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44 CPR PDF
44 CPR PDF
44 CARDIOPULMONARY
RESUSCITATION
David Shimabukuro and Linda L. Liu
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Section VI CONSULTANT ANESTHETIC PRACTICE
5
AED/defibrillator ARRIVES
6
Check rhythm
Shockable rhythm?
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Chapter 44 Cardiopulmonary Resuscitation
Upstroke
1.5 – 2"
Downstroke
Fulcrum
(hip joint)
Figure 44-2 Proper hand and body position for performance of closed-chest (external) cardiac compressions in an adult. (From
Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1999;268:2171-2295, used with permission.)
Breathing
Although several large out-of-hospital studies have
demonstrated that chest compression-alone CPR is not VI
inferior to traditional compression-ventilation CPR,
health care providers are still expected to provide assisted
ventilation.3 A lone rescuer, if not an expert in airway
management, should not use a bag-mask for ventilation,
but should use mouth-to-mouth or mouth-to-mask. Care Figure 44-3 The head tilt–jaw thrust maneuver provides a
should be taken to avoid rapid or forceful breaths. Deliv- patent upper airway by tensing the muscles attached to the
ered tidal volumes are given over 1 second and should tongue, thus pulling the tongue away from the posterior
produce visible chest rise. A lower than normal minute pharynx. Forward displacement of the mandible is accomplished
ventilation (cardiac output is much less than normal) by grasping the angles of the mandible and lifting with both
should be the goal because hyperventilation has been hands, which serves to displace the mandible forward while
proved to be detrimental for neurologic recovery. tilting the head backward.
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Section VI CONSULTANT ANESTHETIC PRACTICE
AIRWAY MANAGEMENT
Bag-mask ventilation and ventilation through an
advanced airway (endotracheal tube, supraglottic air-
way) are acceptable methods of ventilation during
CPR. Because chest compressions are not performed
during tracheal intubation, the rescuer has to weigh
the need for compressions against the need for defini-
tive airway management. Perhaps insertion of an
advanced airway should be deferred until after the
patient fails to respond to several cycles of CPR and
defibrillation. However, this decision is not always
absolutely correct. For example, a patient in severe pul-
monary edema may benefit from endotracheal intuba-
tion sooner rather than later.
With the presence of a more definitive airway, the
adequacy of ventilation should be evaluated again. The
chest should rise bilaterally and breath sounds should
be auscultated. In addition, proper positioning of the
endotracheal tube should be confirmed with a second
test to decrease false positive and false negative findings.
Capnography to measure end-tidal carbon dioxide
Figure 44-4 Schematic depiction of the proper placement of (PETCO2) is the most ideal test and is highly recommended.
paddle electrodes in an adult.
Alternative tests include pH paper (color change) and an
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ADULT CARDIAC ARREST
Shout for help/activate emergency response
CPR quality
• Push hard (≥2 inches
1 [5 cm]) and fast
Start CPR (≥100/mon) and allow
• Give oxygen complete chest recoil
• Minimize interruptions in
• Attach monitor/defibrillator compressions
• Avoid excessive ventilation
• Rotate compressor every
2 minutes
• If no advanced airway,
30:2 compression-
Rhythm ventilation ratio
• Quantitative waveform
shockable? capnography
Yes No – IF PETCO2 <10 mm Hg,
attempt to improve
CPR quality
2 9 • Intra-arterial pressure
VF/VT Asystole/PEA – If relaxation phase
(diastolic) pressure
<20 mm Hg, attempt
to improve CPR quality
3 Return of spontaneous
Shock circulation (ROSC)
• Pulse and blood pressure
• Abrupt sustained
increase in PETCO2
(typically ≥40 mm Hg)
4 • Spontaneous arterial
CPR 2 min pressure waves with
• IV/IO access intra-arterial monitoring
Shock energy
• Biphasic: manufacturer
recomendation
Rhythm No (120–200 J); if unknown,
use maximum available.
shockable? Second and subsequent
10
CPR 2 min doses should be equiva-
Yes lent, and higher doses
• IV/IO access may be considered.
5 • Epinephrine every 3–5 min • Monophasic: 360 J
Shock • Consider advanced airway,
Drug therapy
capnography • Epinephrine IV/IO dose:
1 mg every 3–5 minutes
• Vasopressin IV/IO dose:
40 units can replace
6 CPR 2 min first or second dose of
Rhythm Yes epinephrine
• Epinephrine every 3–5 min
• Consider advanced airway, shockable? • Amiodarone IV/IO dose:
First dose: 300 mg bolus
capnography No Second dose: 150 mg
11 Advanced airway
CPR 2 min • Supraglottic advanced
airway or endotracheal
• Treat reversible causes intubation
Rhythm No • Waveform capnography
shockable? to confirm and monitor
ET tube placement
Yes • 8–10 breaths per minute
with continuous chest
7 Rhythm compressions
shockable?
Shock
No Yes Reversible causes
– Hypovolemia
– Hypoxia
VI
12 – Hydrogen ion (acidosis)
– Hypo-/hyperkalemia
8 • If no signs of return of Go to 5 or 7 – Hypothermia
CPR 2 min spontaneous circulation – Tension pneumothorax
• Amiodarone (ROSC), go to 10 or 11 – Tamponade, cardiac
• Treat reversible causes – Toxins
• IF ROSC, go to – Thrombosis, pulmonary
Post-Cardiac Arrest Care – Thrombosis, coronary
Figure 44-5 Resuscitation algorithm for pulseless arrest. cm, centimeter; ET, endotracheal; IO, intraosseus; IV, intravenous; J, joules;
mg, milligram; min, minute; mm Hg, milliliters of mercury; PEA, pulseless electrical activity; PETCO2, partial pressure of end-tidal
carbon dioxide; VF, ventricular fibrillation; VT, ventricular tachycardia. (From Neumar RW, Otto CW, Link MS, et al. Part 8: Adult
Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines and Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, Circulation 122:S736, 2010.)
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Section VI CONSULTANT ANESTHETIC PRACTICE
Dopamine IV infusion:
6 2–10 mcg/kg per minute
Consider:
• Expert consultation Epinephrine IV infusion:
• Transvenous pacing 2–10 mcg per minute
esophageal detector device (EDD). An EDD involves using available, tube placement should be checked periodically,
a bulb suction that is attached to the end of the endotra- especially during prolonged resuscitation.
cheal tube once the bulb is compressed. If the endotra-
cheal tube is in the trachea, the bulb quickly inflates MEDICATIONS
with air in the lungs because the tracheal rings are stiff Establishing intravenous access is important, but it
and do not collapse around the tube. If the endotracheal should not interfere with CPR and defibrillation. A large
tube is in the esophagus, the esophageal walls, which peripheral venous catheter is sufficient in most resuscita-
are pliable, collapse around the end of the endotracheal tions of pulseless patients. Drugs should be administered
tube, and the bulb remains in the compressed state. Once rapidly and followed with a 20-mL fluid bolus if given
the endotracheal tube is confirmed to be in the trachea, it peripherally. If intravenous access cannot be obtained
should be secured in place. One breath should be deliv- or is lost, certain drugs (epinephrine, lidocaine, vasopres-
ered every 6 to 8 seconds without synchronization with sin, atropine, naloxone) can be given via the endotra-
compressions. Failed resuscitation may reflect poor chest cheal tube. The endotracheal tube dose is 2 to 10 times
compressions or migration of the endotracheal tube out the recommended intravenous dose, and the drug should
of the trachea. Continuous monitoring of PETCO2 can be be diluted in 5 to 10 mL of sterile water before instillation
extremely beneficial during the resuscitation. Although down the endotracheal tube. A preferable alternative
values have not been correlated with ROSC, it does guide to the intravenous route is the intraosseus route. Kits
the rescuers in adequacy of pulmonary blood flow. If are now commercially available to rapidly place these
continuous end-tidal carbon dioxide monitoring is not lines. No dose changes are required from the IV route.
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Chapter 44 Cardiopulmonary Resuscitation
Figure 44-7 Resuscitation algorithm for tachycardia with a pulse. CHF, congestive heart failure; ECG, electrocardiogram; IV,
intravenous; J, joules; kg, kilogram; min, minute; mg, milligram; NS, normal saline; VT, ventricular tachycardia. (From Neumar RW, Otto
CW, Link MS, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines and
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation 122:S751, 2010.)
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Section VI CONSULTANT ANESTHETIC PRACTICE
cardiac rhythms have been combined as the second part of reversible causes, and establishing an advanced airway.
the pulseless arrest algorithm because of similarities A vasopressor may be administered after initiation of
in their management (see Fig. 44-5). Neither will benefit CPR. Epinephrine, 1 mg IV, may be given every 3 to 5
from defibrillation, so the focus should be on performing minutes. Alternatively, a single dose of vasopressin, 40
effective CPR with minimal interruptions, identifying units IV, may replace either the first or second dose of
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Chapter 44 Cardiopulmonary Resuscitation
Table 44-2 Major Causes of Cardiovascular Collapse in A trial of adenosine before cardioversion can be consid-
the Perioperative Period ered in select cases of unstable regular narrow-complex
tachycardia. In stable patients with fast ventricular rates,
8 Hs 8 Ts determining whether the underlying rhythm has a narrow
Hypovolemia Toxins (anaphylaxis/ or wide QRS complex (>0.12 second) on the electro-
anesthesia) cardiogram is important. Patients with asymptomatic
Hypoxia Tamponade tachycardias, especially those with wide-complex tachy-
cardias, should be evaluated by a consultant to help
Hydrogen ion (acidosis) Tension pneumothorax
determine whether the rhythm is ventricular or atrial in
Hyperkalemia/ Thrombosis in coronary artery origin. Treatment should be guided by the consultant’s
hypokalemia opinion, which often can include the use of antidysrhyth-
Hypoglycemia Thrombus in pulmonary artery mic medication or atrioventricular (AV) nodal blocking
drugs. If the rhythm is an irregular narrow-complex
Hypothermia Trauma
tachycardia, the underlying rhythm is probably atrial
Malignant QT interval prolongation fibrillation, and heart rate control should be attempted
hyperthermia with AV nodal blocking drugs. If the rhythm is a regular
Hypervagal response Pulmonary hypertension narrow-complex tachycardia, conversion back to sinus
rhythm should be attempted by vagal maneuvers or the
Adapted from the 5 Hs and 5 Ts proposed by the American Heart administration of adenosine, or both. Cardiac rhythm
Association (AHA).
conversion signifies probable reentry supraventricular
epinephrine. Atropine has been removed from the algorithm tachycardia, and recurrence can be treated with adeno-
because studies show that routine use of atropine is unlikely sine or longer-acting AV nodal blocking drugs. If cardiac
to provide any benefit. Cardiac rhythm checks should be rhythm conversion does not occur, the underlying
performed after every five cycles or 2 minutes of CPR. If an rhythm is possibly atrial flutter or junctional tachycardia.
organized cardiac rhythm is present, the rescuer should check In this case, effort should be made to achieve rate control
for a pulse. If there is no pulse, CPR should be continued. If a with the use of AV nodal blocking drugs.
pulse is present, the rescuer should identify the rhythm and
treat accordingly. Given the poor survival and neurologic ADULT ADVANCED CARDIOVASCULAR LIFE
recovery rates of patients in asystole, the length and effort SUPPORT: DRUG THERAPY (Also See
of resuscitation should be carefully considered. Chapter 7)
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Section VI CONSULTANT ANESTHETIC PRACTICE
pressure and therefore increase coronary perfusion pres- the same algorithm as for adults: C-A-B. Naturally, there
sure with restoration of blood flow to the myocardium. are several specific differences between adult and pediatric
Given its relatively long half-life, it is recommended that patients because children are much smaller. For the health
vasopressin be given only once during the resuscitation care provider, infants are considered to be younger than
of a pulseless patient. 1 year, whereas children are considered to be between 1 year
There are no significant differences in rates of hospital old and adolescence. Adult BLS resuscitation guidelines can
admission or survival between patients with out-of- be used for adolescent children (Table 44-3).
hospital arrest who receive vasopressin or epinephrine.
When compared with epinephrine in patients with asystole,
Airway
vasopressin is associated with more frequent hospital
admission and hospital discharge rates, but not neurologi- The airway of pediatric patients is slightly different
cally intact survival.5 A recent study has shown no from that of an adult, but head tilt–chin lift is still the tech-
improvement in hospital admissions with the addition of nique of choice to open the airway. Children tend to have a
vasopressin to epinephrine during asystole.6 Because the larger tongue and epiglottis in relation to the mouth and
effects of vasopressin and epinephrine in patients with car- larynx. In addition, they have a larger head in relation to
diac arrest are not significantly different, one dose of vaso- the body. Over extension or excessive flexion of the head
pressin may substitute for either the first or second dose of can lead to difficulty visualizing the glottic opening during
epinephrine in the treatment of pulseless cardiac arrest. direct laryngoscopy. Straight laryngoscope blades may be
preferred over curved blades to lift the epiglottis anteriorly
and away from the glottic opening in young children.
Amiodarone
Amiodarone was initially developed as an antianginal
Circulation
drug in the 1950s but was abandoned because of its side
effects. Because it has effects on cardiac sodium and potas- Pulse checks and closed chest compressions are performed
sium channels, as well as a- and b-receptors, amiodarone slightly differently, depending on whether the patient is
has been reinvestigated for its antiarrhythmic effects. In a child or an infant. In children, the pulse is palpated at
this regard, amiodarone prolongs repolarization and the carotid or femoral artery, similar to adults. In infants,
refractoriness in the sinoatrial node, the atrial and ventri- the pulse is checked at the brachial or femoral artery.
cular myocardium, the AV node, and the His-Purkinje car-
diac conduction system. Amiodarone can exacerbate or
External Compressions
induce arrhythmias, especially torsades de pointes. This
drug may interact with volatile anesthetics to produce In a child, the heel of one or both hands should be placed
heart block, profound vasodilation, myocardial depres- on the lower half of the sternum, between the nipples,
sion, and severe hypotension. It has many drug interac- while keeping the fingers off the rib cage and staying
tions, and can prolong the effects of oral anticoagulants, above the xiphoid process. In an infant, chest compressions
phenytoin, digoxin, and diltiazem. Despite its multiple are delivered via the two-finger technique. Two fingers of
disadvantages, amiodarone has been shown in adults with one hand are placed over the lower half of the sternum
out-of-hospital VF/VT arrest to improve survival to approximately one fingerwidth below the intermammary
hospital admission when compared with placebo and lido- line while keeping above the xiphoid process. For both
caine.7,8 The recommended dose of amiodarone for VF/VT infants and children, the sternum should be depressed at
is 300 mg IV. An additional dose of 150 mg IV may be least one third to one half the anterior-posterior diameter
given for persistent VF/VT. of the chest at a rate of at least 100 compressions per
minute. The pattern should be 30 compressions to 2 breaths
(30:2) if there is a single rescuer and 15 compressions to
PEDIATRIC ADVANCED LIFE SUPPORT 2 breaths (15:2) if there are two rescuers.
(Also See Chapter 34)
Defibrillation
Resuscitation of infants and children follows the same basic
principles as those for adults. It is important to remember In children, defibrillation should be performed when a
that most pediatric cardiac events are a result of arterial pulseless rhythm (VT, VF) is present. An initial energy
hypoxemia and respiratory compromise, and thus, airway of 2 to 4 J/kg should be attempted, regardless of the
management and breathing are critical to successful pediat- waveform type. Subsequent defibrillations should be at
ric resuscitation. In contrast, adults tend to experience car- least 4 J/kg, but should not exceed 10 J/kg. Biphasic
diac arrest as a result of VT or VF secondary to myocardial automated external defibrillators can be used in children
ischemia. Defibrillation is the more important early inter- older than 1 year outside the hospital setting. American
vention in these cases. Regardless, pediatric BLS follows Heart Association guidelines recommend the use of a
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Chapter 44 Cardiopulmonary Resuscitation
Table 44-3 Comparative Resuscitation Techniques between Adults, Children, and Infants (Summary of Key BLS
Components for Adults, Children, and Infants*)
Recommendations
Component Adults Children Infants
Unresponsive (for all ages)
Recognition No breathing or no normal
No breathing or only gasping
breathing (i.e., only gasping)
No pulse palpated within 10 seconds for all ages (HCP only)
CPR sequence C-A-B
Compression rate At least 100/min
Compression depth At least 2 inches (5 cm) At least 1/3 AP diameter At least 1/3 AP diameter
About 2 inches (5 cm) About 11/2 inches (4 cm)
Chest wall recoil Allow complete recoil between compressions
HCPs rotate compressors every 2 minutes
Compression interruptions Minimize interruptions in chest compressions
Attempt to limit interruptions to <10 seconds
Airway Head tilt – chin lift (HCP suspected trauma: jaw thrust)
Compression-to-ventilation 30:2 (Single rescuer)
ratio (until advanced airway 30:2 (1 or 2 rescuers)
placed) 15:2 (2 HCP rescuers)
Ventilations: when rescuer
untrained or trained and not Compressions only
proficient
Ventilations with advanced 1 breath every 6–8 seconds (8–10 breaths/min)
airway (HCP) Asynchronous with chest compressions
About 1 second per breath
Visible chest rise
Defibrillation Attach and use AED as soon as available. Minimize interruptions in chest compressions before
and after shock; resume CPR beginning with compressions immediately after each shock.
AED, automated external defibrillator; AP, anterior-posterior; CPR, cardiopulmonary resuscitation; HCP, healthcare provider.
*Excluding the newly born, in whom the etiology of an arrest is nearly always asphyxial.
(From Hazinski MR, ed. Highlights of the 2010 American Heart Association Guidelines for CPR and ECC, 2010, p 8)
pediatric dose attenuator system that will decrease the supportive treatment (Fig. 44-8).9 Postcardiac arrest care
amount of delivered energy. If one is not available, a should be focused to optimize cardiopulmonary function
standard external defibrillator can be substituted. to ensure organ perfusion is adequate. It should be consis-
tent, integrated, and multidisciplinary. When possible,
Drugs therapies are administered concurrently. Specifically, percu-
taneous coronary interventions (PCI) should not be delayed
Most drug dosages are calculated by using current known
weight or ideal body weight based on height. Most pedi-
to institute hypothermia, and the institution of hypothermia VI
should not delay PCI. Often, vasopressors and inotropes
atric units have resuscitation carts divided by weight to
need to be administered during the immediate postresuscita-
facilitate drug administration in an emergency so that
tion period because of the presence of myocardial stunning
calculations do not need to be performed and valuable
and hemodynamic instability. Central venous access for
time is not wasted.
drug administration may be necessary, along with an intra-
arterial catheter to facilitate hemodynamic monitoring.
POSTRESUSCITATION CARE In addition to cardiac recovery, neurologic recovery is of
vital importance. This is especially true during the immedi-
After successful resuscitation with return of spontaneous ate postresuscitation phase. Hypothermia protocols should
circulation, patients should be admitted to the intensive be established to facilitate institution. Consequently, due
care unit (if not already there) for further definitive and to the widespread use of mild hypothermia, traditional
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Section VI CONSULTANT ANESTHETIC PRACTICE
1
Doses/details
Return of spontaneous circulation (ROSC)
Ventilation/oxygenation
2 Avoid excessive ventilation.
Start at 10–12 breaths/min
Optimize ventilation and oxygenation and titrate to target PETCO2
• Maintain oxygen saturation ≥94% of 35–40 mm Hg.
• Consider advanced airway and waveform capnography When feasible, titrate FIO2
• Do not hyperventilate to minimum necessary to
achieve SpO2 ≥94%.
3
IV bolus
Treat hypotension (SBP <90 mm Hg) 1–2 L normal saline
• IV/IO bolus or lactated Ringer’s.
• Vasopressor infusion If inducing hypothermia,
• Consider treatable causes may use 4°C fluid.
• 12-lead ECG
Epinephrine IV infusion:
4 0.1–0.5 mcg/kg per minute
5 (in 70-kg adult: 7–35 mcg
No Follow
Consider induced hypothermia per minute)
commands?
Yes Dopamine IV infusion:
6 5–10 mcg/kg per minute
7
Yes STEMI
Coronary reperfusion OR Norepinephrine
high suspicion of AMI IV infusion:
0.1–0.5 mcg/kg per minute
No (in 70-kg adult: 7–35 mcg
8 per minute)
Advanced critical care
Reversible causes:
– Hypovolemia
– Hypoxia
– Hydrogen ion (acidosis)
– Hypo-/hyperkalemia
– Hypothermia
– Tension pneumothorax
– Tamponade, cardiac
– Toxins
– Thrombosis, pulmonary
– Thrombosis, coronary
Figure 44-8 Algorithm for postcardiac arrest care. AMI, acute myocardial infarction; C, centigrade; ECG, electrocardiogram; FIO2, fraction
of inspired oxygen; IO, intraosseous; IV, intravenous; kg, kilogram; L, liters; mcg; microgram; min, minute; mm Hg, millimeters of mercury;
PETCO2, partial pressure of end-tidal carbon dioxide; SBP, systolic blood pressure; SpO2, pulse oximeter oxygen saturation; STEMI, ST-
elevation myocardial infarction. (From Peberdy M, Callaway CW, Neumar RW, et al. Part 9: Post Cardiac Arrext Care: 2010 American Heart
Association Guidelines and Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation 122:S769, 2010.)
means to determine neurologic prognosis in patients who as inability to follow verbal commands) patients who are
have been cooled have not been validated and should be successfully resuscitated from out-of-hospital VF/VT arrest
interpreted accordingly. to 32 C to 34 C for the first 12 to 24 hours. Hypothermia
has not been well studied in patients with an initial rhythm
of asystole or PEA. However, given recent technologic
Mild Hypothermia
advances in cooling patients quickly and easily, mild hypo-
Temperature should be monitored closely, and hyper- thermia has been expanded to all comatose patients follow-
thermia should be avoided at all times. Mild hypothermia ing return of spontaneous circulation regardless of the
for the first 24 to 48 hours may be beneficial to the neuro- initial pulseless rhythm and whether it occurred out of hos-
logic recovery of patients after out-of-hospital VF/VT pital or in hospital.12 Warming is allowed to occur passively
arrest.10,11 Recommendations are to cool comatose (defined unless it is beyond the 48-hour window.
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Chapter 44 Cardiopulmonary Resuscitation
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Section VI CONSULTANT ANESTHETIC PRACTICE
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