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cardiopulmonary resuscitation (CPR)

An emergency measure to maintain a person's breathing & heartbeat when they have stopped as a result of myocardial infarction, trauma, or other disorder. Ventricular arrhythmias are responsible for the majority of cardiopulmonary arrests in adults. Epidemiology: - see in-hospital cardiopulmonary resuscitation Clinical manifestations: - 40% of cardiac arrest survivors claim recall of events during cardiac arrest [19] - gasping during CPR after cardiac arrest is associated with increased 1-year survival with good neurologic outcome [36] - do NOT terminate chest compressions prematurely Special laboratory: - one time electroencephalography (EEG)* for patients who do not follow commands after return to spontaneous circulation [56] Complications: - pulmonary aspiration & aspiration pneumonia resulting from bag-mask ventilation & endotracheal intubation [41] - seizures [56] Management: - priorities: a) recognition of cardiopulmonary arrest b) activation of the emergency medical system (EMS) c) basic life support (see basic life support) d) defibrillation* - restoration normal effective rhythm as soon as possible the single most important goal of resuscitation [14] - more basic life support prior to defibrillation does not improve outcomes [14] - after initial defibrillation, an additional 2 minutes of chest compression with rescue breathing should follow initial defibrillation before reananalyzing rhythm & checking for pulse [22]* - public access defibrillation (PAD) improves return of spontaneous circulation & survival after out-of-hospital cardiac arrest [44] - only a minority of patients sustain spontaneous circulation after defibrillation; but still favorable neurologic outcomes (37.7% vs 22.6%) & survival (44% vs 32%) are improved by defibrillation [44] - defibrillation for ventricular fibrillation & other shockable rhythms prior to administration of epinephrine in in-hospital cardiac arrest [51] e) airway - intubation - attempts at endotracheal intubation can interrupt chest compressions &/or slow defibrillation [32] - bag mask ventilation vs endotracheal intubation for out-of-hospital cardiac arrest - results of comparison inconclusive [38] - the AHA no longer recommends blind finger sweeping of airway under any circumstances, as this may push foreign objects into the airway & cause an obstruction [22]* f) large bore peripheral IV for fluid resuscitation [29] - preferably 2 large bore IV lines - administration of appropriate IV medications g) non-shockable rhythms - a novel technigue involves an airway adjunct impedance threshold device & active compression-decompression with a device resembling a toilet plunger - combined with automated gradual head-up/torso-up positioning - improves cerebral blood flow impeded by increased intracranial pressure resulting from standard supine CPR [52] - also see pediatric basic & advanced cardiopulmonary life support - hypothermia may (or may not) preserve brain function - for initial rhythms of - ventricular tachycardia/ventricular fibrillation - asystole/pulseless electrical activity [34] - procedures include - therapeutic hypthermia (32-34 degrees C for 24 hours) - all adults who do not follow commands after return to spontaneous circulation [56] - a target temperature of 31 C does not reduce mortality or improve neurologic outcome at 180 days vs a target temperature of 34 C [50] - fever prevention (<= 37.5 C) more important than cooling to a lower temperature [56] - target temperature = 32-37.5 C [56] - for patients initially hypothermic after return to spontaneous circulation, rewarm no faster than 0.5 C/hour [56] - slightly lowering temperature then slowly warming, holding below 37.5 degrees C for 72 hours [34] - mild therapeutic hypothermia for neuroprotection after CPR of benefit [23] - prehospital cooling not recommened [34] - no benefit in neurological outcomes or mortality for maintenance of mild hypothermia for out-of-hospital cardiac arrest [53] - epinephrine - early epinephrine associated with better survival outcomes in adults with shockable & nonshockable out-of-hospital cardiac arrest [49] - epinephrine administered by paramedics associated with improved 30 day survival in out-of-hospital cardiac arrest (3.2% vs 2.4%); survivors more likely to have severe neurologic disability [39] - consider a therapeutic trial of a nonsedating anticonvulsant in patients with EEG evidence of ictal or interictal waveforms [56] - extracorporeal membrane oxygenation (ECMO) - may be appropriate in select patients in qualified health care settings [56] - special considerations for patients with ventricular assist device or artificial heart * pneumomic ABC for Airway, Breathing, Circulation seems no longer recommended [22] * the same logic would seem to apply to rescue breathing as applies to blind finger sweep; both would seem to risk pushing a foreign object further into the airway, whereas compression- only CPR would not (ref [22] does not seem to consider this) Prognosis: - cardiopulmonary resuscitation at the site of cardiac arrest with better ourcomes than immediate transport & resuscitation attempts on the way to the hospital [47] - factors predicting neurologically intact survival include age, renal insufficiency (serum creatinine > 2.0 mg/dL), hypotension, myocardial infarction [28], frailty [46] - the most sensitive early (48 hours) markers of poor outcome (no sedation) are: - no pupillary response or corneal response - absence of motor response to pain - burst suppression pattern on electroencephalogram [54,55] - mortality, brain damage, & nursing home admission at 1 year lower if bystanders had jumped in to help in out-of-hospital cardiac arrest [33] - criteria for unsurvivable out-of-hospital cardiac arrest - cardiac arrest unwitnessed by emergency medical services or medical personnel - nonshockable initial rhythm - lack of return of spontaneous circulation before receipt of a third dose of 1-mg epinephrine [31] - survival of in-hospital cardiac arrest to hospital discharge with good congitive outcome in elderly (70 years) is > 15% [45] - frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest [46] Notes: - often performed poorly [2,15] - when performed properly, delivers only a small fraction of normal cardiac output [14] - chest-compression-only out-of-hospital bystander CPR at least as effective as standard CPR [4,7,8] - uninterrupted chest compressions in out-of-hospital cardiac arrest improves outcomes [5,11] - quality of compressions more important than continuous vs interrupted [26] - compression-only CPR is associated with higher rates of bystander CPR, which boosts the overall survival rate [42] - standard CPR is associated with the highest survival rate [42] - CPR-trained bystanders may give rescue breaths between chest compressions (ratio 30:2) [37] - emergency medical services should provide positive pressure ventilation in addition to chest compressions until supraglottic device or endotracheal tube is established [37] - conventional cardiopulmonary resuscitation better than compression-only CPR for children with noncardiac causes of arrest [6,13] - suction cup device used by emergency medical services personnel may improve survival [12] - CPR is more efficient with use of two devices: a) a chest-wall suction device that allows active decompression as well as compression of the chest b) an airway impedance-threshold device that limits passive ventilation during chest decompression c) ResQCPR System FDA-approved for use by first responders [21] - mechanical CPR does not improve survival over manual CPR in adults with out-of-hospital cardiac arrest [20,27] - giving family members the choice to observe out-of-hospital cardiopulmonary resuscitation is associated with better psychological outcomes [17] - telephone guidance for bystanders improved CPR performance & survival in Arizona [30] - return of spontaneous circulation in out-pf-hospital cardiac arrest lower during the COVID-19 pandemic [48] In 1998, paramedics implemented a new guideline that allows emergency personnel to withhold resuscitation if a patient has a terminal condition & the patient, a family member, or a caregiver has indicated (verbally or in writing) that the patient did not want resuscitation. [3,4] Dispatcher assistance increases use of bystander CPR in children & improves neurologic outcomes [18] bystander CPR before arrival of emergency medical services arrival more than doubles 30-day survival [24] automated external defibrillators in public places improves outcomes [25] fully autonomous drones equipped with a global positioning system & autopilot software could be used to speed delivery of automated external defibrillators to bystanders during an episode of sudden cardiac arrest [35]

Related

cardiac arrest emergency medical system (EMS) outcomes of comatose patients after cardiopulmonary resuscitation (CPR)

Specific

advanced cardiac life support (ACLS) basic life support (BLS) CPR class 1 intervention CPR class 2 intervention CPR class 3 intervention in-hospital cardiopulmonary resuscitation (CPR) termination of cardiopulmonary resuscitation (CPR)

General

clinical procedure

References

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