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C a rd i o p u l m o n a r y Resuscitation Update

Joshua C. Reynolds, MDa, Michael C. Bond, Sanober Shaikh, MDa
KEYWORDS  Cardiopulmonary resuscitation  Cardiac arrest  Chest compression


Based on extensive research into means of lowering the morbidity and mortality associated with cardiac arrest, the American Heart Association (AHA) drastically revised its guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care in 2010. The AHA no longer recommends rescue breathing or pulse checks by untrained laypeople or, for trained responders, the interruption of chest compressions to check the victim’s pulse. Instead, emphasis is placed on the delivery of high-quality chest compressions and early defibrillation. Even medications (eg, epinephrine and atropine) are no longer emphasized, because they have not been shown to improve outcomes. This article summarizes the AHA 2010 guidelines for CPR and emergency cardiovascular care with a discussion of the science supporting these recommendations; in certain instances, additional recommendations beyond that of the AHA are made (Table 1). The old mantra of “A-B-C” (airway, breathing, and circulation) has been replaced by “C-A-B” (circulation, airway, and breathing). Delay in the start of chest compressions is minimized by placing circulation first. Individuals who are fearful of performing rescue breathing are more likely to start the resuscitation process if they only have to do chest compressions.1 The “C” in “CAB” is further delineated by the four “Cs” of cardiac arrest care: (1) chest compressions; (2) cardioversion and defibrillation; (3) cooling (ie, postarrest therapeutic hypothermia); and (4) catheterization (ie, early catheterization for all patients who have had a cardiac arrest, regardless of whether ST segment elevation is evident on their electrocardiogram).

Circulation, specifically, high-quality chest compressions, is the most critical portion of CPR. Chest compressions augment the cardiocerebral circulation, and any interruption in them decreases the likelihood of favorable neurologic outcomes. Cardiocerebral
Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, MD, USA Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA * Corresponding author. 110 South Paca Street, Suite 200, 6th Floor, Baltimore, MD 21201. E-mail address:
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Emerg Med Clin N Am 30 (2012) 35–49 doi:10.1016/j.emc.2011.09.006 0733-8627/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved.

100 compressions/min at a depth of at least 2 inches. For symptomatic or unstable bradycardia. chest compressions should be performed. Postcardiac arrest care in those who have not returned to a normal mental status should include the initiation of therapeutic hypothermia to optimize neurologic recovery. it should be used only to improve visualization of the vocal cords. patients suspected of having acute coronary syndrome should be transported to a facility with reperfusion capabilities. intravenous infusion of chronotropic drugs is now recommended as an equally effective alternative to external pacing when atropine is not effective. Circulation is to be addressed first with the initiation of chest compressions. In the field. Push Fast (high-quality CPR is emphasized) Hands-only CPR for the untrained lay rescuer ACLS Should follow all of the BLS recommendations listed above. Postresuscitation therapeutic hypothermia Cardiac catheterization .36 Reynolds et al Table 1 Major changes of the 2010 AHA cardiopulmonary resuscitation guidelines BLS Change No pulse checks Explanation If the patient is unresponsive and has no breathing or abnormal breathing. A new Class 1 recommendation for all adults who are intubated is that they have continuous quantitative waveform capnography for confirmation and monitoring of endotracheal tube placement. Instead. Atropine removed from asystole/PEA Atropine is no longer recommended for routine use in the management of asystole and PEA arrest. “ABC” becomes “CAB” Push Hard. Compression:ventilation ratio of 30:2 should be maintained after the first round of 30 chest compressions. The routine use of cricoid pressure during the placement of an endotracheal tube is no longer recommended. Hands-only CPR is easier to perform for those with no training and eliminates the reluctance that individuals may have with rescue breathing. End-tidal carbon dioxide monitoring of all intubated patients Cricoid pressure is no longer recommended for routine use Routine use of chronotropic drugs is recommended for bradycardia. Patients with return of spontaneous circulation should be considered for urgent cardiac catheterization regardless of whether there is ST-segment elevation on their postresuscitation electrocardiogram.

humming. It emphasizes chest compressions over ventilation in patients thought to have had an arrest from a cardiac cause. decreased coronary perfusion pressure.28 Place the heel of one hand on the lower half of the sternum. emergency care providers have been trained to check for a carotid or femoral pulse.18 Compression Technique Chest compressions restore partial circulation to the heart and brain by building up and maintaining coronary and cerebral perfusion pressure. Hyperventilation and pauses in compressions to administer rescue breathing impair cardiocerebral blood flow and are associated with increased morbidity and mortality rates (discussed later).19 The perfusion of these two organs is critical to short-term and meaningful long-term survival. or listening to the Bee Gees’ song “Stayin’ Alive” improved compliance with the 100-compressions-perminute recommendation.45 . The ideal components of effective chest compressions and alternative methods of delivering them are discussed next. Patients who have an in-hospital cardiac arrest are usually on a bed or stretcher.9. and the chest should re-expand completely before the next compression.5. Compression time and recoil time should be equal. cardiac index. Matlock demonstrated that singing. and the mattress absorbs a significant amount of the force delivered. and cerebral perfusion). air-filled mattresses should be deflated before starting compressions. but this scenario is not common in adults.7–16 and the search can become a lengthy process.23–26 If possible. Healthcare providers should spend a maximum of 10 seconds searching for a pulse. the rescuer should stand beside the bed at the level of the patient’s torso. myocardial blood flow. if a definitive and reliable pulse is not detected.43 The total number of compressions per minute is a predictor of return of spontaneous circulation (ROSC) and neurologically intact survival.5. Placing a firm backboard between the patient and the mattress minimizes this loss.2–5 In patients who have experienced a primary pulmonary arrest. with the heel of the opposite hand over top of the first.Cardiopulmonary Resuscitation Update 37 resuscitation represents a comprehensive strategy to maximize circulation.21 but it is imperative that they be performed with the highest degree of perfection possible. Inadequate recoil results in higher intrathoracic pressure and an impaired hemodynamic profile (ie.6 Pulse Check Assessment of circulation traditionally begins with a pulse check.17. This technique helps ensure adequate recoil.37–41 During the upstroke of compressions.44. The recommended position in out-of-hospital scenarios is to kneel perpendicular beside the patient’s torso. For many years.20. because those pulses are closest to the central circulation and should be palpable at lower arterial blood pressures. rescue breathing should commence as soon as possible.42 The recommended raw rate for compression delivery is at least 100 compressions per minute.18.39.29–32 In adults. Even seasoned healthcare providers have difficulty reliably discerning the presence of a pulse. depress the sternum at least 2 inches33–36 and allow proper recoil before the next compression. the hands should be slightly removed from the chest wall.27.12 Laypersons are now instructed not to check for a pulse but to focus instead on evaluating the person for other signs of life.22 For in-hospital cardiac arrest response. They should assume that a person is in cardiac arrest if he or she is unresponsive and breathing abnormally. Chest compressions are deceptively difficult to deliver correctly. they should begin chest compressions immediately. Proper positioning of the patient and rescuer is fundamental to proper compression delivery.

Compressions should not be stopped to check the patient’s pulse unless there is some other evidence of ROSC. However.2. such as an increase in the patient’s oxygenation level.46–50 The general guideline is a ratio of 30:2 (compressions:ventilations) in adults. compressions were continued while the defibrillator was charging. the average hands-off time was 11. the average hands-off time was only 3. However.51–56 If an advanced airway management device is in place.64 Pulse checks should be limited to 10 seconds.57–60 Interruptions are common and can consume 24% to 57% of the total resuscitation time. Measuring EtCO2 is an easy.61 Adequate coronary perfusion washes out inflammatory mediators and renews myocardial energy substrates.57–60 Even the interruption in compressions while preparing for defibrillation results in a drop-off of coronary perfusion pressure. as recommended by the current AHA guidelines. Chest compressions restore adequate coronary perfusion pressure. charging the defibrillator. analyzing the heart rhythm. if appropriate. This time could be further reduced if the providers immediately resumed compressions after rhythm analysis. even after successful defibrillation. In accordance with the AHA guidelines. Advanced airway management accounts for almost 25% of all interruptions. because ROSC is not instantaneous. if the defibrillator was charged in anticipation of shocking the patient.5 seconds.61 Edelson and colleagues66 reported that the traditional method of stopping compressions.9 seconds.44 Even a brief pause in compressions results in a dramatic drop-off in coronary and cerebral perfusion pressures.8 seconds. and then compressions were held for rhythm analysis and immediate shock delivery.5.67. as measured by pulse oximetry or end tidal carbon dioxide (EtCO2) measurement. Barriers to Delivering Effective Chest Compressions Every effort should be made to minimize interruptions in chest compressions.001). an advanced airway device should be inserted and used to provide ventilations only after the patient has received 2 to 3 minutes of chest compressions and attempted defibrillation. Several studies have shown that it is completely safe for a rescuer wearing standard examination gloves to continue chest compressions during use of a biphasic defibrillator with self-adhesive pads.62. respectively. and then delivering the shock to the patient resulted in an average hands-off time of 14. so every effort should be made to transition seamlessly into defibrillation. Chest compressions should be continued through defibrillation or resumed immediately afterward without a postshock pulse check.21. then two providers can perform a combination of uninterrupted compressions and intermittent ventilations. Pokorna and colleagues65 showed that individuals with ROSC had a mean increase of 10 mm Hg on EtCO2 readings compared with cardiac arrest victims who did not survive (P<.20.2.38 Reynolds et al The best outcomes have been achieved in patients who received 68 to 89 compressions per minute after out-of-hospital arrest and at least 80 compressions per minute after in-hospital cardiac arrest. which are far less than the occupational and medical electrical safety .63 Maintaining perfusion pressure to cerebral tissue is also vital because of the brain’s extreme sensitivity to ischemic injury. noninvasive way to monitor for ROSC without the need to interrupt chest compressions.68 Lloyd and colleagues67 reported that the average and maximal current leakages were 280 and 900 mA. Typical advanced cardiac life support (ACLS) interventions result in numerous pauses in chest compressions.44 The recommended compression-to-ventilation ratio is based on expert consensus and one case series. with a median duration of almost 2 minutes. When compressions were stopped only during the rhythm analysis and shock delivery. but they must be truly continuous if they are to reach a threshold for successful defibrillation and resuscitation.

Rescuer fatigue is another pitfall in delivering high-quality. because blood oxygen levels usually remain adequate for several minutes after a cardiac arrest from a nonrespiratory cause. Agonal gasping and chest wall recoil may provide some amount of passive ventilation and oxygenation during handsonly CPR. Hands-only CPR removes many of the barriers to delivering effective chest compressions. who are often reluctant to perform mouth-to-mouth resuscitation for fear of acquiring a communicable disease.85 The first provider performs conventional chest compressions. intraoperatively) or cardiac arrest occurs soon after thoracotomy or laporatomy.72. This simplified version of conventional CPR is easier for laypersons.70 Providers delivering chest compressions should rotate every 2 minutes to minimize the effects of rescuer fatigue. Yu and colleagues68 demonstrated that these currents can be reduced further by the use of a resuscitation blanket. Case series of open-chest CPR for nontraumatic cardiac arrest in inpatients after cardiac surgery82–84 and out-of-hospital cardiac arrest83–86 revealed improved coronary perfusion pressure and ROSC compared with conventional (closed-chest) CPR. After just 1 minute of performing CPR. The third provider delivers intermittent . One technique to minimize the interruption is to position a rescuer on either side of the patient for more seamless transitions.74–78 Alternative CPR Techniques Many alternative techniques of CPR have been documented in the literature. continuous chest compressions. the depth of compressions is compromised.71 The performance of hands-only CPR allows the rescuer to focus solely on compression technique.73 Hands-only CPR has better patient outcomes than no CPR and outcomes similar to those achieved with conventional CPR.40. High-frequency chest compressions are delivered at a rate exceeding 120 per minute but are otherwise similar to conventional chest compressions. Rescuers tend not to recognize their own fatigue until after approximately 5 minutes of CPR.81 There is insufficient evidence to recommend the routine use of this technique. IAC requires three providers and involves alternating chest compressions with abdominal compressions. The fear of rescuers being shocked dates back to the use of older monophasic defibrillators. Incomplete recoil further compromises coronary perfusion pressure and adversely increases intrathoracic pressure. while the second compresses the abdomen with similar hand position and depth midway between the xiphoid process and umbilicus during chest wall recoil.69 A shallow depth not only fails to generate adequate coronary perfusion pressure but also leads to inadequate chest recoil. Ventilations are often not necessary during the first few minutes of resuscitation.80. recent studies demonstrate that this risk is not present with the newer biphasic defibrillators. Interposed abdominal compression (IAC) is another strategy that has been proposed to increase cardiocerebral perfusion. but it may be used if the chest is already open (ie.79 Two clinical trials demonstrated improved hemodynamic profiles generated by rapid compressions but not improved patient outcome. There is insufficient evidence to recommend routine use of this technique.1 The acceptable duration is not known. Hands-only CPR Minimizing interruptions in chest compressions is paramount to restoring circulation to the heart and brain. and the switch should take less than 5 seconds. Open-chest CPR with direct cardiac massage is typically used after cardiac arrest from a traumatic chest injury. with mixed evidence of effectiveness.Cardiopulmonary Resuscitation Update 39 standards for medical equipment.

88 The only published complication of IAC CPR is traumatic pancreatitis in a child. The AHA did not adopt this practice in the . stroke. which is used to mechanically stun the myocardium to convert a ventricular tachyarrhythmia into a perfusable rhythm. Several case reports and small case series have documented successful resuscitation with this technique. Two randomized controlled trials (by the same author) of in-hospital cardiac arrest demonstrated improved survival compared with conventional CPR. IAC improves the diastolic aortic pressure and venous return. However.98–100 The precordial thump technique is not recommended for unwitnessed cardiac arrests. An external study to validate the findings of the two original studies is needed before this technique can be recommended for routine use. uninterrupted manual chest compressions are feasible during shock delivery. In the past. but there is insufficient evidence to support its routine use. which results in higher coronary perfusion pressure. given the need to prevent electrocution of the rescuer during shock delivery.112. studies have affirmed that it is extremely safe to continue compressions during defibrillation when a biphasic defibrillator is used with self-adhesive electrodes and the rescuer wears standard examination gloves. despite voltage delivery during the compressions.67.114 Every minute that a patient remains in VF/pulseless VT arrest decreases the chance of survival by 10%.68 The simulated rescuers in these studies perceived no electrical charge. Therefore. is essentially rhythmic percussion of the chest wall with a fist to pace the myocardium. osteomyelitis. The most frequent initial rhythm in out-of-hospital witnessed SCA is ventricular fibrillation (VF). and adverse arrhythmias.20 Patients who receive early defibrillation have a higher likelihood of survival and of return to their prearrest quality of life. an extension of the precordial thump. hands-off time during defibrillation was thought to be unavoidable.89 This technique could be considered for victims of in-hospital cardiac arrest if a sufficient number of trained providers are present.90 Case reports and case series demonstrate mixed effectiveness for this maneuver.86. Chest compressions increase the myocardial readiness for the defibrillation by delivering oxygen and metabolic substrates. without risk of harm to the rescuer. monitored. but it may be considered for witnessed.111 CPR Before Defibrillation The rate of survival-to-hospital discharge is higher among patients who experienced an unwitnessed SCA and received 1. typically via an advanced airway management device. early defibrillation is imperative.5 to 3 minutes of CPR followed by defibrillation.101–107 DEFIBRILLATION Early defibrillation is critical to survival after sudden cardiac arrest (SCA).1 Percussion pacing. unstable ventricular tachycardia (VT) if a defibrillator is not immediately available and if it does not delay conventional resuscitation.87 but a randomized controlled trial of out-of-hospital cardiac arrest patients showed no benefit with this technique.90–100 It has been associated with sternum fracture. and the chance of successful defibrillation diminishes rapidly over time.108–110 ACLS protocols continue to stress the importance of early defibrillation for the unstable rhythms of VF and pulseless VT.40 Reynolds et al ventilation. CPR should be performed while the defibrillator is being prepared.115 Hands-on Defibrillation Minimizing interruptions during chest compressions improves the likelihood of ROSC.113 In witnessed SCA. A precordial thump is a forceful striking of the anterior chest wall.

Details about airway management in the cardiac arrest patient are beyond the scope of this article but are presented elsewhere in this issue. Relevant AHA recommendations are summarized next116: 1. the oxygen reserve tends to be adequate. as evidenced by an increase of more than 10 mm Hg in the patient’s EtCO2 level. so giving priority to ventilation lowers the survival rate. however. 2. The routine use of cricoid pressure is no longer recommended. in addition to clinical assessment. the use of 100% oxygen is reasonable during initial resuscitative efforts.120–123 Cricoid pressure should be reserved for helping to visualize the vocal cords during endotracheal intubation. Chest compressions cause air to be expelled during the compression phase and oxygen to be passively drawn into the chest during the recoil phase. The pulse and rhythm can be checked at the next 2-minute interval. If advanced airway placement interrupts chest compressions. the myocardium is probably stunned and unable to generate adequate perfusion pressures.Cardiopulmonary Resuscitation Update 41 2010 guidelines. Higher ventilations rates. poor cardiocerebral oxygenation is caused by decreased perfusion. it is recommended that a tidal volume of approximately 600 mL be delivered over 1 second at a rate of 8 to 10 times per minute. In this scenario. Compressions support and maintain adequate perfusion. or respiratory failure). but future iterations might recommend interruption of chest compressions solely for the purpose of rhythm analysis. which are common during resuscitation. the passive inhalation of oxygen via a nonrebreather facemask is likely to be sufficient for several minutes after the onset of SCA in patients who have a patent airway. AIRWAY AND BREATHING The current AHA basic life support and ACLS guidelines have repositioned airway and breathing below circulation for individuals who have experienced SCA from a cardiac cause. The application of this pressure does not decrease the risk of aspiration117–119 and impedes ventilation. for patients who have experienced SCA from a pulmonary cause (eg. In the early stages of SCA. the airway and breathing should be restored as quickly as possible. compressions should be continued throughout the defibrillation and stopped only to relieve a tired rescuer or for a rhythm check before the next defibrillation attempt. Capnography also has the benefit of alerting the providers to ROSC. Ventilations should be provided every 6 to 8 seconds (8–10 breaths per minute). Therefore. 5. It is unknown whether administration of 100% inspired oxygen is beneficial to people who have sustained SCA. Pulse Check After Defibrillation Compressions should be resumed immediately after defibrillation. Even if the patient is successfully converted out of VF/VT. Therefore. in whom oxygen reserve is likely depleted. The patient’s rhythm and pulse should not be checked after defibrillation. drowning. there is no evidence that it causes harm in short-term resuscitation. insertion of the airway can be delayed until the patient fails to respond to initial CPR or defibrillation attempts or demonstrates ROSC. can increase . Continuous waveform capnography. 6. 4. Bag-mask ventilation can be challenging to perform correctly and is best done by two trained rescuers. is the most reliable method of confirming and monitoring correct placement of an endotracheal tube. Ideally. However.65 7. 3. If this technique is used. choking. not decreased ventilation or oxygenation.

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