]

Prevalence

Chance of receiving CPR

Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14%[61] and 45%[62] of the time, with a median of 32%. This indicates that around a third of out-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.[63][64]

There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services.[61][65] It was also found that CPR was more commonly given by a bystander in public than when an arrest occurred in the patient's home, although health care professionals are responsible for more than half of out-of-hospital resuscitation attempts.[62] This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family.[66] This is likely because of the shock 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. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.[66]

Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told to only perform the chest compression element of the resuscitation.[27]

Chance of receiving CPR in time

CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,[67] because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 4–6 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge[68] A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. Hypothermia seems to protect the victim by slowing down metabolic and physiologic processes, greatly decreasing the tissues' need for oxygen.[69] There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia.[70]

In film and television

Portrayed effectiveness

CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a person who is not breathing and has no circulation. A 1996 study published in the New England Journal of Medicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67% survival to discharge.[71][72] This gives members of the public an unrealistic expectation of a successful outcome.[71] 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%.[73]

Stage CPR

Chest compressions are capable of causing significant local blunt trauma, including bruising or fracture of the sternum or ribs. Performing CPR on a healthy person may or may not disrupt normal heart rhythm, but regardless 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 the performance of CPR may bend their elbows while appearing to compress, to prevent force from reaching the chest 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.

History

Sign showing old Silvester and Holger-Nielson methods of resuscitation

In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation.[74] The procedure is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in films made in the early part of the 20th century.

A second technique, called the Holger Neilson technique, described in the first edition of the Boy Scout Handbook in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, resting on the palms of both hands. Upward pressure applied at the patient’s elbows raised the upper body while pressure on their back forced air into the lungs, essentially the Silvester Method with the patient flipped over. This form is seen well into the 1950s (it is used in an episode of Lassie during the Jeff Miller era), and was often used, sometimes for comedic effect, in theatrical cartoons of the time (see Tom and Jerry's "The Cat and the Mermouse"). This method would continue to be shown, for historical purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in 1979. The technique was later banned from first-aid manuals in the UK.

However, it was not until the middle of the 20th century that the wider medical community started to recognize and promote artificial respiration combined with chest compressions as a key part of resuscitation following 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 William Kouwenhoven 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. It was at Johns Hopkins University where the technique of CPR was originally developed. The first effort at testing the technique was performed on a dog by Redding, Safar and JW Perason. Soon afterward, the technique was used to save the life of a child.[75] Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour they undertook. Peter Safar wrote the book ABC of resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s.[76]

Artificial respiration was combined with chest compressions based on the assumption that active ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted without comparing its effectiveness with chest compressions alone. However, research over the past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressions alone (see Cardiocerebral resuscitation in this article).[4]

Application on animals

It is entirely feasible to perform CPR on animals including cats and dogs. The principles and practices are virtually identical to CPR for humans. 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 become weakened after CPR is performed.[77]

See also

References

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  60. ↑ Hallstrom, Al; Rea, Thomas; Sayre, Michael; Christenson, James; Anton, Andy; Mosesso, Vince; Ottingham, Lois; Olsufka, Michele; Pennington, Sarah; White, Lynn; Yahn, Stephen; Husar, James; Morris, Mary; Cob, Leonard. "Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest" (PDF). Journal of the American Medical Association 295 (22). http://jama.ama-assn.org/cgi/reprint/jama;295/22/2620.pdf?ijkey=V96Oxk0wfyGibgF&keytype=finite. 
  61. ↑ 61.0 61.1 Swor, RA; Jackson, RE; Cynar, M; Sadler, E; Basse, E; Boji, B; Rivera-Rivera, EJ; Maher, A et al. (June 1995). "Bystander CPR, ventricular fibrillation and survival in witnessed, unmonitored out-of-hospital cardiac arrest". Annals of Emergency Medicine 25 (6): 780–4. doi:10.1016/S0196-0644(95)70207-5. PMID :7755200. 
  62. ↑ 62.0 62.1 Wik, L; Steen PA; Bircher NH (December 1994). "Quality of bystander cardiopulmonary resuscitation influence outcome after prehospital cardiac arrest". Resuscitation 28 (4): 195–203. doi:10.1016/0300-9572(94)90064-7. PMID 7740189 : 7740189. 
  63. ↑ Van Hoeyweghen, RJ; Bossaert LL; Mullie (August 1993). "Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group". Resuscitation 26 (1): 47–52. PMID 8210731. 
  64. ↑ Gallagher, EJ; Lombardi G; Gennis P (December 1995). "Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest". JAMA 274 (24): 1922. doi:10.1001/jama.274.24.1922. PMID 8568985 : 8568985. 
  65. ↑ jackson, RE; Swor RA (June 1997). "Who gets bystander cardiopulmonary resuscitation in a witnessed arrest?". Academy of Emergency Medicine 4 (6): 560–4. PMID 9189184 : 9189184. 
  66. ↑ 66.0 66.1 Bossaert, L; Van Hoeyweghen R (1989). "Bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest. The Cerebral Resuscitation study group". Resuscitation 17 (Suppl S55-69): S55–69; discussion S199–206. PMID 2551021 : 2551021. 
  67. ↑ Cummins, RO; Eisenberg MS; Hallstrom AP; Litwin PE (March 1985). "Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation". American Journal of Emergency Medicine 3 (2): 114–9. doi:10.1016/0735-6757(85)90032-4. PMID 3970766 : 3970766. 
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