The history of CPR traces back to the biblical ages. James Elan and Peter Safar reinforced and explained the importance of ventilation by mouth-to-mouth breathing. William B Kouwenhoven had introduced chest compressions, while defibrillation to break ventricular fibrillations was introduced by Claude Beck and Paul Zoll. The standards for CPR performance were generated at the National Research Council conference in 1966, when the modern era of CPR began.
The chest compressions cause a rise in the intrathoracic pressures more than that of extrathoracic regions, which cause the blood to flow. The direction of flow of blood toward the arterial tree is explained by the presence of venous valves, which prevent retrograde flow of blood at the thoracic inlet.
Transesophageal echocardiography (TEE) during CPR in humans has helped in real-time visualization of changes in the heart and blood flow. During the chest’s compression, blood is ejected from the ventricles into the aorta and pulmonary system while the tricuspid and mitral valves close. When the pressure on the chest is released, the pressure gradient allows the heart’s venous flow. Any factors that affect the intrathoracic pressure like high-pressure mechanical ventilation, inadequate recoil of the chest also hinders adequate heart-filling and decreases chances of restoration of spontaneous circulation (ROSC). Providing adequate chest compressions is vital soon after a sudden cardiac arrest (SCA) because blood flow rather than oxygen content is the limiting factor for oxygen delivery to vital organs like the brain and heart. In most cases, this holds unless hypoxia is the cause of the arrest as in conditions like suffocation or drowning.
To locate the carotid, locate the trachea using two or three fingers, and slide them to the groove between the trachea and muscles. If no pulse can be palpated within 10 seconds, chest compressions should be started. The assessment of breathing and pulse, followed by appropriate action, is tabulated below (Table 40.1).
Positioning yourself: Heel of one hand rests in the center of the victim’s chest on the lower half of the breastbone (sternum). Heel of the other hand rests on top of the first hand. Position yourself such that your shoulders are directly over your hands.
Place your hands on either side of the victim’s head and your fingers under the lower jaw’s angles. The jaw needs to be lifted with both hands and displaced anteriorly. The provider can rest the elbows on the surface on which the victim is lying.
For providing mouth-to-mouth breaths, a pocket mask with a one-way valve can be used, which helps to divert the air exhaled by the victim away from the provider. Alternatively, bag and mask devices can be used.
The BLS skills include performing effective chest compressions, use of the bag and mask for ventilation, and use of an AED and is usually provided by the emergency response team. However, health care workers (HCWs) and physicians require to provide more advanced assessment and management (Flowchart 40.1).
The assessment of airway and appropriate actions is summarized in Table 40.2.
The assessment of breathing and appropriate actions is summarized in Table 40.3.
The assessment of circulation and appropriate actions is summarized in Table 40.4.
The most common causes of cardiac arrest should be kept in mind while managing cardiac arrest (Table 40.5).
The cardiac arrest algorithm consists of two limbs: The management of a shockable rhythm, while the other is regarding the nonshockable rhythm, including asystole and pulseless electrical activity (PEA).
If no pulse is palpable or there is a doubt regarding the pulse palpability, then the chest compressions should be resumed without exceeding an interruption of 10 seconds (Flowchart 40.2).
Flowchart 40.2 Algorithm for management of shockable or nonshockable rhythms. Abbreviations: CPR, cardiopulmonary resuscitation; IO, intraosseous; IV, intravascular; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; VF/PVT, ventricular fibrillation/pulseless ventricular tachycardia.
Post cardiac arrest care has known to reduce the early mortality caused by hemodynamic instability, and later morbidity and mortality caused by multiorgan dysfunction and brain injury. The further management required to ensure the success of post cardiac arrest care includes:
The treatment of the cause of the cardiac arrest should be initiated, and if unknown, then investigations required to identify the precipitating cause of arrest should be advised. A comprehensive, multidisciplinary system of care should be implemented for the care of post cardiac arrest patients.
Targeted temperature management is started in those who remain comatose or unresponsive despite ROSC after cardiac arrest, with a target to maintain a constant temperature between 32 and 36ºC for a period of 24 hours to improve the neurological outcome after cardiac arrest.
The optimal method to achieve the target temperature is unknown, but a combination of various techniques like the rapid infusion of ice-cold, isotonic, nonglucose containing liquid (30 mL/kg), surface cooling devices, or simple surface techniques like ice bags are used commonly.
Pediatric CPR requires expertise and an understanding of the unique clinical conditions and their therapeutic considerations. Unlike adults, the most common of cardiac arrest in infants and children is asphyxia, making airway management and ventilation crucial during pediatric resuscitation. Although ventilation is deemed important, due to lack of insufficient data in this population, the 2015 AHA guidelines maintained the chest compression-airway maintenance-breathing (C-A-B) sequence to reduce the no-blood flow time to a minimum.
A manual defibrillator is preferable in infants when a health care provider identifies a shockable rhythm. An AED with pediatric attenuator and pediatric pads can be used in children up to 8 years, with pads placed in an anteroposterior position.
In pediatric cardiac arrest, initial defibrillation energy of 2 J/kg is used and may be increased to 4 J/kg in the second shock. Increased energy levels may be subsequently considered but should not exceed 10 J/kg. If a pediatric defibrillator is not available, then an adult AED can be used without hesitation.
For pediatric patients, management of different life-threatening arrhythmias, PEA arrest/asystole, or ventricular fibrillation (VF)/ventricular tachycardia (VT) arrest is similar to adults, except for the dosage (defibrillation/medication) for children is weight-based. Actual body weight is recommended to calculate initial resuscitation drug doses. Vascular access can be challenging in critically ill children; therefore, intraosseous (IO) access is recommended in difficult IV access cases.