Cardiopulmonary Resuscitation (CPR)

Overview

Introduction

• Annual incidence of sudden cardiac arrest in the United States: 180,000–450,000 +
• Cardiopulmonary resuscitation (CPR) is attempted in approximately ⅔ of cases.
• Early initiation of high-quality CPR has been shown to dramatically increase survival rate.

Cardiopulmonary resuscitation sequence overview

Cardiopulmonary resuscitation consists of chest compressions and rescue breaths carried out sequentially. 

• Identification of cardiac arrest:
  • Patient seen losing consciousness or found unconscious 
  • Assess scene for safety.
  • Feel pulse and assess breathing simultaneously:
    • Carotid pulse should be felt for no longer than 10 seconds.
    • Look for chest movement, and listen and feel for air movement (patient may be apneic or with abnormal or agonal breathing).
• Prepare for CPR:
  • Activation of emergency response system:
    • Outside hospital, call 911.
    • In hospital, call cardiac arrest code.
  • Obtain automatic external defibrillator (AED), if available.
• If pulse is present, but no breathing:
  • Provide rescue breath (1 every 6 seconds).
  • Recheck pulse every 2 minutes.
• If no pulse present:
  • Start with chest compressions before giving rescue breath.
  • If trained in CPR, initiate CPR at rate of 30 chest compressions followed by 2 rescue breaths (30:2).
  • If sole lay rescuer, compression-only CPR (CPR without mouth-to-mouth breaths)
  • Apply AED as soon as available.
  • Continue CPR and deliver shocks as directed by AED.

Rescue Breaths

Rescue breath technique

• If possible, use face shield or other form of personal protective equipment (PPE).
• Clear mouth of objects before rescue breaths. 
• Tilt head back slightly.
• Lift chin. 
• Pinch nose.
• Place your mouth fully over theirs. 
• Blow hard enough to get chest rise (retilt head if chest does not rise).

Heimlich maneuver

If patient’s chest does not rise, foreign object may be obstructing airway:

• With patient supine → open airway using jaw lift →  if foreign body is visible, remove object with finger sweep (do not perform blind finger sweep).
• Attempt rescue breaths → if unsuccessful, retilt head and reattempt rescue breaths.
• If no chest rise → kneel next to or straddle hips of patient → use 2 hands on top of each other and place heel of bottom hand below xiphoid process → press both hands into abdomen with quick upward thrust 5 times.
• Open airway with jaw lift → if foreign body is visible, remove it → if not, repeat Heimlich maneuver until ventilation is successful.

Chest Compressions

Positioning

• Patient must be supine.
• Patient must be lying on a firm surface.

Technique

• In adults, use 2-hand chest compression technique:
  • 1 hand on top of the other 
  • Place heel of bottom hand over lower portion of the sternum, slightly below nipples.
• Push “hard and fast”: 
  • Appropriate rate: 100–120 compressions/min
  • Adequate depth: 5.0–7.6 cm (2–3 in) 
  • Allow full chest recoil.

Limit pauses during CPR

• Pause only to give rescue breaths.
• If possible, have other providers prepare to take turns performing compressions (change every 2 minutes).
• Avoid hyperventilation: ventilation rate around 6/min

Defibrillation

Early defibrillation has been shown to significantly improve morbidity and mortality in ventricular fibrillation (VF)/ventricular tachycardia (VT) cardiac arrest.

Timing

• Chest compressions should be initiated before placing defibrillator.
• Rhythm analysis/shock should be performed as soon as possible without interrupting high-quality chest compression.
• Ideal timing is to pause between switching providers; done every 2 minutes.

Positioning

• Different models vary slightly, so follow instructions provided.
• Usually, 1 pad is placed under the right collarbone and the other on the left side of the chest.

Analysis and shock

• Providers should not touch the patient during analysis/shock.
• AED automatically analyzes patient rhythm and suggests shock delivery and voltage.
• Repeat analysis every 2-minute cycle.

Differences in Children

Rescue breaths

• Order of CPR:
  • Cardiac arrest in children is often due to hypoxia.
  • Perform 2 rescue breaths before starting compressions.
• Differences in technique:
  • If choking suspected, do not use Heimlich maneuver:
    • Use back blows in infants.
    • Use chest thrusts in small children.
  • Positioning of mouth:
    • For infants, place your mouth over their nose and mouth. 
    • For children, pinch their nose shut and place your mouth over theirs.

Chest compressions

• In infants, use 2-finger technique or 2-thumb technique (when hands can fit around child).
• In children, use 1-hand technique in center of chest.

Defibrillation

• Pediatric pads should be utilized:
  • Different size and shape
  • Different positioning
• Voltage should be lowered, as specified by instructions in defibrillator.

Do Not Resuscitate (DNR)

A DNR order is a medical order, part of a patient’s advance directives.

Do not resuscitate orders prevent healthcare providers from performing the following procedures in case a patient’s breathing stops or heart rate stops:

• CPR (chest compressions, artificial breathing)
• Electrical cardioversion
• Administering antiarrhythmic medications or cardiac resuscitation medications (e.g., epinephrine)

Advance directives:

• Patient’s ability to decide and reflect on their wishes about future medical care
• Can be provided by family members (surrogate decision-maker)
• Often includes more than a DNR order (e.g., vegetative state directives)

Being under a DNR order does not prohibit patients from receiving appropriate medical care (surgeries, biopsies, dialysis, blood samples, move to intensive care unit (ICU), etc.).