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CPR.
Cardiopulmonary Resuscination.
INITIALAPPROACH 1 Cardiopulmonary resuscitation (CPR) is required if a collapsed person is unconscious or unresponsive, not breathing, and has no pulse in a large artery such as the carotid or femoral.
(i) The following may also be seen:
(a) occasional, ineffectual (agonal) gasps
(b) pallor or cyanosis
(c) dilated pupils
(d) brief tonic grand mal seizure.
2 Sudden cardiac arrest still causes over 60% of deaths from coronary heart disease in adults.
Management. 1 This is based on the International Liaison Committee on Resuscitation (ILCOR) 2010 International Consensus on CPR Science with Treatment Recommendations (CoSTR).
(i) The first person on the scene stays with the patient, checks for danger and commences resuscitation, making a note of the time.
(ii) The second person summons help to organize the arrival of equipment, then assists with the resuscitation.
2 Immediate actions
The aim is to maintain oxygenation of the brain and myocardium until a stable cardiac output is achieved.
(i) Lay the patient flat on a hard surface such as a trolley. If the patient is on the floor and enough people are available, lift the
patient onto a trolley to facilitate the resuscitation procedure.
(ii) Rapidly give a single, sharp precordial thump within the first few seconds of the onset of a witnessed or monitored arrest, where the
rhythm is pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF), and a defibrillator is not immediately to hand.
(iii) Check the victim for a response, and then open the airway by tilting the head and lifting the chin if there is no response (‘head
tilt, chin lift’):
(a) this prevents the tongue from occluding the larynx
(b) look, listen and feel for breathing for no more than 10 s, while keeping the airway open.
(iv) If breathing is not normal or absent, check for signs of a circulation:
(a) assess a large pulse such as the carotid or femoral, or look for signs of life for no more than 10 s.
(v) Start CPR immediately if there are no signs of life:
(a) commence external cardiac massage
(b) commence assisted ventilation.
3 External cardiac massage
(i) Place the heel of one hand in the centre of the patient’s chest.Place the heel of the other hand on top, interlocking the fingers.
(ii) Keeping the arms straight and applying a vertical compression force, depress the sternum 5–6 cm at a rate of at least 100
compressions/min (but not exceeding 120/min):
(a) release all the pressure on the chest without losing contact with the sternum after each compression
(b) do not apply pressure over the upper abdomen, lower end of sternum or the ribs, and take equal time for compression and
for release.
(iii) Perform 30 compressions, which should create a palpable femoral pulse.
(iv) Use a one- or two-hand technique to compress the lower half of the sternum in small children by approximately one-third of its
depth, at a rate of at least 100 compressions/min but not greater than 120/min:
(a) use the tips of two fingers in infants, also at a rate of at least 100/min (see p. 343).
4 Assisted ventilation
(i) Open the airway again using head tilt and chin lift.
(ii) Start mouth-to-mouth/nose or mouth-to-mask respiration without delay if breathing is absent, using a pocket mask such as
the Laerdal.
(iii) Deliver two effective rescue breaths that should be completed within 5 s total time, and immediately resume compressions.
(iv) Use a bag-valve mask setup such as an Ambu or Laerdal bag with oxygen reservoir attached and face mask instead, if trained in the
technique
(a) quickly look in the mouth and remove any obstruction with forceps or suction. Leave well-fitting dentures in place
(b) or try inserting an oropharyngeal (Guedel) airway if necessary
(c) check for leaks around the mask or convert to a two-person technique if the chest fails to inflate
(d) consider possible obstruction of the upper airway, if ventilation is still ineffective
CARDIOPULMONARY RESUSCITATION
5 Basic life support: external cardiac massage with assisted ventilation
(i) Continue with chest compressions and rescue breaths in a ratio of 30:2.
(ii) Change the person providing chest compressions every 2 min, but ensure minimum interruption to compressions during the changeover.
6 Defibrillation
(i) As soon as the defibrillator arrives, apply self-adhesive pads or paddles to the patient whilst continuing chest compressions
(a) rapidly shave excessive male chest hair, without delay
(b) place one self-adhesive defibrillation pad or conventional paddle to the right of the sternum below the clavicle, and the
other adhesive pad or paddle in the mid-axillary line level with the V6 electrocardiogram (ECG) electrode or female
breast
(c) avoid positioning self-adhesive pads or paddles over an ECG electrode, medication patch, or implanted device, e.g.
pacemaker or automatic cardioverter defibrillator.
(ii) Analyse the rhythm with a brief pause, and charge the defibrillator if the rhythm is VF or pulseless VT. Continue chest compressions until fully charged.
(iii) Quickly ensure that all rescuers are clear, then give the patient an immediate 150–200 J direct current (DC) shock using a biphasic
waveform defibrillator (all modern defibrillators are now biphasic)
(a) minimize the delay in delivering the shock, which should take less than 5 s
(b) ensure good electrical contact is made when applying manual paddles by using gel pads or electrode jelly, and apply firm
pressure of 8 kg force in adults
(c) give a 360 J shock if an older monophasic defibrillator is used.
(iv) Immediately resume chest compressions without reassessing the rhythm or feeling for a pulse.
(v) The only exception is when VF is witnessed in a patient already connected to a manual defibrillator, or during cardiac
catheterization, and/or early post-cardiac surgery
(a) use a stacked, three-shock strategy rapidly delivering three shocks in a row before starting chest compressions.
(vi) Continue external chest compressions and assisted ventilation for 2 min, then pause briefly to assess the rhythm again.
Warning: adequate oxygenation is achieved by the above measures. Endotracheal intubation should only be attempted by those who are
trained, competent and experienced.
CARDIOPULMONARY RESUSCITATION
7 Observe one of four possible traces
(i) Shockable rhythms such as VF) or pulseless VT
(ii) Non-shockable rhythms such as asystole and pulseless electrical activity (PEA)
8 Establish an initial i.v. line in the antecubital fossa.
(i) Give at least 20 mL of normal saline to flush any drugs administered, that are given after the third DC shock.
(ii) Elevate the limb for 10–20 s to facilitate drug delivery to the central circulation.
(iii) Establish a second i.v. line unless the cardiac resuscitation is rapidly successful
(a) ideally this line should be inserted into a central vein, either the external or internal jugular or the subclavian
(b) a central line should only be inserted by a skilled doctor, as inadvertent arterial puncture, haemothorax or pneumothorax
may invalidate further resuscitation attempts
(c) also, the central venous route poses additional serious hazards should thrombolytic therapy be indicated
(d) all drugs are then given via this central line.
9 Endotracheal intubation
A skilled doctor with airway training may insert a cuffed endotracheal tube This maintains airway patency, prevents regurgitation with
inhalation of vomit or blood from the mouth or stomach, and allows lung ventilation without interrupting chest compressions.
(i) Confirm correct endotracheal tube placement by seeing the tube pass between the vocal cords, and by observing bilateral chest
expansion, and auscultating the lung fields and over the epigastrium.
(ii) Immediately connect an exhaled carbon dioxide detection device such as a waveform capnograph, and look for a tracing, as the
signs above are not completely reliable
(a) never delay CPR to intubate the airway except for a brief pause in chest compressions of not more than 10 s, as the
tube is passed between the vocal cords.
(iii) Once the airway has been secured, continue cardiac compressions uninterrupted at a rate of at least 100/min, and ventilate the lungs
at 10 breaths/min (without any need now to pause for the chest compressions)
(a) take care not to hyperventilate the patient at too fast a rate.
10 Subsequent management depends on the cardiac rhythm and the patient’s condition. Keep the ECG monitor attached to the patient at all time
INITIALAPPROACH 1 Cardiopulmonary resuscitation (CPR) is required if a collapsed person is unconscious or unresponsive, not breathing, and has no pulse in a large artery such as the carotid or femoral.
(i) The following may also be seen:
(a) occasional, ineffectual (agonal) gasps
(b) pallor or cyanosis
(c) dilated pupils
(d) brief tonic grand mal seizure.
2 Sudden cardiac arrest still causes over 60% of deaths from coronary heart disease in adults.
Management. 1 This is based on the International Liaison Committee on Resuscitation (ILCOR) 2010 International Consensus on CPR Science with Treatment Recommendations (CoSTR).
(i) The first person on the scene stays with the patient, checks for danger and commences resuscitation, making a note of the time.
(ii) The second person summons help to organize the arrival of equipment, then assists with the resuscitation.
2 Immediate actions
The aim is to maintain oxygenation of the brain and myocardium until a stable cardiac output is achieved.
(i) Lay the patient flat on a hard surface such as a trolley. If the patient is on the floor and enough people are available, lift the
patient onto a trolley to facilitate the resuscitation procedure.
(ii) Rapidly give a single, sharp precordial thump within the first few seconds of the onset of a witnessed or monitored arrest, where the
rhythm is pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF), and a defibrillator is not immediately to hand.
(iii) Check the victim for a response, and then open the airway by tilting the head and lifting the chin if there is no response (‘head
tilt, chin lift’):
(a) this prevents the tongue from occluding the larynx
(b) look, listen and feel for breathing for no more than 10 s, while keeping the airway open.
(iv) If breathing is not normal or absent, check for signs of a circulation:
(a) assess a large pulse such as the carotid or femoral, or look for signs of life for no more than 10 s.
(v) Start CPR immediately if there are no signs of life:
(a) commence external cardiac massage
(b) commence assisted ventilation.
3 External cardiac massage
(i) Place the heel of one hand in the centre of the patient’s chest.Place the heel of the other hand on top, interlocking the fingers.
(ii) Keeping the arms straight and applying a vertical compression force, depress the sternum 5–6 cm at a rate of at least 100
compressions/min (but not exceeding 120/min):
(a) release all the pressure on the chest without losing contact with the sternum after each compression
(b) do not apply pressure over the upper abdomen, lower end of sternum or the ribs, and take equal time for compression and
for release.
(iii) Perform 30 compressions, which should create a palpable femoral pulse.
(iv) Use a one- or two-hand technique to compress the lower half of the sternum in small children by approximately one-third of its
depth, at a rate of at least 100 compressions/min but not greater than 120/min:
(a) use the tips of two fingers in infants, also at a rate of at least 100/min (see p. 343).
4 Assisted ventilation
(i) Open the airway again using head tilt and chin lift.
(ii) Start mouth-to-mouth/nose or mouth-to-mask respiration without delay if breathing is absent, using a pocket mask such as
the Laerdal.
(iii) Deliver two effective rescue breaths that should be completed within 5 s total time, and immediately resume compressions.
(iv) Use a bag-valve mask setup such as an Ambu or Laerdal bag with oxygen reservoir attached and face mask instead, if trained in the
technique
(a) quickly look in the mouth and remove any obstruction with forceps or suction. Leave well-fitting dentures in place
(b) or try inserting an oropharyngeal (Guedel) airway if necessary
(c) check for leaks around the mask or convert to a two-person technique if the chest fails to inflate
(d) consider possible obstruction of the upper airway, if ventilation is still ineffective
CARDIOPULMONARY RESUSCITATION
5 Basic life support: external cardiac massage with assisted ventilation
(i) Continue with chest compressions and rescue breaths in a ratio of 30:2.
(ii) Change the person providing chest compressions every 2 min, but ensure minimum interruption to compressions during the changeover.
6 Defibrillation
(i) As soon as the defibrillator arrives, apply self-adhesive pads or paddles to the patient whilst continuing chest compressions
(a) rapidly shave excessive male chest hair, without delay
(b) place one self-adhesive defibrillation pad or conventional paddle to the right of the sternum below the clavicle, and the
other adhesive pad or paddle in the mid-axillary line level with the V6 electrocardiogram (ECG) electrode or female
breast
(c) avoid positioning self-adhesive pads or paddles over an ECG electrode, medication patch, or implanted device, e.g.
pacemaker or automatic cardioverter defibrillator.
(ii) Analyse the rhythm with a brief pause, and charge the defibrillator if the rhythm is VF or pulseless VT. Continue chest compressions until fully charged.
(iii) Quickly ensure that all rescuers are clear, then give the patient an immediate 150–200 J direct current (DC) shock using a biphasic
waveform defibrillator (all modern defibrillators are now biphasic)
(a) minimize the delay in delivering the shock, which should take less than 5 s
(b) ensure good electrical contact is made when applying manual paddles by using gel pads or electrode jelly, and apply firm
pressure of 8 kg force in adults
(c) give a 360 J shock if an older monophasic defibrillator is used.
(iv) Immediately resume chest compressions without reassessing the rhythm or feeling for a pulse.
(v) The only exception is when VF is witnessed in a patient already connected to a manual defibrillator, or during cardiac
catheterization, and/or early post-cardiac surgery
(a) use a stacked, three-shock strategy rapidly delivering three shocks in a row before starting chest compressions.
(vi) Continue external chest compressions and assisted ventilation for 2 min, then pause briefly to assess the rhythm again.
Warning: adequate oxygenation is achieved by the above measures. Endotracheal intubation should only be attempted by those who are
trained, competent and experienced.
CARDIOPULMONARY RESUSCITATION
7 Observe one of four possible traces
(i) Shockable rhythms such as VF) or pulseless VT
(ii) Non-shockable rhythms such as asystole and pulseless electrical activity (PEA)
8 Establish an initial i.v. line in the antecubital fossa.
(i) Give at least 20 mL of normal saline to flush any drugs administered, that are given after the third DC shock.
(ii) Elevate the limb for 10–20 s to facilitate drug delivery to the central circulation.
(iii) Establish a second i.v. line unless the cardiac resuscitation is rapidly successful
(a) ideally this line should be inserted into a central vein, either the external or internal jugular or the subclavian
(b) a central line should only be inserted by a skilled doctor, as inadvertent arterial puncture, haemothorax or pneumothorax
may invalidate further resuscitation attempts
(c) also, the central venous route poses additional serious hazards should thrombolytic therapy be indicated
(d) all drugs are then given via this central line.
9 Endotracheal intubation
A skilled doctor with airway training may insert a cuffed endotracheal tube This maintains airway patency, prevents regurgitation with
inhalation of vomit or blood from the mouth or stomach, and allows lung ventilation without interrupting chest compressions.
(i) Confirm correct endotracheal tube placement by seeing the tube pass between the vocal cords, and by observing bilateral chest
expansion, and auscultating the lung fields and over the epigastrium.
(ii) Immediately connect an exhaled carbon dioxide detection device such as a waveform capnograph, and look for a tracing, as the
signs above are not completely reliable
(a) never delay CPR to intubate the airway except for a brief pause in chest compressions of not more than 10 s, as the
tube is passed between the vocal cords.
(iii) Once the airway has been secured, continue cardiac compressions uninterrupted at a rate of at least 100/min, and ventilate the lungs
at 10 breaths/min (without any need now to pause for the chest compressions)
(a) take care not to hyperventilate the patient at too fast a rate.
10 Subsequent management depends on the cardiac rhythm and the patient’s condition. Keep the ECG monitor attached to the patient at all time
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