Cardiopulmonary Resuscitation (CPR)


Article Author:
Amandeep Goyal
Joseph Sciammarella
Austin Cusick


Article Editor:
Pujan Patel


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
9/21/2019 11:41:00 PM

Introduction

Cardiopulmonary resuscitation (CPR) is a collection of interventions performed to provide oxygenation and circulation to the body during cardiac arrest. Our current modern-day approach to this process stemmed from the work of a handful of doctors in the 1950s and has now evolved into the process that will be discussed further here. The most widely accepted guidelines in North America are those produced by the American Heart Association (AHA). These are published every 5 years, after the International Liaison Committee on Resuscitation (ILCOR) meeting. [1] 

Etiology

Every year almost 350,000 Americans die from heart disease. Half of these will die suddenly, outside of a hospital, because of the sudden cessation of spontaneous organized cardiac function. The most common cause of sudden cardiac arrest in adults is ventricular fibrillation. Although advances in emergency cardiac care continue to improve the chances of survival, sudden cardiac arrest remains a leading cause of death in many parts of the world. As of 2016, cardiac disease continues to be the leading cause of death in the United States.

Epidemiology

Seventy percent of cardiac arrests that occur outside of a hospital occur in the home. Half of these cardiac arrests are unwitnessed. Despite advances in emergency medical services, the survival rate remains low. Adult victims of non-traumatic cardiac arrest that receive resuscitation attempts by emergency medical services have a survival rate to hospital discharge of only 10.8%. In comparison, adult patients who experience cardiac arrest in a hospital setting have rates of survival to hospital discharge of up to 25.5%. [2]

Pathophysiology

The definitive treatment for ventricular fibrillation is electrical defibrillation. This is most often performed using an automated external defibrillator (AED). If an AED is not readily available for defibrillation, brain death is likely to occur in less than 10 minutes. CPR is a means of providing artificial circulation and ventilation until defibrillation can be performed. Conventional manual CPR, combining chest compressions with rescue breathing can provide up to 33% of normal cardiac output and oxygenation when done properly. [3]

History and Physical

Patients requiring CPR are unconscious and unresponsive with absent pulses. There is a prognostic benefit in determining the last time the patient was seen normal, or better yet, the time when pulses were lost. Additionally, collateral history from bystanders, family members, friends, and the primary care physician can help etiologic evaluation.

There are no specific physical examination findings, but signs of cyanosis and reduced peripheral perfusion can suggest a cause for the arrest.

Evaluation

The absence of a palpable pulse in an unresponsive patient indicates the need for CPR.

Treatment / Management

Note: The technique described here is intended for a healthcare provider performing one-rescuer CPR on an adult victim in the out-of-hospital setting. The modifications for children, infants, and for in-hospital CPR are listed below. These recommendations are current as of the 2015 American Heart Association's Guidelines update for CPR and Emergency Cardiac Care.

The immediate recognition of cardiac arrest is essential to both initiate the emergency medical services (EMS) response and to begin CPR as soon as possible. In this era of universal mobile phone availability, it is now possible to call 911 while remaining with the victim. Make sure that the scene is safe, then call for help. Simultaneously, begin CPR by first performing chest compressions (C), followed by opening the airway (A) and delivering rescue breaths (B) (the CAB sequence as compared to the former ABC sequence). The hands are placed on the lower half of the sternum, and chest compressions are begun at a rate of 100 to 120 compressions per minute. The goal is to depress the sternum to a depth of at least two inches while avoiding excessive depth of compressions. The chest wall should be allowed to recoil fully on the upstroke to maintain coronary artery perfusion pressure. [4] Thirty compressions are performed, followed by a brief pause for two rescue breaths. Because of the critical contribution of chest compressions to coronary artery perfusion, interruptions in chest compressions should be minimized, and any interruptions should be as short as possible when needed. [5][6]

After 30 chest compressions, the rescuer performs a head tilt/chin lift maneuver to open the airway (assuming there is no suspicion of a cervical spinal injury). If a cervical spine injury is suspected, the airway is opened by using the jaw-thrust maneuver without extending the head. Two rescue breaths are administered: the rescuer takes a "regular" breath (not deep or excessive) and delivers a rescue breath lasting approximately one second, which should be enough just to allow the chest to rise. The process is repeated for a second rescue breath prior to resuming chest compressions.

Ideally, a healthcare provider who is inclined to intervene as an out-of-hospital rescuer should have ready access to a barrier device such as a rescue mask. However, this is not always the case. Mouth-to-mouth rescue breaths have been the alternative, which many untrained rescuers are hesitant to perform, especially on an unknown victim. This is a decision that healthcare providers must make for themselves. Compression-only CPR has been accepted as appropriate for untrained lay rescuers. If extenuating circumstances prohibit a healthcare provider in the out-of-hospital setting from performing rescue breathing without a barrier device, compression-only CPR should be performed until EMS arrives. [7][8]

The cycle of 30 chest compressions alternated with two rescue breaths is continued until an AED becomes available, or until additional help arrives.  If an AED arrives, its pads should be applied to the front and back of the patient, taking care to minimize any delay in restarting chest compressions.  Most modern devices verbalize further instructions—after attached to the patient, AEDs will detect the current cardiac rhythm and advise whether the patient should receive defibrillation.  If the AED advises shock, cease chest compressions and stay clear of the patient until defibrillation is completed.  After defibrillation is completed, or if no shock is advised, immediately resume cycles of chest compressions and rescue breaths following the CAB sequence until additional help arrives.

Differential Diagnosis

A quick physical exam focused on palpable pulses and mental status is important as sometimes drug overdose including heavy alcohol intake may mimic cardiac arrest.

Prognosis

According to 2015 AHA data, survival to hospital discharge in patients who experience out-of-hospital cardiac arrest remains low at 10.6%.  8.3% of patients experiencing cardiac arrest out-of-hospital will be discharged with good neurologic function.  Witnessed cardiac arrests in patients receiving high-quality CPR have better prognosis, with 25.5% of patients surviving to hospital discharge.

Complications

Cardiac arrest carries a dismal prognosis--most patients do not survive.  In those that do survive, their hospital course can be complicated by varying degrees of neurologic injury due to hypoxic encephalopathy.  All organ systems can suffer ischemic injury.  Chest compressions when performed correctly can cause rib fractures, which may be complicated by pneumothorax.

Deterrence and Patient Education

In the event of cardiac arrest, the patient's family and/or their surrogate or power of attorney should be notified.  It is important to ascertain the patient's code status, and any prior directives should be honored if appropriate documentation in accordance with laws of the local jurisdiction can be obtained.

Pearls and Other Issues

Pediatric CPR

By definition, infant CPR applies to patients whose age is less than one year. Child CPR applies to patients from one year of age through puberty. From puberty onward, adult CPR guidelines apply. The modifications for infant and child CPR are listed below. All other aspects of CPR follow the adult guidelines, including starting the process with the Compression first (CAB) sequence, and the rate of compressions being 100 to 120 per minute. The sternum should be depressed to a depth of approximately one-third of the anteroposterior diameter of the chest; this is about two inches in the child, and 1.5 inches in the infant. [9]

Child CPR Modifications

Chest compressions on a child are performed by placing the heel of one or two hands (depending on the size of the child) over the lower half of the sternum. The chest is compressed to a depth of approximately two inches, at a rate of 100 to 120 per minute. After 30 compressions, administer two sequential breaths and return to chest compressions. Continue the cycle of 30 compressions to two breaths until help arrives.

Infant CPR Modifications

Chest compressions on an infant are performed by placing two fingers on the sternum just below the nipple line. The infant's chest is compressed to a depth of approximately 1.5 inches, at a rate of 100 to 120 per minute. After 30 compressions, administer two sequential breaths and return to chest compressions. Continue the cycle of 30 compressions to two breaths until help arrives.

In-hospital CPR

In the hospital setting, multiple rescuers are generally available, and ventilation is usually performed with a bag-valve-mask (BVM) device. BVM ventilation needs to be performed by a provider skilled in its use. If the patient is not intubated, CPR is done by one provider performing chest compressions, while the second provider provides breaths with BVM ventilation. The ratio of compressions to breaths in this situation changes to 15 compressions to two breaths. Once a patient is intubated, it is unnecessary to perform cycles of compressions and ventilation--chest compressions are performed continuously, while rescue breaths are given independently via the BVM at a rate of 10 per minute (one breath every six seconds). Novice operators frequently tend to provide BVM ventilations at a higher rate than this.

Enhancing Healthcare Team Outcomes

All healthcare workers including nurses and pharmacists must know how to perform CPR. In fact many hospitals now make it mandatory that healthcare workers have a valid CPR certificate in order to work. When done promptly and properly, CPR can save lives.


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Cardiopulmonary Resuscitation (CPR) - Questions

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What is the drug of choice used during advanced cardiac life support (ACLS) of an adult?



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What is the correct sequence for adult basic CPR in the field?



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In adults, what percentage of normal, pre-arrest cardiac output can result from properly performed closed-chest cardiac massage?



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Which complication of cardiopulmonary resuscitation (CPR) is the leading cause of death in cardiopulmonary-resuscitated patients?



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During adult CPR, where should the hands be placed for the most effective chest compressions?



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According to the American Heart Association, what should be used to monitor intubated adult patients during CPR?



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When performing chest compressions over the xiphoid process during CPR, injury may occur to which of the following structures?



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How much should the sternum be depressed during adult CPR?



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How is exhalation achieved in a patient undergoing cardiopulmonary resuscitation?



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How many chest compressions should be performed each minute when administering cardiopulmonary resuscitation to children and adults?



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In addition to CPR, what is the most important factor in a successful resuscitation effort in a community setting?



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A woman is found with no pulse at her residence. What is the next step after calling 911?



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Which of the following is the most important when performing CPR on an adult?



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A 2 year old female has been brought to your facility in cardiopulmonary arrest. As a member of the code team, what device will best assist you in the care of this patient?

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According to Pediatric Advanced Life Support (PALS), pediatric dysrhythmias are divided into three basic classifications. Which of the following is not one of those classifications?

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A 17-year-old female arrives into the emergency department with resuscitative efforts in progress. She was found in the woods about five miles from her home. First responders report she was found by some hikers. A journal revealed she was a runaway in transit to a boyfriend's house. A cold front moved through the area with rain the night before. Core temperature on arrival is 26 C. Definitive airway is in place and compressions are in progress. Prolonged extrication time of 50 minutes. Aggressive rewarming techniques are underway. Paramedics report ventricular fibrillation upon movement to helicopter for transport. One attempt at defibrillation made and amiodarone administered. No response to rewarming has occurred thus far, and resuscitative efforts are proving to be futile. Which of the following will not aid the code team in their decision to stop life-sustaining measures?



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An infant has a pulse of 50 with mottling, capillary refill >2.0 seconds, and is lethargic despite oxygenation and ventilation attempt with normal blood glucose. What is the next step in the management of this infant?



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High-quality CPR is essential for a positive outcome in a cardiac arrest. Which of the following contributes to high-quality CPR?



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Pediatric bradycardia with a pulse and poor perfusion that persists after oxygenation and ventilation can be treated with which of the following medications if the result of a known vagal cause or primary AV block?



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Compression rate for infants and children should be?



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In pulseless VT or VF arrest, what is the dose of epinephrine given IV/IO?



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Of the following, what is the ideal method of monitoring cardiopulmonary resuscitation?



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You witness a child collapse. She is unresponsive and not breathing. No palpable pulse is detected over 10 seconds. What is the correct ratio of compressions to ventilation for a single-rescuer CPR?



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You are asked to teach infant CPR using the American Heart Association guidelines. Which of the following is the preferred site for pulse check in this age group?



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High-Quality CPR is an integral part of basic and advanced cardiovascular life support. What fundamental concepts indicate compressions are being performed appropriately? Select all that apply.



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A 65-year-old male with a history of coronary artery disease and congestive heart failure collapses. He is unresponsive and has no palpable pulses. As cardiopulmonary resuscitation (CPR) is started, he is placed on a cardiac monitor. What is his most likely cardiac rhythm?



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A 65-year-old female with a history of diabetes mellitus is found unresponsive and pulseless. After calling for help, what is the first step in management?



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A 65-year-old male is found unresponsive and pulseless in an airport. Cardiopulmonary resuscitation (CPR) is initiated with chest compressions. After two cycles of chest compressions and rescue breaths performed by a single rescuer, an automated external defibrillator (AED) arrives. A shockable rhythm is detected, and the AED performs defibrillation. What is the next step in management after the shock is delivered?



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A female is found unresponsive and pulseless after being submerged in a lake. Cardiopulmonary resuscitation (CPR) is initiated. An automated external defibrillator (AED) is brought, and after being applied to the patient, no shock is advised. What is the next step in the management of this patient?



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A 65-year-old male is brought to the resuscitation bay of the emergency department. He is unresponsive and pulseless, and he has no airway device in place. A bag valve mask (BVM) is available at the bedside for immediate use while further airway equipment is prepared. What modifications to cardiopulmonary resuscitation (CPR) should be made while the BVM is used before intubation?



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Cardiopulmonary Resuscitation (CPR) - References

References

Current Approaches to Cardiopulmonary Resuscitation., Truong HT,Low LS,Kern KB,, Current problems in cardiology, 2015 Jul     [PubMed]
ABC versus CAB for cardiopulmonary resuscitation: a prospective, randomized simulator-based trial., Marsch S,Tschan F,Semmer NK,Zobrist R,Hunziker PR,Hunziker S,, Swiss medical weekly, 2013 Sep 6     [PubMed]
Part 3: Adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations., Perkins GD,Travers AH,Berg RA,Castren M,Considine J,Escalante R,Gazmuri RJ,Koster RW,Lim SH,Nation KJ,Olasveengen TM,Sakamoto T,Sayre MR,Sierra A,Smyth MA,Stanton D,Vaillancourt C,, Resuscitation, 2015 Oct     [PubMed]
Compression-only CPR or standard CPR in out-of-hospital cardiac arrest., Svensson L,Bohm K,Castrèn M,Pettersson H,Engerström L,Herlitz J,Rosenqvist M,, The New England journal of medicine, 2010 Jul 29     [PubMed]
Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest., Bobrow BJ,Clark LL,Ewy GA,Chikani V,Sanders AB,Berg RA,Richman PB,Kern KB,, JAMA, 2008 Mar 12     [PubMed]
Chest compression depth and survival in out-of-hospital cardiac arrest., Vadeboncoeur T,Stolz U,Panchal A,Silver A,Venuti M,Tobin J,Smith G,Nunez M,Karamooz M,Spaite D,Bobrow B,, Resuscitation, 2014 Feb     [PubMed]
Giacoppo D, Impact of bystander-initiated cardiopulmonary resuscitation for out-of-hospital cardiac arrest: where would you be happy to have a cardiac arrest? European heart journal. 2019 Jan 14;     [PubMed]
Liao X,Chen B,Tang H,Wang Y,Wang M,Zhou M, [Effects between chest-compression-only cardiopulmonary resuscitation and standard cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest: a Meta-analysis]. Zhonghua wei zhong bing ji jiu yi xue. 2018 Nov;     [PubMed]
Maconochie IK,de Caen AR,Aickin R,Atkins DL,Biarent D,Guerguerian AM,Kleinman ME,Kloeck DA,Meaney PA,Nadkarni VM,Ng KC,Nuthall G,Reis AG,Shimizu N,Tibballs J,Pintos RV, Part 6: Pediatric basic life support and pediatric advanced life support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation. 2015 Oct;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Child Health PN. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Child Health PN, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Child Health PN, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Child Health PN. When it is time for the Nurse-Child Health PN board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Child Health PN.