COMPRESSIONS ONLY CPR
Mary Boudreau Conover BSNed
Recent studies have flagged
three common errors in technique during the performance of cardiopulmonary
resuscitation (CPR) that decrease blood flow to the heart and brain,
worsen the chances for survival, and increase the chances for brain
damage. They are:
- Excessive ventilation
- Incomplete chest
wall recoil
- Interruption of
chest compressions
In the past 30 years, the rigidly
followed CPR guidelines for the chest compression-ventilation ratio
have had a nearly flat survival rate.1 In the past 30 years,
the rigidly followed CPR guidelines for the chest compression-ventilation
ratio have had a nearly flat survival rate.1 This has been
true even after the “update” in 2000. Anyone who has assisted
in an out-of-hospital resuscitation attempt using this ineffective method
knows the tragic outcome intimately.
Cardiocerebral Resuscitation
(CCR)
We now know that even mildly
excessive ventilation rates and incomplete chest-wall recoil during
CPR can be lethal. This, quite simply, is the reason for improvement
in CPR by eliminating the mouth-to-mouth ventilations and using 100
uninterrupted compressions/minute, a proven method of resuscitation
that results in:
- More efficient oxygen
delivery to the heart and brain during cardiac arrest
- More successful
responses to electroshock, and
- Better neurological
outcomes for the future
Cardiocerebral Resuscitation
is the term used to describe, not just the bystander chest compression
only portion, but also the professional resuscitation method of delivering
200 preshock compressions and delaying advanced airway placement.
The switch from CPR to CCR
had its beginnings in 2003 in Tucson, Arizona; in 2004 in the Rock and
Walworth counties of Wisconsin; and in 2005 statewide in Arizona, where
it has been shown if you survive, 80% of the time you have a good neurological
outcome. The 80% becomes more meaningful knowing that the Phoenix
group has had 300% more survivors.2
The CCR method is composed
of 3 components.4,5 They are:
- Continuous chest
compressions for bystander resuscitation without mouth-to-mouth ventilation
- A new EMT algorithm;
and
- Aggressive post-resuscitation
care.
In this article we will address
only bystander resuscitation with and without an automatic external
defibrillator (AED). Lay rescuers and public safety officers may be
more willing and able to perform chest compression only CPR.
Back off on ventilation.
“The higher the pressure within the chest the lower
the pressure of the blood within the coronary arteries and to the brain.”
6
That’s a pretty simple statement
and it’s all we need to feel comfortable backing off of ventilation
and increasing the rate of cardiac compressions; otherwise the heart
muscle and the brain will receive less oxygen. When ventilation
rates and duration are increased, it becomes more difficult for venous
blood to return to the right heart and for blood to be squeezed out
of the heart and into the circulation against the pressure in the lungs.
Additionally, when there is reduced blood flow to the lungs, over-ventilation
causes a ventilation/perfusion mismatch and further compromises the
delivery of oxygen to the heart and brain.6
Pay attention to recoil.
For an adult, compress the chest 1 ½ to 2 inches with a complete release
to create recoil. With each chest-wall recoil, a small intrathoracic
vacuum develops, promoting venous blood flow back into the chambers
of the right heart. Most of the blood flow to the coronary arteries
and perfusion into the myocardium (heart muscle) itself occurs during
this key decompression phase.
Apply pressure straight down
on the middle of the sternum, pressing the heart between the sternum
and the spine and forcing the blood into the aorta and pulmonary artery.
Have a firm surface under the victim’s chest. This is hard work,
especially at 100 uninterrupted compressions/minute. However,
you can rejoice that you don’t have to worry about mouth-to-mouth
ventilation.
Gasping after Cardiac Arrest
For a short time immediately
after cardiac arrest some victims can be seen to gasp. You may
be inclined to think that the heart is still pumping and be dissuaded
from activating 911 and beginning chest compressions promptly.
Gasping represents minimal perfusion to the brain. There will
be no pulse. Be aware that gasping is common during the
first 3-4 minutes of cardiac arrest and is associated with increased
survival. 7 Do not delay CCR because of it. If an adult
suddenly collapses and is NOT breathing NORMALLY, initiate chest compressions!
Out-Of-Hospital Bystander
Response to Cardiac Arrest 2, 7
When no AED is at hand.
Rub the sternum hard to check for responsiveness. If no response,
get someone to call 911 and start 100 compressions/min without mouth-to-mouth
ventilations. Do not stop for anything until the EMT team takes over
from you. If you switch rescuers, do so without interruption of
compressions. This will be demonstrated in the video.
When AED is at hand and
you have seen the victim go down, if you are alone:
- Check the clock.
You have a 5-minute window to use the AED to the best advantage for
the victim.
- Get someone to call
911.
- Get the AED fast,
and use it. This will be your best shot.
- If the wait for
defibrillation goes beyond 5 minutes, the victim is in a less favorable
phase. Deliver 200 chest compressions at 100/minute before
you deliver the shock. The same applies if you don’t know when the
arrest occurred.
- The rescuer should
always be either following the AED commands OR delivering chest compressions.
No Room to Slack Off
There’s no room for slacking
off on the compressions or allowing interruptions. Even with 100 compressions
per minute, the perfusion of heart and brain is fragile at best and
pauses will put the victim behind the curve. The 100/min is a little
over 8 (8.3 to be exact) compressions every 5 seconds; tough to sustain
without a partner. Significant rescuer fatigue sets in after only
1 minute; if at all possible, rotate rescuers frequently.
The proper way to rotate rescuers is demonstrated in the video. Check
that 911 has been called. The victim cannot survive without defibrillation.
This video was made for the
Arizona Dept. of Health Services byTyler Vadeboncoeur M.D. and Bently
Bobrow M.D. Mayo Clinic Emergency Dept.
View How-to Video
CCC-CPR is easy to learn, easy to remember, and easy to do. More...
What to Expect from the
EMT Team
- Single shock is
delivered rather than stacked shocks.
- Chest compression
100/min. is resumed immediately after a shock is delivered with no delay
for post shock rhythm and pulse checks.
- Initial airway management
is limited to an oral pharyngeal device and supplemental oxygen.
- In witnessed cardiac
arrest, assisted ventilations and intubation are delayed until either
return of spontaneous circulation or until three series of compressions/analysis/shock
are completed.
- Early-administration
epinephrine either IV or orally.2
Electrical phase (0-5 minutes).
When the EMT team arrives with the defibrillator, the heart is in a
very vulnerable state, having passed through what is called the electrical
phase, during which defibrillation will be most successful.
Hemodynamic phase (>5
minutes). The next phase is the hemodynamic phase, during
which the heart has used up its energy stores and will not respond well
to defibrillation. Therefore, if the arrest has not been witnessed,
you will have to assume that it has been longer than 5 minutes and proceed
with 200 chest compressions at 100/minute before attempting defibrillation.
The person doing the compressions
does not let up until the defibrillator is ready to be discharged.
Do not lose focus when the EMT team takes over; watch the procedure.
Remember (1) the need for 100 uninterrupted compressions/minute with
good recoil, and (2) the disadvantages of ventilation. This has
happened on your watch and it may be that CCR hasn’t reached everyone.
Acknowledgement
Many thanks to Bentley Bobrow
M.D., Mayo Clinic Emergency Dept., for his in-depth review, corrections,
and encouragement.
- Fenici P,
Idris AH, Lurie KG, Ursella S, Gabrielli A: What is the optimal
chest compression-ventilation ratio? Curr Opin Crit Care. 2005
Jun;11(3):204. Department of Emergency Medicine, Catholic University
Hospital of Rome, Italy.
- Bobrow BJ,
et al: Minimally interrupted cardiac resuscitation by emergency medical
services for out-of-hospital cardiac arrest, JAMA, 2008 299:1158.
- Kellum
MJ.: Compression-only cardiopulmonary resuscitation for bystanders and
first responders. Curr Opin Crit Care. 2007 Jun;13(3):268-72.
Rock and Walworth County Sudden Cardiac Death Project, Mercy Walworth
Hospital and Clinic, Lake Geneva, WI.
- Ewy GA: Cardiocerebral
resuscitation: a better approach to cardiac arrest. Curr Opin Cardiol.
2008 Nov;23(6):579-84. Section of Cardiology, University of Arizona
Sarver Heart Center, University of Arizona College of Medicine, Tucson,
Arizona, USA.
- Ewy
GA, Kern KB: Recent advances in cardiopulmonary resuscitation: cardiocerebral
resuscitation. J Am Coll Cardiol. 2009 Jan 13;53(2):149-57. University
of Arizona Sarver Heart Center, University of Arizona College of Medicine,
Tucson, AZ 85724, USA
- Aufderheide
TP: The problem with and benefit of ventilations: should our approach
be the same in cardiac and respiratory arrest? Curr Opin Crit Care.
2006 Jun;12(3):207-12. Department of Emergency Medicine, Medical College
of Wisconsin
- Bobrow BJ,
Zuercher M, Ewy GA, et al: Gasping during cardiac arrest in humans is
frequent and associated with improved survival. Circulation 2008, 118(24):2495-7.
Hannah completing a round and Dave starting a new one.
Leif and his cousin.
Connor running it out
The 6am crew.
Photo taken November 08.
