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the Association’s newest set of [23, 25] guidelines for CPR. Changes for 2010 include the following :
The initial sequence of steps is changed from ABC (airway, breathing, chest compressions) to CAB (chest compressions, airway, breathing), except for newborns “Look, listen, and feel” is no longer recommended The compression depth for adults should be at least 2 inches (instead of up to 2 inches) The compression rate should be at least 100/min Emergency cardiac treatments no longer recommended include routine atropine for pulseless electrical activity (PEA)/asystole, cricoid pressure (with CPR), and airway suctioning for all newborns (except those with obvious obstruction).  Post–cardiac arrest care is covered in a new section
Several studies that looked at the quality of CPR being performed in hospitals and by EMS systems found that providers often did not perform CPR up to the standards of the ECC guidelines. Specifically, they found that providers were often deficient in both rate and depth of chest compressions and often provided ventilations at too high a rate. Other studies demonstrated the impact of inadequate rate and depth on survival. The 2010 AHA guidelines state that untrained bystanders should perform COCPR (previous AHA guidelines did not address untrained bystanders separately). Several studies concluded that stopping compressions in order to give ventilations may be detrimental to the patient’s outcome. While a bystander halts compressions to give 2 breaths, blood flow also stops, and this cessation of blood flow leads to a quick drop in the blood pressure that had been built up during the previous set of compressions. Indications CPR should be performed immediately on any person who has become unconscious and is found to be pulseless. Assessment of cardiac electrical activity via rapid “rhythm strip” recording can provide a more detailed analysis of the type of cardiac arrest, as well as indicate additional treatment options. Loss of effective cardiac activity is generally due to the spontaneous initiation of a nonperfusing arrhythmia, sometimes referred to as a malignant arrhythmia. The most common nonperfusing arrhythmias include the following:
VF Pulseless VT PEA Asystole Pulseless bradycardia
Although prompt defibrillation has been shown to improve survival for VF and pulseless VT rhythms, CPR should be started before the rhythm is identified and should be continued while the defibrillator is being applied and charged. Additionally, CPR should be resumed immediately after a defibrillatory shock until a pulsatile state is established. This is supported by studies showing that “preshock pauses” in CPR result in lower rates of defibrillation success and patient recovery. In a study involving out-of-hospital cardiac arrests in Seattle, 84% of patients regained a pulse when defibrillated during VF. Defibrillation is generally most effective the faster it is deployed.
However. with the CPR provider kneeling over him or her. such devices had not been shown to be more effective than highquality manual compressions. A relative contraindication to performing CPR may arise if a clinician justifiably feels that the intervention would be medically futile. so that he or she can use body weight to adequately compress the chest (see the video below). Regardless of the equipment available. Some hospitals and emergency medical services (EMS) systems employ devices to provide mechanical chest compressions. In the out-of-hospital setting. The health care provider giving compressions should be positioned high enough above the patient to achieve sufficient leverage. the patient is often positioned on the floor. and further study in this area is warranted. and no cases of disease transmission via CPR delivery have been reported. An additional device employed in the treatment of cardiac arrest is a cardiac defibrillator. compared with patients receiving standard CPR. Universal precautions (ie. can be performed anywhere without the need for specialized equipment. gloves. gown) should be taken. . Equipment CPR. physician. However. thereby helping them improve the quality of compressions during CPR. having the CPR provider stand on a step-stool. where patients are in gurneys or beds. Delivery of CPR on a mattress or other soft material is generally less effective. 2 retrospective cohort studies have called into question the value of prehospital endotracheal intubation. or both.Contraindications The only absolute contraindication to CPR is a do-not-resuscitate (DNR) order or other advanced directive indicating a person’s desire to not be resuscitated in the event of cardiac arrest. nurse. Additionally. in its most basic form. appropriate positioning is often achieved by lowering the bed. mask. anesthetic agents are not typically required for cardiopulmonary resuscitation (CPR). Positioning CPR is most easily and effectively performed by laying the patient supine on a relatively hard surface. CPR is delivered without such protections. Preparation Anesthesia Because a person in cardiac arrest is almost invariably unconscious. which allows effective compression of the sternum. paramedic) may also elect to insert an endotracheal tube directly into the trachea of the patient (intubation). although this is clearly a complex issue that is an active area of research. A study has been published that shows increased survival with better neurologic outcome in patients receiving active compression-decompression CPR with augmentation of negative intrathoracic pressure. although until relatively recently. which provides the most efficient and effective ventilations. In the hospital setting. proper technique (see Technique) is essential. in the vast majority of patients who are resuscitated in the out-of-hospital setting. other health systems have begun to implement devices to monitor CPR electronically and provide audiovisual CPR feedback to providers. An Advanced Cardiac Life Support (ACLS) provider (ie. This device provides an electrical shock to the heart via 2 electrodes placed on the patient’s chest and can restore the heart into a normal perfusing rhythm.
cardiopulmonary resuscitation (CPR) comprises 3 steps: chest compressions. The chest is released and allowed to recoil completely (see the video below). If one does not feel comfortable giving ventilations. In the in-hospital setting. and breathing). Care should be taken to not lean on the patient between compressions. Chest compressions are to be delivered at a rate of 100 compressions per minute. or when a paramedic or other advanced provider is present in the out-of-hospital setting. should perform all 3 components of CPR (chest compressions. chest compressions alone are still better than doing nothing. 2008. Before beginning ventilations. compressing the chest at least 2 in. defibrillation. The techniques described here refer specifically to CPR as prescribed by the Basic Cardiac Life Support (BCLS) guidelines. Video courtesy of Daniel Herzberg. Advanced Cardiac Life Support (ACLS) guidelines call for a more robust approach to treatment of cardiac arrest. and invasive airway procedures. airway. rule out airway obstruction by looking in the patient’s mouth for a foreign body blocking the patient’s airway. Healthcare providers. The elbows are extended and the provider leans directly over the patient (see the image below). airway. fingers interlaced. CPR is initiated using 30 chest compressions. Chest compression The heel of one hand is placed on the patient’s sternum. and the other hand is placed on top of the first. CPR compressions. The provider presses down. the compressions are repeated 30 times at a rate of 100/min. with the rescuer's arms extended. Attempting to perform CPR is better than doing nothing at all. even if the provider is unsure if he or she is doing it correctly. to be performed in that order in accordance with the 2010 American Heart Association (AHA) guidelines. . as this prevents chest recoil and worsens blood flow. electrocardiographic (ECG) monitoring. For an unconscious adult. Perform the head-tilt chin-lift maneuver to open the airway and determine if the patient is breathing. With the hands kept in place. Note that artificial respirations are no longer recommended for bystander rescuers. however. lay rescuers should perform compression-only CPR (COCPR). The key thing to keep in mind when doing chest compressions during CPR is to push fast and hard. Note the overlapping hands placed on the center of the sternum. including drug interventions. This especially applies to many people’s aversion to providing mouth-to-mouth ventilations. thus. Delivery of chest compressions.Technique Overview In its full. standard for. and breathing (CAB). CPR in the presence of an airway obstruction results in ineffective ventilation/oxygenation and may lead to worsening hypoxemia.
CPR without rescue breaths). an intubated patient should receive continuous compressions while ventilations are given 8-10 times per minute. Failure to observe chest rise indicates an inadequate mouth seal or airway occlusion. compressions are restarted. health care providers use a BVM. Ventilation If the patient is not breathing. The mouth-to-mouth technique is performed as follows (see the video below): The nostrils of the patient are pinched closed to assist with an airtight seal The provider puts his mouth completely over the patient’s mouth The provider gives a breath for approximately 1 second with enough force to make the patient’s chest rise CPR ventilation. More commonly. When done properly. which forces air into the lungs when the bag is squeezed. giving the chest compressor a rest while another rescuer continues CPR). The bag is squeezed with one hand for approximately 1 second. Next. the provider delivers only the chest compression portion of care at a rate of 100/min to a depth of 38-51 mm (1-1. 2 ventilations are given via the provider’s mouth (see the image below) or a bag-valvemask (BVM). Several adjunct devices may be used with a BVM. As noted (see above). chest compressions are begun. If possible. This entire process is repeated until a pulse returns or the patient is transferred to definitive care. This delivery of compressions continues until the  arrival of medical professionals or until another rescuer is available to continue compressions. Delivery of mouth-to-mouth ventilations.) without pause. the provider checks for a carotid or femoral pulse. CPR can be quite fatiguing for the provider.5 in. When breaths are completed. The BVM or invasive airway technique is performed as follows: The provider ensures a tight seal between the mask and the patient’s face. Of note. If the patient has no pulse. high-quality CPR and prevent provider fatigue or injury. For COCPR (ie. in order to give consistent. providers should swap out. 2008. a barrier device (pocket mask or face shield) should be used. new providers should intervene every 2-3 minutes (ie. 2 such exhalations should be given in sequence after 30 compressions (the 30:2 cycle of CPR). Video courtesy of Daniel Herzberg. Effective mouth-to-mouth ventilation is determined by observation of chest rise during each exhalation. . 2 breaths are given (see Ventilation). including oropharyngeal and nasopharyngeal airways. If available. forcing at least 500 mL of air into the patient’s lungs.After 30 compressions.
bag-valve-mask [BVM]) can often result in gastric insufflation. Artificial respiration using noninvasive ventilation methods (eg. which can further lead to airway compromise or aspiration. mouth-to-mouth. which prevents air from entering the esophagus.Post-Procedure Complications Performing chest compressions may result in the fracturing of ribs or the sternum. though the incidence of such fractures is widely considered to be low. . This can lead to vomiting. The problem is eliminated by inserting an invasive airway.