CHAPTER 40 Cardiopulmonary Resuscitation

The goal of cardiopulmonary resuscitation (CPR) is to achieve the best possible outcome for individuals who are experiencing a life-threatening event.

History and Basics of CPR

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.

Theories of CPR

The blood flow generated by chest compressions provided during CPR can be explained by two theories, which include:

  • Thoracic pump theory.

  • Cardiac pump theory.

Thoracic Pump Theory

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.

Cardiac Pump Theory

This theory states that blood flow is generated due to compression of the heart between the sternum and vertebral column.

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.

Basic Life Support (AS2.1)

Basic life support (BLS) includes some fundamental steps to be taken in case of any cardiac arrest, which are as follows:

  • Recognition of SCA.

  • Ensure scene safety.

  • Activation of the emergency response team/call for help.

  • Rapid initiation of high-quality CPR with chest compressions.

  • Defibrillation using automated external defibrillator (AED).

The BLS interventions are all time-sensitive and designed to increase the probability of ROSC.

If the rescuer encounters an unresponsive individual, the steps to be followed include:

  • Verify the safety of the scene for both the victim and the provider.

  • Check the responsiveness of the victim by tapping the shoulder and shout, “Are you OK?

  • If the victim is unresponsive, call for help.

  • Activate the emergency response team appropriate to your setting (if alone).

If another person is available, send the person to get the AED and emergency equipment and activate the emergency response team.

  • If alone, get the AED and emergency equipment.

Assess for Breathing and Pulse

The victim’s breathing and pulse should be assessed simultaneously to minimize delay, and this should not take more than 10 seconds.

To assess breathing:

  • Look for chest rise and fall.

  • If breathing, monitor victim until help arrives.

  • If gasping or not breathing, it indicates cardiac arrest.

To assess pulse:

  • In an adult, palpate the carotid.

  • If no pulse can be felt within 10 seconds, initiate high-quality CPR with chest compressions.

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).

Table 40.1 Assessment of victim of cardiac arrest

Table 40.1 Assessment of victim of cardiac arrest


Next step

If breathing and pulse are normal

Monitor the victim until, emergency response team arrives

If normal pulse is present, but victim is not breathing normally

Provide rescue breathing and confirm that emergency response team has been activated

If victim has no pulse and is not breathing normally

Start high-quality CPR, with chest compressions

Abbreviation: CPR, cardiopulmonary resuscitation.

Chest Compressions

  • Rate: 100 to 120/min.

  • Depth: At least 2 inches (5 cm).

  • Push hard and push fast.

  • Allow adequate chest recoil after each compression.

  • Minimize interruptions in chest compression.

If two rescuers are available, then a compres­sion is to ventilation ratio of 30:2 has to be

  • The victim should preferably be placed on a firm surface in order to provide effective chest compressions. A soft surface does not allow adequate compression for blood pumping, and the compression provided will push the body into the soft surface.

Steps to Provide Good Quality Chest Compressions

  • Position yourself by the victim’s side.

  • Make sure the victim is lying supine and on a firm surface. If the victim is in the prone position, positioning should be done carefully, keeping the head, neck, and torso in a line.

  • 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.

  • Provide chest compressions at a rate of 100 to 120/min.

  • Push at least 5 cm during each compression.

  • Allow adequate chest recoil after each compression.

  • Minimize interruptions.

Providing Breaths during CPR

The victim’s airway has to be opened using two maneuvers:

  • Head tilt-chin lift.

  • Jaw thrust.

If a cervical spine injury is suspected, use ONLY jaw thrust maneuver to minimize neck spine movement.

Head Tilt–Chin Lift Maneuver

Place one hand on the victim’s forehead and tilt the head backward, while the other hand is used to lift the victim’s chin and bring it forward by placing fingers on the bony part of the lower jaw.

Jaw Thrust Maneuver

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.

The rate of infection from victim to health care provider is very low during CPR. However, all personal precautions should be taken because some cases of infectious transmission have been reported.

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.

Advanced Cardiovascular Life Support (AS2.2)

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).

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Flowchart 40.1 Systematic approach by the ACLS provider. Abbreviations: ACLS, advanced cardiovascular life support; BLS, basic life support.

Primary Assessment

The unconscious patient’s primary assessment is done after the BLS, while in conscious patients, the primary assessment is done right away. The primary assessment is done under the following heads:

  • A—airway.

  • B—breathing.

  • C—circulation.

  • D—disability.

  • E—exposure.


The assessment of airway and appropriate actions is summarized in Table 40.2.

Table 40.2 Airway assessment

Table 40.2 Airway assessment


Actions to be taken

  • Is the airway patent?

  • Is there an indication for an advanced airway to be placed?

  • Is the advanced airway placed properly?

  • Is the advanced airway securely placed and position reconfirmed?

  • Airway patency is to be maintained in the unconscious by head tilt, chin lift, nasopharyngeal, or oropharyngeal airway placement

  • More advanced airways to be used if required

  • Confirm proper placement

  • Secure the advanced airway

  • Proper placement and position to be monitored continuously by waveform capnography


The assessment of breathing and appropriate actions is summarized in Table 40.3.

Table 40.3 Assessment of breathing

Table 40.3 Assessment of breathing


Actions to be taken

  • Is the ventilation and oxygenation being provided adequate?

  • Is the oxyhemoglobin saturation and quantitative capnograph being monitored continuously?

  • Oxygen supplementation to be provided as required, to maintain a saturation of 94% or greater

  • For patients of cardiac arrest, 100% oxygen to be administered

  • Excessive ventilation to be avoided

  • Adequacy of oxygenation and ventilation should be monitored using quantitative capnography and pulse oximetry


The assessment of circulation and appropriate actions is summarized in Table 40.4.

Table 40.4 Assessment of circulation

Table 40.4 Assessment of circulation


Actions to be taken

  • Assess the adequacy of chest compressions

  • Assess the cardiac rhythm

  • Is there a requirement of defibrillation or cardioversion?

  • IV/IO access has been established and secured?

  • Is ROSC present?

  • Is there a need to administer medication for maintenance of pulse and blood pressure?

  • CPR quality can be monitored by intra-arterial pressure and end-tidal CO2 monitoring

  • Provide defibrillation/cardioversion as necessary

  • Obtain IV/IO access

  • Intravenous fluids to be administered if needed

  • Drugs are required to maintain rhythm and blood pressure to be administered as needed

  • Glucose and temperature to be monitored

Abbreviations: CPR, cardiopulmonary resuscitation; IO, intraosseous; IV, intravenous; ROSC, return of spontaneous circulation.


  • Check for neurologic function.

  • Check for the pupillary response, level of consciousness, and responsiveness.

  • Alert, voice, pain, unresponsive (AVPU).


All clothing is removed and looked for obvious injuries, burns, bleeding, or any other signs of trauma.

Secondary Assessment

This involves a focused history and search for the cause of cardiac arrest. A focused history is recommended by the American Heart Association (AHA) using the mnemonic SAMPLE.

S—signs and symptoms.


M—medications (including the last dose taken).

P—past medical history.

L—last meal consumed.


The most common causes of cardiac arrest should be kept in mind while managing cardiac arrest (Table 40.5).

Table 40.5 Common causes of cardiac arrest

Table 40.5 Common causes of cardiac arrest




Tension pneumothorax



Hydrogen ions (acidosis)



Thrombosis (pulmonary)


Thrombosis (coronary)

When the patient shows ROSC, post cardiac arrest care should be initiated.

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).

Following 2 minutes of uninterrupted CPR, a rhythm check should be done, which should not exceed 10 seconds. Other noteworthy points are as follows:

  • In the case of no electrical activity, epinephrine bolus is given, and chest compressions should be resumed.

  • If electrical activity is present, then the pulse should be palpated.

  • If palpable, then post cardiac arrest care is initiated.

  • 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).

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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

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:

  • Optimization of oxygenation and ventilation.

  • Optimization of hemodynamics.

  • Initiation of targeted temperature management.

  • Immediate coronary reperfusion by per­cutaneous coronary intervention (PCI).

  • Immediate neurologic care.

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.

Optimization of Oxygenation and Ventilation

  • An advanced airway can be placed for mechanical support of breathing in an unconscious/unresponsive patient.

  • Continuous waveform capnography to be used to confirm and monitor correct endotracheal tube (ETT) placement.

  • Excessive ventilation should be avoided.

  • 100% oxygen can be administered until the patient arrives in an advanced center and reduced thereafter to maintain a saturation of at least 94%.

Optimization of Hemodynamics

  • Intervene whenever systolic blood pressure (SBP) < 90 mm Hg, initially by obtaining intravenous (IV) access.

  • Fluid bolus—1 to 2 L to be administered, normal saline or Ringer lactate.

  • Norepinephrine (0.1–0.5 µg/kg/min)/epine­phrine (0.1–0.5 µg/kg/min) or dopa­mine (5–10 µg/kg/min) infusion titrated to attain SBP > 90 mm Hg or a mean arterial pressure of > 65 mm Hg.

Initiate Targeted Temperature Management

  • 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.

Immediate Coronary Reperfusion by PCI

Twelve-lead ECG should be obtained, and in cases of ST-elevation myocardial infarction (STEMI) or high suspicion of acute myocardial infarction (AMI), reperfusion should be planned and performed.

Immediate Neurologic Care

A neurologic assessment should be done, and targeted temperature monitoring (TTM) should be considered if the patient does not follow commands.

The prognostication of neurological outcome should be done after 72 hours of spontaneous circulation return in those who did not receive TTM and after 72 hours of TTM in those who received it.

Pediatric CPR

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.

The 2015 AHA guidelines for CPR and ECC on pediatric BLS continue to emphasize the five components of high-quality CPR, which include:

  • Ensuring chest compressions of adequate rate.

  • Ensuring chest compressions of adequate depth.

  • Allowing full chest recoil between compressions.

  • Minimizing interruptions in chest compressions.

  • Avoiding excessive ventilation.


Rate: 100 to 120/min.

Location: In infants, two fingers are used, placed below the inframammary line on the sternum.

In children, the lower half of the sternum (avoiding the xiphoid process) with one or two hands.

Depth of compression: One-third of the antero­posterior diameter of the chest (approximately 1.5 inches [4 cm] in infants to 2 inches [5 cm] in children).

The guidelines also recommend the usage of feedback devices to ensure adequate rate and depth.

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.

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Dec 11, 2022 | Posted by in ANESTHESIA | Comments Off on CHAPTER 40 Cardiopulmonary Resuscitation

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