Cardiopulmonary Resuscitation Chaiyanfen Tianjin Medical University General Hospital Department of Emergency Medicine
At the end of the course the student will be able to
1.Define the sudden cardiac arrest, the clinical death and biologic death. CPR defination
2.Master the cardiopulmonary cerebral resuscitation skill, procedure and the method of BLS.
3.Know the complication of CPR.
4.Know the chain of survival .
3.Complications of CPR
4.Monitoring during CPR
1. CPR definition
2.History of CPR
3.Anatomy and function of the circulatory system
5.The chain of survival
CPR is a technique through mechanical, physiologic and pharmacologic methods to resuscitate the individuals in sudden unexpected death resulting from reversible disease.
The purpose of CPR is
To temporarily provide effective oxygenation of vital organs (especially the brain and heart) until appropriate, definitive medical treatment
There are three goals of resuscitaition
① Basic life support, providing temporary perfusion of vital tissues.
② Restoration of spontaneous cardiac and respiratory activity and establishment of circulatory self-sufficiency.
③ Correction of the underlying disease, while supporting and protecting all organs and assisting them in recovery to as near prearrest state as possible.
CPR is a key part of emergency medicine.
History of CPR
The history of CPR and cerebrial arrest prophylaxis begins in ancient times.
5000 -first artificial mouth to mouth ventilation in 3000 BC
1780 – first attempt of newborn resuscitation by blowing
1874 – first experimental direct cardiac massage
1901 – first successful direct cardiac massage in man
1946 – first experimental indirect cardiac massage and defibrillation
1960 – indirect cardiac massage
1980 – development of cardiopulmonary resuscitation due to the works of Peter Safar
History of CPR Inversion method Silvester’s method of artificial Ventilation
History of CPR
History of CPR
There were no immediately effective emergency resuscitation techniques available before 1950s.
Modern respiratory resuscitation was pioneered in 1950s
safar opening airway 1958,
Elam mouth to mouth breath, ),
Modern circulatory resuscitation in the 1960s Kouwenhoven ECC,1960 ,
Therapeuticall promising reseach on brain resuscitation began in 1970.
Anatomy and function of the circulatory system
The circulatory system is similar to a city water system:
The heart functions as a pump
The blood vessels as a network pipes
The blood as fluid
Blood picks up oxygen in the lungs ,it goes to the heart ,which pumps the oxygenated blood to rest of the body.
The cells of the body absorb oxygen and nutrients from the blood and produce waste products(including carbon dioxide),that blood carries back to the lungs.In lungs ,the blood exchanges the carbon dioxide for more oxygen .Blood then returns to the heart to be pumped out again.
If the heart stop contracting,and no blood is pumped through the blood vessels.Without a supply of blood, the cells of the body will die because they cannot get any oxygen and nutrients and they cannot eliminate waste products.
Death is a physiologic and biologic process, it just occurs after cardiac arrest.
Sudden Cardiac Death
Clinical Death has been defined by Negovsky as “the period of respiratory,circulatory,and brain arrest during which initiation of resuscitation can lead to recovery with prearrest central nervous system function.” Clinical Death is a reversible state
The duration of clinical death depends on the length of time of the cerebral cortex survives in the absence of circulation and respiration.
Biologic death which sets in after clinical death, is an irreversible state of cellular destruction.
On normal temperature , the period does not exceed 3-6min from clinical death to biologic death
Sudden cardiac death
Sudden cardiac death (also called sudden arrest) is death resulting from an abrupt loss of heart function (cardiac arrest).
Sudden cardiac death is clinical death
The victim may or may not have diagnosed heart disease.
The time and mode of death are unexpected .
It occurs within minutes to 1 hour after symptoms appear.
The most common cause of cardiac arrest is coronary heart disease.
Extracardiac 1.airway obstruction 2.acute respiratory failure 3.shock 4.Reflective cardiac arrest 5.embolisms of different origin 6.drug overdose 7.Electrocution 8.poisoning
follwing abrupt cessation of effective cardiac output :
Loss on consciousness at about 10~15seconds;
Pupillary dilation at about 30~45 seconds ;
Brain damage begins within 4 ~ 6 minutes after cardiac arrest;
Irreversible cerebral cortical damage occurring within 8~10 minutes after cardiac arrest.
Sudden cardiac arrest is reversible in most victims if it's treated within a few minutes with an electric shock to the heart to restore a normal heartbeat. This process is called defibrillation.
Sudden cardiac death － ECG
The arrest is usually associated with the lethal arrhythmia of ventricular fibrillation triggered by an acutely ischemic or infarcted myocardium or by a primary electrical disturbance .
There several ECG in sudden cardiac arrest:
Pulseless Ventricular tachycardia
Electric –mechanical activity dissociation
Ventricular fibrillation Asystole Electric –mechanical activity dissociation Pulseless Ventricular tachycardia
Epidemiology of Sudden cardiac death Cardiac arrest accounts for between 250 000-350 000 death each year in USA. Expert estimate that the overall survival rate may be beween 3% and 5% , in many large urban areas maybe less than 2% . In China , approximately 1 000 000 - 1800,000 people suffer cardiac arrest every year .Mortality of cardiac arrest is 95%-98% in USA ， and 98%-99% in China 。 Delay Initiation of CPR are the main cause o f low survival rate. .
Chain of Survival
Early Access to Medical Care (calling 911 in USA ,and calling 120 in China immediately)
Early CPR (within 4 min after cardiac arrest)
Early Defibrillation (for an out of hospital sudden cardiac death within 5min,for a in hospital victims within 3min ( In guideline 2005 )
Early Advanced Care including intubation and IV medication(should be initiated within 8min of arrest)
In 1991 ， American Heart Association has introduced
Chain of Survival
Chain of Survival Early Defibrillation Resuscitation success depend on each link in the chain. Early defibrillation has emerged the greatest impact on ultimate survival. When defibrillation alone is added to the BLS regimen,survival increases from 6% to 25% for prehospital VF.
No CPR 0%-2% survive Delayed defibrillation
Early CPR 2%-8% survive Delayed defibrillation
Early CPR 20% survive Early defibrillation
Early CPR 30% survive Very early defibrillation Early ACLS
Source: American Heart Association, 1994
Better chance of survival Brain damage starts in 4-6 minutes Brain damage is certain after 10 minutes without CPR
Sudden death is unique. Time constraints are extreme. A victim's chances of survival are reduced by 7 to 10%with every minute that passes without defibrillation
If resuscitative interventions are not begun within 5~7min, there is little likelihood of successful resuscitation and functional survival.
Few attempts at resuscitation succeed after 10 minutes .
Most survivors of cardiac arrest are from the group of patients . . .
Whose collapse is witnessed by a bystander,
Who receive CPR within 4 to 5 minutes, and
Who receive advanced cardiac life support (ACLS), e.g., defibrillation, intubation, drug therapy, within the first 10 minutes.
2. CPR Steps
3.Complication of CPR
4.Monitoring during CPR
1. Basic Life Support, BLS
2. Advanced Life Support, ALS
Basic Life Support- BLS
BLS is the application of artificial ventilation and circulation without special equipment or drugs to prevent brain damage.
Combines rescue breathing and chest compressions
Revives heart (cardio) and lung (pulmonary) functioning
Use when there is no breathing and no pulse
Provides O2 to the brain until ALS arrives
Effective CPR provides 1/4 to 1/3 normal blood flow
Rescue breaths contain 16% oxygen (21%)
BLS 1.CALL Check the victim for unresponsiveness 2. BLOW Tilt the head back and listen for breathing . . 3. PUMP If the victim is still not breathing normally, coughing or moving, begin chest compressions. Push .
New BLS process (2005) unresponsiveness opening the airway& check the victim CPR 2:30 until defibrillation or monitoring defibrillation once :360J Continue CPR for 5 groups (2:30)
Recognition of cardiac arrest
1.Recognition of Cardiac Arrest
Sudden cardiac death can be confirmed by the absence of detectable pulse, unresponsiveness, and apnea, gasping （喘息） respiration”.
Tap shoulder and shout “Are you ok?”
Note: The presence of spontaneous respiration dose not exclude the possibility of cardiac arrest.
Normal respiratory motion may persist for approximately 1 minute after loss of cardiac function.
Once unresponsiveness has been determined, assistance obtained and a defibrillator requested.
Start ＢＬＳ Immediately
stabilize the cervical spine by maintaining the head ,neck, and trunk in a straight line
Positioning the patient supine on a flat, firm surface with arms along the sides of the body, Always be aware of head and spinal cord injuries
2.A – airway control
In an unconscious patient, airway obstruction is most commonly due to relaxation of the muscles of the tongue allowing it to rest against the posterior pharyngeal wall.
There are several simple airway maneuver to relieve this obstruction--opening the airway method:
if no concern cervical spine injury . Head-tilt/neck stretch
Head-tilt/chin-lift if no concern cervical spine injury . (2005 guidline new) In patients with suspected cervical spine injuries-if unable to open airway using the jaw thrust, use the head-tilt chin lift
Jaw-thrust T he jaw –thrust is the safest method for opening the airway if there is the possibility of cervical spine injury.
Cleaning the secretion of airway tract or foreign body (such as gastric contents regurgitation , blood clotting or denture in the mouth inspired into the airway) 。
Sweeping out by fingers
Check For Breathing
After opening the airway ， you should quickly Check For Breathing
look the patient’s chest and abdomen movement,
listen for sounds of breathing, placing your ear over the patient’s nose and mouth and
feel and hear the movement of air
No longer than 10 seconds
Once you determine the patient not spontaneous breathing ,you must begin artificial ventilation immediately.
Pinch the nose- prevent air escape
take a deep breath
Seal the mouth with yours
give two breaths (1 second or longer)
If the first two breaths don’t go in, re-tilt and give two more breaths (if breaths still do not go in, suspect choking)
Can’t open mouth
Can’t make a good seal
Severely injured mouth
mouth-to-nose ventilation may be more effective.
After tracheotomy , the stoma becomes the patient’s airway . mouth-to-stoma
To prevent transmission of disease from the victim to rescuer, a bag –valve mask or other suitable device should be used in place of mouth-to-mouth technique.
mouth to mask
Both mouth to mouth and mouth to nose ventilation can provide large volumes ， the concentration of oxygen delivered to the patient is 16%~17% ， may produce an alveolar partial pressure of oxygen of 80mmHg,more than enough to patient’s life.
mouth to mask ventilation connected to high flow oxygen ， the concentration of oxygen is up to 55% 。
4.C-circulation (extenal chest compression)
Once the airway has been established and the lungs have been ventilated ， If there is not carotid pulse ， external chest compression should be started.
The rescuer positions- bedside the victim’s chest.
Locate proper hand position for chest compressions
Place heel of one hand on the lower half of the sternum .
The fingers interlocked
Keeping the arms straght
Compression rate 100/min
Depth of compressions: 1 .5 to 2 inches(4-5cm)
After 30 chest compressions give: 2 slow breaths ( Ratio of compression-to-ventilations 30:2)
Continue until help arrives or victim recovers
If the victim starts moving: check breathing
Early defibrillation has emerged as a single element of BLS that appears to have the greatest impact on ultimate survival.
When defibrillation alone is added to the BLS regimen, survival increases from 6% to 25% for prehospital VF.
Defibrillation is the definitive treatment for the vast majority of cardiac arrests. It should be delivered as early as possible.
At least 50%of patient in cardiac arrest are in VF when the first ECG ,in early 1970s “blind” defibrillation was recommended as soon as a defibrillator was available.
However, current defibrillators with quick-look paddles enable display the rhythm disturbance
As soon as ventricular fibrillation is documented, defibrillation should be perform immediately.
The method of defibrillation
If an electrical defibrillator is not immediately available, a precordial thump should be used. A sharp blow using the fleshy outside of a closed fist is delivered to the sternum from a height of 8 ～ 12in (25 ～ 30cm).
If this successfully results in sinus rhythm, a bolus of lidocaine should be given.
If VF persists, proceed to BLS and to defibrillation as soon as the defibrillator is available.
While awaiting arrival a defibrillator, effective BLS must be maintained.
The method of defibrillation
2.Electrical defibrillation :passing an electrical current through a fibrillating heart, and causing synchronous depolarization the disorganized contracting myofibrils at once, and allowing for uniform repolarization and subsequent organized cardiac electromechanical activity.
traditional handheld defibrillator
Automated external defibrillators (AED) With a large pads are currently available. These machine can recognize VF and deliver direct current (DC) countershock with better than 85% sensivity and with 100%specificity.
Defibrillation success rate appears equal traditional handheld defibrillator.
The potential impact of using this technology widely in office building, stadiums, factories and rural areas served by volunteer rescue personnel 。
Procedure of Electrical defibrillation
⑴ Adiminister BLS until the equipment and personnel arrive.
⑵ Assess the patient’s pulse and ECG.
⑶ Proper asynchronous mode
⑷ Selection energy level—360J
⑸ Adequate contact Apply electrode gel or saline-soaked4×4 gauze pads between paddles and skin
⑹ Proper position of the paddles :one paddle placed to the right of the upper half of the sternum, below the clavicle. the other is placed to
the left of the
⑺ Clear the area ,no contact with anyone other than the victim.
⑻ Recheck the
⑼ Activate the
⑽ If no skeletal muscle twitch or spasm has occurred ， you should check the equipment ， contacts ， and synchronizer switch
⑾ The rhythm should be assessed after each countershock and the patient should be checked for a pulse at appropriate time.
⑿ If unsuccessful, continue BLS.
Checking for CPR Effectiveness
★ With each compression, an arterial pulse should appear.The carotid artery pulse is more meaningful than either the radial artery or femoral artery pulse.
Does chest rise and fall with rescue breaths?
Have a second rescuer check pulse while you give compressions
★ The ECG also responds to the ECC, Various types of electrocardiographic artifacts may appear with each compression.
Occasionally, each ECC cause a recognizable QRS complex and T wave to appear.
★ The reaction of the pupils -if present, is a good indicator of cerebral circulation
Advanced Life Support
Advanced Life Support-ALS
ALS refers to used special equipment to manage airway, breathing and circulation and provide definitive care, including defibrillation , advanced airway managment,, mechanical ventilation and drug therapy of dysrhythimas and acid- base disturbance.
ALS may be applied by trained individuals operating within an emergency medical services system in the community, in transport, and in the hospital setting.
1. Oropharyngeal airway
2. Nasopharyngeal airway
3. Endotracheal intubation
Note : The resuscitative
efforts should not be
interrupted by than
more 30s with each attempt.
2. Artificial ventilation
⑴ Bag-valve-mask manual ventilation
⑵ Mechanical ventilation
3.Support of circulation
Chest compression during ALS are performed in the same manner as in BLS.
Newer techniques include the use of compression-decompression devices and abdominal counterpulsation compression-decompression device. These mechanical devices were used, have result in improved rates of return of spontaneous circulation but not in improved ultimate survival.
The establishment of a reliable intravenous route is an essential part of ALS ， this allow administration of necessary drugs and fluids in the course of the CPR .
● Peripherial veins : may be used because of convenience ， usually recommed median cubital vein ， particularly during the arrest situation when access to the neck and chest is restricted by BLS procedure.when these route are being used, IV medication should be administered rapidly by bolus injection and following by a 20ml fluid bolus injection and elevation of the extremity .
● Central venous : offers more secure route for drug administration ， internal jugular or subclavian are preferable because of proximity to the heart ， but their placement should not be allowed delay defibrillation attempts or interfere with BLS. femoral vein cannulation is difficult to achieve during CPR.
If intravenous lines cannot be established quickly ， some drugs （ such as epinephrine ， lidocaine ， atropine ） can be administered by endotracheal ， and intracardiac routes.
★ Endotracheal route requires a higher dose to achieving an equivalent blood level .It is suggested that 2.5 times the IV dose be administered.Delivery of the drug to the circulation is facilitated by diluting the drug to a 10ml volume and delivering it though a catheter positioned to the tip of the endotracheal tube.
★ Intracardiac injection should be avoided and is indicated only if intravenous and endotracheal toutes are not available.
The roles of fluid and drug therapy
Increase central volume ， rising the perfusion pressure of myocardium and brain.
Treatment of arrhythmias and prevent recurrent cardiac arrest.
Correction of acidosis and hypoxia
Correction the causes of cardiac arrest.
To maintain the IV access and increased central volume are often required during CPR.
The standard fluid infusion for ALS should be normal saline or lactated Ringer’s solution, rather than dextrose in water, since hyperglucose may exacerbate anoxic injury to the brain.
Actions: Epinephrine can stimulate peripheral α-adrenergic receptor and cardial β adrenergic receptor ， increases resistance in non-cerebral and non-coronary arteries,result in decreased blood flow to non-cerebral and non coronary vessels.in creased aortic blood pressure and increased perfusion of heart and brain vessel.
It possible β-receptor effect on the coronary arteries and brain vessels ， resulting in increased blood flow to both of these organs during CPR. And also help to restore spontaneous norm tension in cardiac arrest of more than about 1 to 2minute’s duration.
It can help convert fine VF into coarse VF ， which is more susceptible to termination by electrical countershock.
Indication: include all forms cardiac arrest. It is recommeded in VF/VT cardiac arrest if there is no ROSC after first three defibrillation.It is recommended in EMD and asystole after initiation of CPR.
The standard adult dose: is 1mgIV bolus and repeated every 3~5min until return of spontaneous circulation.
Actions: Lidocaine is a classIB agent that depresses myocardial excitability by blocking sodium channels without extending action potential dduration.
Indication and dose: The drug is indicated in Ventricular ectopy, ventricular tachycardia and ventricular fibrillation that has recurred after a successful defibrillation or that has been refractory to defibrillation. Prophylactic lidocaine therapeutic dose is deemphasized.
Its onset of action is rapid.its duration of action is brief but may be prolonged by use of a continuous infusion of drug .
dose : In cardiac arrest the recommened dose is 1.5mg/kg bolus repeated in 5~10 min for total dose of 3mg/kg.
Actions: Amiodarone is classIII agent that has some classI activity weak non-competitive β-blocking effects.It lowers the defibrillation threshold and has potent antifibrillatory effect.its broad spectrum of antidysthythmic effects make it a potentially useful agent.
Indication and dose: can be considered if multiple DC shocks and epinephrine have failed to revert VF/VT.The initial dose is 5mg/kg given as a slow intravenous infusion over 5-15min.This may be repeated if indicated
Actions: Atropine antagonizes parasympathetic nervous effects on the heart by blocking cholinergic receptors,leading to increased sinoatrial and atrioventricular automaticity and rate on conduction.
Indication and dose:It is retained as pharmacotherapy for symptomatic bradycardia. It is given in dosages of 0.5~1.0mg every 3~5min, The total dose of atropine is 0.04mg/kg(3mg)
Class I recommendation (definitely helpful) : symptomatic sinus bradycardia
Class II recommendation (acceptable, or possibly helpful) : atrioventricular block （ AVB ） at the nodal level, or in asystole.
Class III recommendation (not indicated, maybe harmful) : In Mobitz AVB or CHB.
Actions: Magnesiun is an essential electrolyte that may be depleted by duretics,severe diarrhoca and alcohol abuse.Hypomagnesaemia may cause cardiac dysrhythmias.
Indication and dose: Magnesium may be considered in refractory VF/VT,particularly hypokalaemia is present,and is an agent of choice in torsaded de pointes.
The initial dose is 5mmol given over1 minute, which may be repeated if indicated and followed by an infusion of 20 mmol over 4 hours.
⑥ Sodium bicarbonate
Acidosis is often present in victims of cardiorespiratory arrest, particularly if the arrest condition has persisted for more a few minutes.
There two components contributing to he acid load. Respiratory acidosis result from failure carbon dioxide elimination, carbon dioxide(CO 2 ) production continues , but it can not be remove because pulmonary and heart failure during CPR, the PaCO 2 rise.
Metabolic acidosis develops concomitantly with tissue hypoperfusion and conversion to anaerobic forms of metabolism.
Actions: Sodium bicarbonate (NaHCO 3 )is an alkalinizing agent,that theoretically reverse the metabolic acidosis associated with profound ischemia.However,provided CPR is effective, acidosis does not develop rapidly or severely in otherwise healthy individuals during during cardiac arrest.
Indication and dose: It is unneccessary in brief resuscitation when the patient have been previously well.It can be considered if cardiac arrest exceeds 10-15mintures duration.It should be considered when cardiac arrest occurs in a patient with a prexisting profound acidosis or in special conditions,such as hyperkalaemia and tricyclie antidepressant overdose.
Note: If alveolar ventilation is not adequate, the CO 2 released from the NaHCO 3, ,and correction of the acidosis will not be attained, and may result in increased central venous and tissue PaCO 2 level .Tissue acidosis may worsen following NaHCO 3, administration.
NaHCO 3 administration is not indicated for hypoxic lactic acidosis.
The initial dose should be 1mmol/kg
4. Different diagnosis （ 5H 、 5T ）
hypoxemia ( cerebral anoxia 、 central nervous system disease )
hypopotassaemia ／ hyperpotassaemia (or other electrolyte disturbance )
hypothermia ／ hyperthermia
hypoglycemia ／ hyperglykemia
hypovolemia ( drug overdose or anaphylactic response 、 blood loss or pregnant )
Thromboembolism of pulmonary
Thromboembolism of coronary artery （ or ACS ）
Toxication (acidosis) ; tension pneumothorax and etc.
2. CPR Steps
3.Complication of CPR
4.Monitoring during CPR
Complications of CPR
The complication of CPR are legion( 很多 ), but unavoidable complications are acceptable compared with an otherwise certain death .
Complication of ECC :
fractures of ribs, sternum or spine;
Laceration related to the tip of the sternum ：
lung 、 liver spleen or other abdominal organs;
pulmonary or cerebral fat embolism;
laceration or rupture of heart;
herniation of the heart through the pericardium;
hemothorax or pneumothorax .
These complications can be minimized by careful attention to the details of ECC.
Complication of artificial ventilation: Gastric distension and regurgitation and aspiration are common without endotracheal.
Place victim on left side
Wipe vomit from mouth with fingers wrapped in a cloth
Reposition and resume CPR
Air in the stomach Creates pressure against the lungs
This complication is more likely to occur when ventilation pressure exceeded the opening pressure of the lower esophageal sphincter .
Prevention of Stomach Distension
Don’t blow too hard
Slow rescue breathing
Re-tilt the head to make sure the airway is open
Use mouth to nose method
In mouth-to-mouth ventilation, 1.5~2.0 seconds should be allowed for air delivery to the lungs to prevent airway pressure from exceeding 20~25cmH 2 O.Breathing rapidly without allowing full exhalation should be avoided for same reason.
pulmonary edema, gastrointestinal hemorrhage, pneumonia and recurrent cardiopulmonary arrest.
Anoxic brain injury can occur in a resuscitated individual who suffered prolonged hypoxia. It is the most common cause of death in resuscitated patients.
2. CPR Steps
3.Complication of CPR
4.Monitoring during CPR
Monitoring during CPR
It is essential during resuscitation, both as a diagnostic tool and as a guide to the most effective therapy. Initially, the “quick look” paddles should be used. If available, the standard ECG machine or monitoring unit with a display screen should be attached as soon as possible.
Intra- arterial pressure monitoring provides an accurate and continuous measure of SBP, DBP and MAP. Continuous intra-arterial monitoring during CPR allows for rational titration of vasoconstrictor therapy and accurate assessment of the hemodynamic effectiveness of spontaneous rhythms 。
3.Endotracheal CO2 monitoring
Provide a noninvasive measure of pulmonary perfusion (CO). Which also has been shown to correlate with coronary perfusion pressure. Patients who have undergoing 10~15 min of ECC with accompanying ALS ,and have an endotracheal CO2 above 10-15mmHg are unlikely to survive.
Will guide ongoing therapy. The most useful initial measurements include arterial blood gas, the hematocrit, serum glucose, sodium, potassium, calcium. If abnormalities are noted, they may be treated, and the success of such treatment maybe monitored by repeated measurement.
2. CPR Steps
3.Complication of CPR
4.Monitoring during CPR
When Can I Stop CPR?
2.Trained help arrives （ or Replaced by another rescuer ）
3.Too exhausted to continue
5.Physician directed (do not resuscitate orders)
6.Cardiac arrest of longer than 30 minutes ( controversial)
The decision to terminate unsuccessful resuscitative efforts is always difficult, particulary if the patient is a child or a young adult.
Why CPR May Fail
Delay in starting
Improper procedures (ex. Forget to pinch nose)
No ACLS follow-up and delay in defibrillation
Only 15% who receive CPR live to go home
Terminal disease or unmanageable disease (massive heart attack,diffusely metastatic cancer)