Update in cardiopulmonary resuscitation.

Despite the passage of 50 years since the introduction of closed chest compression and mouth-to-mouth rescue breathing as the techniques of modern cardiopulmonary resuscitation (CPR), the simple techniques remain the backbone of successful resuscitation of victims of cardiac arrest. In particular, the importance of high quality chest compressions is increasingly clear. Current evidence demonstrates chest compressions should be provided at a rate of 100 compressions a minute to a depth of 4 to 5 cm (1.5 to 2 inches) with full chest recoil between compressions. Additionally, all efforts should be made to minimize interruptions in chest compressions, including single shock defibrillation and elimination of pulse check postdefibrillation in favor of continued chest compressions immediately postshock. The emphasis on high quality chest compressions is echoed in the most recent CPR guidelines of the American Heart Association and the International Liaison Committee on Resuscitation. The role of rescue breathing is currently debated; however, it is likely important in prolonged arrests or those of non-cardiac etiology. Current recommendations encourage inclusion of rescue breaths by trained responders, but allow for elimination of rescue breathing and emphasis on chest compressions for responders untrained or unconfident in rescue breathing. Early defibrillation is a key component to successful resuscitation of ventricular tachycardia and ventricular fibrillation arrest; however, implementation of defibrillation should be coordinated with CPR to minimize interruptions in chest compressions. Aside from early defibrillation, there are no clear adjuncts to CPR that improve survival. However, postresuscitation therapies such as therapeutic hypothermia may become an important part of early resuscitation management as tools to provide hypothermia become increasingly portable and capable of rapid cooling.

Update on cardiopulmonary resuscitation.

Adult cardiopulmonary resuscitation (CPR) has been shown to improve survival for individuals suffering cardiac arrest. Despite this, the delivery of basic life support to victims outside the clinical environment remains poor, particularly as only a minority receive resuscitation. In addition, research continues to examine the optimal techniques for CPR and guidelines have been modified to reflect the latest developments. These guidelines are a compromise between simplicity and effectiveness. While the core of the guidelines remains unchanged, the latest recommendations focus on minimising any delay in the assessment of the collapsed patient and the initiation of CPR. They also address the recent body of opinion promoting compression-only CPR as an alternative to the combined technique of compression and mouth-to-mouth ventilation. Throughout the guidelines a more pragmatic approach to resuscitation is adopted to try to encourage all individuals, whether trained healthcare professionals or lay people, to initiate resuscitation. An acknowledgement of the reasons why individuals may be reluctant to start resuscitation through fear or anxiety will hopefully help to encourage the instigation of these techniques. This overview will summarise the guidelines and highlight alterations or alternatives where appropriate.

Survival is similar after standard treatment and chest compression only in out-of-hospital bystander cardiopulmonary resuscitation.

BACKGROUND: We sought to compare the 1-month survival rates among patients after out-of-hospital cardiac arrest who had been given bystander cardiopulmonary resuscitation (CPR) in relation to whether they had received standard CPR with chest compression plus mouth-to-mouth ventilation or chest compression only. METHODS AND RESULTS: All patients with out-of-hospital cardiac arrest who received bystander CPR and who were reported to the Swedish Cardiac Arrest Register between 1990 and 2005 were included. Crew-witnessed cases were excluded. Among 11,275 patients, 73% (n=8209) received standard CPR, and 10% (n=1145) received chest compression only. There was no significant difference in 1-month survival between patients who received standard CPR (1-month survival=7.2%) and those who received chest compression only (1-month survival=6.7%). CONCLUSIONS: Among patients with out-of-hospital cardiac arrest who received bystander CPR, there was no significant difference in 1-month survival between a standard CPR program with chest compression plus mouth-to-mouth ventilation and a simplified version of CPR with chest compression only.

Coastal Fishermen as Lifesavers While Sailing at High Speed: A Crossover Study.

PURPOSE: Starting basic cardiopulmonary resuscitation (CPR) early improves survival. Fishermen are the first bystanders while at work. Our objective was to test in a simulated scenario the CPR quality performed by fishermen while at port and while navigating at different speeds. METHODS: Twenty coastal fishermen were asked to perform 2 minutes of CPR (chest compressions and mouth-to-mouth ventilations) on a manikin, in three different scenarios: (A) at port on land, (B) on the boat floor sailing at 10 knots, and (C) sailing at 20 knots. Data was recorded using quality CPR software, adjusted to current CPR international guidelines. RESULTS: The quality of CPR (QCPR) was significantly higher at port (43% ± 10) than sailing at 10 knots (30% ± 15; p = 0.01) or at 20 knots (26% ± 12; p = 0.001). The percentage of ventilation that achieved some lung insufflation was also significantly higher when CPR was done at port (77% ± 14) than while sailing at 10 knots (59% ± 18) or 20 knots (57% ± 21) (p = 0.01). CONCLUSION: In the event of drowning or cardiac arrest on a small boat, fishermen should immediately start basic CPR and navigate at a relatively high speed to the nearest port if the sea conditions are safe.

Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group.

Incorrectly performed bystander CPR might compromise survival of the cardiac arrest patient. We therefore evaluated the outcome in 3306 out-of-hospital primary cardiac arrests of which 885 received bystander CPR. bystanders performed CPR correctly in 52%, incorrectly in 11%, 31% performed only external chest compressions (ECC) and 6% only mouth-to-mouth ventilation (MMV). The initial ECG in cases without bystander CPR was ventricular fibrillation in 28% (95% confidence interval: 27-30%); 45% (41-50%) and 39% (29-48%), respectively when bystander CPR was performed correctly or incorrectly; 43% (37-49%) when only ECC was applied and 22% (11-33%) when only MMV was practiced. Long term survival, defined as being awake 14 days after CPR, was 16% (13-19%) in patients with correct bystander CPR; 10% (7-14%) and 2% (0-9%), respectively when only ECC or only MMV was performed; 7% (6-8%) when no bystander was involved; 4% (0-8%) when bystander CPR was performed incorrectly. Bystander CPR might have a beneficial effect on survival by maintaining the heart in ventricular fibrillation by ECC. A negative effect of badly performed bystander CPR was not observed compared to cases which had not received bystander CPR.

[Changes in the management of cardiac arrest]. / Changements dans la prise en charge de l'arrêt cardiaque.

NEW RECOMMENDATIONS: for cardio-pulmonary resuscitation Methods such as mouth to mouth or the search for a pulse, until now the fundamental preliminaries, have now become second line. Everything must be organised to allow for defibrillation as rapidly as possible. NEW MODALITIES FOR CARDIAC MASSAGE: The frequency of compressions recommended is currently 100 per minute in the adult with a rhythm of compression-ventilation reaching 15/2 before intubation. Concerning the haemodynamic agents for cardiac arrest, the efficacy of high doses of adrenalin is not greater than with conventional doses. Vasopressin is not superior to intravenous adrenalin regarding survival at 24 hrs exepet in case of asystoly. Dopamine at a "renal" dose is no longer used. ANTIARRYTHMICS: Amiodarone is part of the decisional tree in the case of ventricular fibrillation or ventricular tachycardia without a pulse. Semi-automatic defibrillator accessibility should be generalized. INFUSED SOLUTIONS: Sodium bicarbonate does not improve the survival except in particular cases. Physiological serum should be preferred to glucosed serum during reanimation.

[Cardiopulmonary resuscitation via telephone instruction. Chest compression more appropriate for instruction via telephone than CPR]. / Telefoninstruktion i hjärt-lungräddning. Bröstkompressioner lämpligare behandling för teleinstruktion än HLR.

Cardiopulmonary resuscitation (CPR) initiated by a bystander prior to arrival of the ambulance increases the chance of survival 2-3 times. Unfortunately a majority of patients do not receive such treatment. One way to approach the problem is to let the dispatcher instruct the witness in CPR via telephone when a presumed cardiac arrest occurs. In a recently performed study in Seattle patients with a presumed cardiac arrest were randomized to receive either traditional CPR (mouth-to-mouth ventilation plus chest compressions) or only chest compressions. Treatment was given by a witness via telephone instruction by the dispatcher. Among patients who only received chest compressions 14.6% could be discharged from hospital compared with 10.4% among patients who received traditional CPR. The difference was not significant. The results indicate that telephone instruction in CPR when a presumed cardiac arrest occurs might in certain cases preferably be restricted to chest compressions. The results of the trial are, however, difficult to translate into Swedish conditions, since ambulance response times in Sweden are much longer than in Seattle.

Microglial depletion using intrahippocampal injection of liposome-encapsulated clodronate in prolonged hypothermic cardiac arrest in rats.

Trauma patients who suffer cardiac arrest (CA) from exsanguination rarely survive. Emergency preservation and resuscitation using hypothermia was developed to buy time for resuscitative surgery and delayed resuscitation with cardiopulmonary bypass (CPB), but intact survival is limited by neuronal death associated with microglial proliferation and activation. Pharmacological modulation of microglia may improve outcome following CA. Systemic injection of liposome-encapsulated clodronate (LEC) depletes macrophages. To test the hypothesis that intrahippocampal injection of LEC would attenuate local microglial proliferation after CA in rats, we administered LEC or PBS into the right or left hippocampus, respectively. After rapid exsanguination and 6min no-flow, hypothermia was induced by ice-cold (IC) or room-temperature (RT) flush. Total duration of CA was 20min. Pre-treatment (IC, RTpre) and post-treatment (RTpost) groups were studied, along with shams (cannulation only) and CPB controls. On day 7, shams and CPB groups showed neither neuronal death nor microglial activation. In contrast, the number of microglia in hippocampus in each individual group (IC, RTpre, RTpost) was decreased with LEC vs. PBS by ∼34-46% (P<0.05). Microglial proliferation was attenuated in the IC vs. RT groups (P<0.05). Neuronal death did not differ between hemispheres or IC vs. RT groups. Thus, intrahippocampal injection of LEC attenuated microglial proliferation by ∼40%, but did not alter neuronal death. This suggests that microglia may not play a pivotal role in mediating neuronal death in prolonged hypothermic CA. This novel strategy provides us with a tool to study the specific effects of microglia in hypothermic CA.

Outcomes of chest compression only CPR versus conventional CPR conducted by lay people in patients with out of hospital cardiopulmonary arrest witnessed by bystanders: nationwide population based observational study.

OBJECTIVE: To compare the effectiveness of cardiopulmonary resuscitation (CPR) with chest compression only and conventional CPR on outcomes after cardiopulmonary arrest out of hospital. DESIGN: Nationwide population based observational study. SETTING: A nationwide emergency medical service system in Japan. Population All consecutive patients with out of hospital cardiopulmonary arrest, January 2005 to December 2007 in Japan, witnessed at the moment of collapse. Lay people attempted chest compression only CPR (n = 20,707) or conventional CPR (mouth to mouth ventilation and chest compression) (n = 19,328), and patients were transferred to hospital by ambulance. MAIN OUTCOME MEASURES: Factors associated with better outcomes (assessed with χ(2), multiple logistic regression analysis, odds ratios and their 95% confidence intervals): one month survival and neurologically favourable one month survival rates defined as category one (good cerebral performance) or two (moderate cerebral disability) of the cerebral performance categories. RESULTS: Conventional CPR was associated with better outcomes than chest compression only CPR, for both one month survival (adjusted odds ratio 1.17, 95% confidence interval 1.06 to 1.29) and neurologically favourable one month survival (1.17, 1.01 to 1.35). Neurologically favourable one month survival decreased with increasing age and with delays of up to 10 minutes in starting CPR for both conventional and chest compression only CPR. The benefit of conventional CPR over chest compression only CPR was significantly greater in younger people in non-cardiac cases (P = 0.025) and with a delay in start of CPR after the event was witnessed in non-cardiac cases (P = 0.015) and all cases combined (P = 0.037). CONCLUSIONS: Conventional CPR is associated with better outcomes than chest compression only CPR for selected patients with out of hospital cardiopulmonary arrest, such as those with arrests of non-cardiac origin and younger people, and people in whom there was delay in the start of CPR.

Continuous chest compression resuscitation in arrested swine with upper airway inspiratory obstruction.

BACKGROUND: This study was designed to compare 24-h survival rates and neurological function of swine in cardiac arrest treated with one of three forms of simulated basic life support CPR. METHODS: Thirty swine were randomized equally among three experimental groups to receive either 30:2 CPR with an unobstructed endotracheal tube (ET) or continuous chest compression (CCC) CPR with an unobstructed ET or CCC CPR with a collapsable rubber sleeve on the ET allowing air outflow but completely restricting air inflow. The swine were anesthetized but not paralyzed. Two min of untreated VF was followed by 9 min of simulated single rescuer bystander CPR. In the 30:2 CPR group, each set of 30 chest compressions was followed by a 15-s pause to simulate the realistic duration of interrupted chest compressions required for a single rescuer to deliver 2 mouth-to-mouth ventilations. The other two groups were provided continuous chest compressions (CCC) without assisted ventilations. At 11 min post-arrest a biphasic defibrillation shock (150 J) was administered followed by a period of advanced cardiac life support. RESULTS: In the 30:2 group, 8 of 10 animals had good neurological function at 24-h post-resuscitation. In the CCC open airway group, 10 of 10, and in the CCC inspiratory obstructed group, 9 of 10. The number of shocks (P<0.05) and epinephrine doses (P<0.05) required for ROSC was greater in the 30:2 CPR group than in the other two groups. CONCLUSIONS: There were no differences in 24-h survival with good neurological function among these three different CPR protocols.

[Rescue breathing is still a part of basic life support]. / Kunstigt åndedraet udgør fortsat en del af basal genoplivning.

Bystander cardiopulmonary resuscitation (CPR) consisting of mouth-to-mouth ventilation and chest compressions improves survival from cardiac arrest. Bystanders perform CPR only in a minority of cardiac arrests. To improve the number of bystanders initiating CPR, the American Heart Association recommends that laypersons omit rescue breathing and perform Hands-only CPR. In this paper studies on Hands-only CPR are reviewed. Currently, the evidence is insufficient to herald immediate changes to CPR guidelines and further research is warranted.

Role of mouth-to-mouth rescue breathing in bystander cardiopulmonary resuscitation for asphyxial cardiac arrest.

There is increasing evidence that mouth-to-mouth rescue breathing may not be necessary during brief periods of bystander cardiopulmonary resuscitation (CPR) for ventricular fibrillation. In contrast to ventricular fibrillation cardiac arrests, it has been assumed that rescue breathing is essential for treatment of asphyxial cardiac arrests because the cardiac arrests result from inadequate ventilation. This review explores the role of mouth-to-mouth rescue breathing during bystander CPR for asphyxial cardiac arrests. Clinical data suggest that survival from apparent asphyxial cardiac arrest can occur after CPR consisting of chest compressions alone, without rescue breathing. Two randomized, controlled swine investigations using models of bystander CPR for asphyxial cardiac arrest establish the following: a) that prompt initiation of bystander CPR is a crucially important intervention; and b) that chest compressions plus mouth-to-mouth rescue breathing is markedly superior to either technique alone. One of these studies further demonstrates that early in the asphyxial pulseless arrest process doing something (mouth-to-mouth rescue breathing or chest compressions) is better than doing nothing.

Alternative ventilation strategies in cardiopulmonary resuscitation.

The introduction of the 2000 Guidelines for Cardiopulmonary Resuscitation emphasizes a new, evidence-based approach to the science of ventilation during cardiopulmonary resuscitation (CPR). New laboratory and clinical science underemphasizes the role of ventilation immediately after a dysrhythmic cardiac arrest (arrest primarily resulting from a cardiovascular event, such as ventricular defibrillation or asystole). However, the classic airway patency, breathing, and circulation (ABC) CPR sequence remains a fundamental factor for the immediate survival and neurologic outcome of patients after asphyxial cardiac arrest (cardiac arrest primarily resulting from respiratory arrest). The hidden danger of ventilation of the unprotected airway during cardiac arrest either by mouth-to-mouth or by mask can be minimized by applying ventilation techniques that decrease stomach gas insufflation. This goal can be achieved by decreasing peak inspiratory flow rate, increasing inspiratory time, and decreasing tidal volume to approximately 5 to 7 mL/kg, if oxygen is available. Laboratory and clinical evidence recently supported the important role of alternative airway devices to mask ventilation and endotracheal intubation in the chain of survival. In particular, the laryngeal mask airway and esophageal Combitube proved to be effective alternatives in providing oxygenation and ventilation to the patient in cardiac arrest in the prehospital arena in North America. Prompt recognition of supraglottic obstruction of the airway is fundamental for the management of patients in cardiac arrest when ventilation and oxygenation cannot be provided by conventional methods. "Minimally invasive" cricothyroidotomy devices are now available for the professional health care provider who is not proficient or comfortable with performing an emergency surgical tracheotomy or cricothyroidotomy. Finally, a recent device that affects the relative influence of positive pressure ventilation on the hemodynamics during cardiac arrest has been introduced, the inspiratory impedance threshold valve, with the goal of maximizing coronary and cerebral perfusion while performing CPR. Although the role of this alternative ventilatory methodology in CPR is rapidly being established, we cannot overemphasize the need for proper training to minimize complications and maximize the efficacy of these new devices.

Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation.

BACKGROUND: Despite extensive training of citizens of Seattle in cardiopulmonary resuscitation (CPR), bystanders do not perform CPR in almost half of witnessed cardiac arrests. Instructions in chest compression plus mouth-to-mouth ventilation given by dispatchers over the telephone can require 2.4 minutes. In experimental studies, chest compression alone is associated with survival rates similar to those with chest compression plus mouth-to-mouth ventilation. We conducted a randomized study to compare CPR by chest compression alone with CPR by chest compression plus mouth-to-mouth ventilation. METHODS: The setting of the trial was an urban, fire-department-based, emergency-medical-care system with central dispatching. In a randomized manner, telephone dispatchers gave bystanders at the scene of apparent cardiac arrest instructions in either chest compression alone or chest compression plus mouth-to-mouth ventilation. The primary end point was survival to hospital discharge. RESULTS: Data were analyzed for 241 patients randomly assigned to receive chest compression alone and 279 assigned to chest compression plus mouth-to-mouth ventilation. Complete instructions were delivered in 62 percent of episodes for the group receiving chest compression plus mouth-to-mouth ventilation and 81 percent of episodes for the group receiving chest compression alone (P=0.005). Instructions for compression required 1.4 minutes less to complete than instructions for compression plus mouth-to-mouth ventilation. Survival to hospital discharge was better among patients assigned to chest compression alone than among those assigned to chest compression plus mouth-to-mouth ventilation (14.6 percent vs. 10.4 percent), but the difference was not statistically significant (P=0.18). CONCLUSIONS: The outcome after CPR with chest compression alone is similar to that after chest compression with mouth-to-mouth ventilation, and chest compression alone may be the preferred approach for bystanders inexperienced in CPR.

Accidents, near accidents and complications during anaesthesia. A retrospective analysis of a 10-year period in a teaching hospital.

A retrospective analysis is presented of all reports of faults, accidents, near accidents and complications associated with anaesthesia in one hospital from 1978 to 1987. 113,074 anaesthetics were administered in that period, of which 97,496 were for noncardiac procedures. There were 148 reports; 39 were of dental damage. Peri-operative cardiac arrests during noncardiac surgery were reported 29 times. Sixteen of these were fatal. Anaesthesia was thought to have played an important role in 13 cardiac arrests (1 per 7500 anaesthetics) and six were not successfully resuscitated (1 per 16,250 anaesthetics). There were 12 reports of postoperative peripheral neuropathies (1 per 9422 anaesthetics). Failure to check, lack of vigilance and inattention or carelessness were the most frequently associated factors with the rest of the reports.

Cardiopulmonary resuscitation without ventilation.

Current resuscitation methods, although occasionally effective, rarely perform as well as initially anticipated. Some of the disappointment can be attributed to the difficulty of the task for many, including both professional and lay first responders. Significant attention has been paid recently to the need to simplify both the technique and the teaching of resuscitation. In considering simplification of the current resuscitation scheme, a logical start is an honest reappraisal of the importance and priorities of each of the once sacrosanct ABCs, specifically, establishment of an Airway, artificial Breathing (mouth-to-mouth breathing), and chest compressions for temporary Circulation. Experimental data continue to accumulate indicating that most important within this triad is circulation. Adequate oxygen exists within the blood during at least the first 10 mins of cardiac arrest. If circulation is provided to distribute such oxygen, no survival disadvantage results with chest compression-only basic life support (BLS) efforts. Even a totally occluded airway during the first 6 mins of cardiac arrest does not compromise survival if reasonable circulation is provided with chest compressions. Clinical studies support the same conclusion that what most influences survival in any BLS effort is circulation, not ventilation. Belgium investigators have shown equal survival rates among those treated with chest compressions plus ventilation and those who received chest compressions alone. Telephone dispatcher-guided BLS cardiopulmonary resuscitation (CPR) has likewise shown no survival disadvantage to chest compression-only CPR when compared with telephone-guided standard BLS CPR. Based on this reasoning, a new simplified BLS method has been proposed. "Staged" CPR consists of a strategy to initially teach laypersons a simplified approach to BLS, which requires only chest compressions and not mouth-to-mouth breathing. "Bronze" CPR, in which chest compression-only BLS is taught, was compared with the standard European Resuscitation Council BLS course for laypersons. Manikin "exit testing" at course completion has revealed significant advantages of the simplified approach compared with standard CPR courses for the lay public.