cardiopulmonary resuscitation

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More about Cardiopulmonary Resuscitation (CPR): Purpose Precautions Preparation Aftercare Risks Normal results Abnormal results Resources

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the problem and notification of the emergency medical system (EMS), followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in attempt to get the heart to beat normally), and advanced cardiac life support measures.

CPR must be performed within four to six minutes after cessation of breathing so as to prevent brain damage or death. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to a person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate blood through the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest compression should be performed together, but if the rescuer is not strong enough to do both, the external chest compressions should be done. This is more effective than no resuscitation attempt, as is CPR that is performed "poorly."

When performed by a bystander, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.

According to the American Heart Association, early CPR and defibrillation combined with early advanced emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving emergency medical service personnel time to arrive.

However, many CPR attempts are not ultimately successful in restoring a person to a good quality of life. Often, there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for the chronically or terminally ill or frail elderly. For these people, it represents a traumatic and not a peaceful end of life.

Each year, CPR helps save thousands of lives in the United States. More than five million Americans annually receive training in CPR through American Heart Association and American Red Cross courses. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but use different terms. These organizations recommend that family members or other people who live with people who are at risk for respiratory or cardiac arrest be trained in CPR. A hand-held device called a CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines. CPR has been practiced for more than 40 years.

The basic procedure for CPR is the same for all people, with a few modifications for infants and children to account for their smaller size.

PERFORMING CPR ON AN ADULT. The first step is to call the emergency medical system for help by telephoning 911; then to begin CPR, following these steps:

• The rescuer opens a person's airway by placing the head face up, with the forehead tilted back and the chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing (mouth-to-mouth artificial respiration), pinching the nostrils shut while holding the chin in the other hand. The rescuer's mouth is placed against the unconscious person's mouth with the lips making a tight seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for a moment and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks the unconscious person's pulse by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the unconscious person has a heartbeat, the rescuer continues rescue breathing until help arrives or the person

• begins breathing without assistance. If the unconscious person is breathing, the rescuer turns the person onto his or her side.
• If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the unconscious person, placing the heel of one hand in the spot on the lower chest where the two halves of the rib cage come together. The rescuer puts one hand on top of the other on the person's chest and interlocks the fingers. The arms are straightened, the rescuer's shoulders are positioned directly above the hands on the unconscious person's chest. The hands are pressed down, using only the palms, so that the person's breastbone sinks in about1.5–2 inches. The rescuer releases pressure without removing the hands, then repeats about 15 times per 10–15 second intervals.
• The rescuer tilts the unconscious person's head and returns to rescue breathing for one or two quick breaths. Then breathing and chest compressions are alternated for one minute before checking for a pulse. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the unconscious person is breathing but has no pulse, the chest compressions are continued. If the unconscious person has a pulse but is not breathing, rescue breathing is continued.
• For children over the age of eight, the rescuer performs CPR exactly as for an adult.

PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT. The procedures outlined above are followed with these differences:

• The rescuer administers CPR for one minute, then calls for help.
• The rescuer makes a seal around the child's mouth or infant's nose and mouth to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1.5–2 seconds for each breath.
• Chest compressions are given with only one hand for a child and with two or three fingers for an infant. The breastbone is depressed only 1–1.5 in (2.5–3.8 cm) for a child and 0.5–1 in (1.3–2.5 cm) for an infant, and the rescuer gives at least 100 chest compressions per minute.

Some new ways of performing CPR have been tried. Active compression-decompression resuscitation, abdominal compression done in between chest compressions, and chest compression using a pneumatic vest have all been tested but none are currently recommended for routine use.

The active compression-decompression device was developed to improve blood flow from the heart, but clinical studies have found no significant difference in survival between standard and active compression-decompression CPR. Interposed abdominal counterpulsation, which requires two or more rescuers, one compressing the chest and the other compressing the abdomen, was developed to improve pressure and therefore blood flow. It has been shown in a small study to improve survival but more data is needed. A pneumatic vest, which circles the chest of an unconscious person and compresses it, increases pressure within the chest during external chest compression. The vest has been shown to improve survival in a preliminary study but more data is necessary for a full assessment.

— L. Fleming Fallon, Jr., MD, DrPH

An emergency procedure, often employed after cardiac arrest, in which cardiac massage, artificial respiration, and drugs are used to maintain the circulation of oxygenated blood to the brain.

Definition

Cardiopulmonary resuscitation, commonly called CPR, combines rescue breathing (one person breathing into another person) and chest compression in a lifesaving procedure performed when a person has stopped breathing or a person's heart has stopped beating.

Purpose

When performed quickly enough, CPR can save lives in such emergencies as loss of consciousness, heart attacks or heart "arrests," electric shock, drowning, excessive bleeding, drug overdose, and other conditions in which there is no breathing or no pulse. The purpose of CPR is to bring oxygen to the victim's lungs and to keep blood circulating so oxygen gets to every part of the body. When a person is deprived of oxygen, permanent brain damage can begin in as little as four minutes and death can follow only minutes later.

Description

There are three physical symptoms that indicate a need for CPR to be performed immediately and for emergency medical support to be called: unconsciousness, not breathing, and no pulse detected.

CPR in basic life support. Figure A: The victim should be flat on his back and his mouth should be checked for debris. Figure B: If the victim is unconscious, open airway, lift neck, and tilt head back. Figure C: If victim is not breathing, begin artificial breathing with four quick full breaths. Figure D: Check for carotid pulse. Figure E: If pulse is absent, begin artificial circulation by depressing sternum. Figure F: Mouth-to-mouth resuscitation of an infant. (Illustration by Electronic Illustrators Group.)

Unconsciousness

Unconsciousness is when the victim seems to be asleep but has lost all awareness and is not able to respond to questions or to touch or gentle shaking. A sleeping person will usually respond to a loud noise, shouting, or gentle shaking. An unconscious person will not respond to noise or shaking. When unconscious, a person can not cough or clear the throat, which can block the windpipe and cause suffocation and death. People with a major illness or injury or who have had recent surgery are at risk for losing consciousness. If the person has fainted, which is brief unconsciousness, the cause may be dehydration (lack of body fluids), low blood pressure, or low blood sugar. This is a temporary condition. If the victim is known to have diabetes, a bit of fruit juice may revive the person once they have regained consciousness.

Just before a person loses consciousness, symptoms may include:

• lack of response to voice or touch
• disorientation or stupor
• light-headedness
• headache
• sleepiness

Not Breathing

Not breathing, which is also called apnea, is the lack of spontaneous breathing. It requires immediate medical attention. The victim may become limp and lifeless, have a seizure, or turn blue. Prolonged apnea is called respiratory arrest. In children, this can lead quickly to cardiac arrest in which the heart stops beating. In adults, cardiac arrest usually happens first and then respiratory arrest. The common causes of apnea in adults are obstructive sleep apnea (something blocks the airway during sleep), choking, drug overdose, near-drowning, head injury, heart irregularities (arrhythmia, fibrillation) or cardiac arrest, nervous system disorders, or metabolic disorders. In children the causes may be different, such as prematurity, bronchial disturbances or pneumonia, airway blockage or choking on a foreign object, holding the breath, seizures, meningitis, regurgitating food, or asthma attacks.

No Pulse Detected

If the rescuer is unable to detect a pulse or has difficulty in feeling a pulse it can be an indication of the use of improper technique by the rescuer, or shock or cardiac arrest in the victim. If a sudden, severe decrease occurs in pulse quality (such as pulse weakness) or pulse rate (how many beats in a minute) when other symptoms are also present, life-threatening shock is suspected. The rescuer may need to explain to a doctor or medical professional where on the victim's body the pulse was measured, if the pulse is weak or absent altogether, and what other symptoms are present.

Medical help and CPR are needed immediately if any of these symptoms is found. Time is critical. A local emergency number should be called immediately. If more than one person is available to help, one can call 911 or a local emergency medical service, while the other person begins CPR. Ideally, someone CPR certified performs the procedure. Local medical personnel, a hospital, or the American Heart Association teaches special accredited CPR courses. If a critically ill patient or post-operative patient is being cared for at home, it is a good idea for a family member to take a CPR course to be better prepared to help in case of an emergency.

The steps usually followed in CPR are as follows:

• If the victim appears to be unconscious with either no breathing or no pulse, the person should be shaken or tapped gently to check for any movement. The victim is spoken to loudly, asking if he or she is OK. If there is no response, emergency help must be called and CPR begun immediately.
• The victim is placed on his or her back on a level surface such as the ground or the floor. The victim's back should be in a straight line with the head and neck supported slightly by a rolled up cloth, small towel, or piece of clothing under the neck. A pillow should not be used to support the head. The victim's clothing should be loosened to expose the chest.
• The rescuer kneels next to the victim, tilts the victim's head back, lifts the jaw forward, and moves the tongue forward or to the side, making sure it does not block the opening to the windpipe. The victim's mouth must be kept open at all times, reopening as necessary.
• The rescuer listens close to the victim's mouth for any sign of breathing, and watches the chest for movement. If the victim is found to be breathing, and has perhaps fainted, he or she can be placed in the recovery position until medical assistance arrives. This is done by straightening the victim's legs and pulling the closest arm out away from the body with the elbow at a right angle or 3 o'clock position, and the other arm across the chest. The far leg should be pulled up over the victim's body with the hip and knee bent. This allows the victim's body to be rolled onto its side. The head should be tilted back slightly to keep the windpipe open. The head should not be propped up.
• If the victim is not breathing, rescue breathing begins, closing the victim's nostrils between a thumb and index finger, and covering the victim's mouth with the rescuer's mouth. Two slow breaths, about two seconds each, are breathed into the victim's mouth with a pause in between. This is repeated until the chest begins to rise. The victim's head should be repositioned as often as necessary during the procedure. The mouth must remain open and the tongue kept away from the windpipe.
• When the chest begins to rise, or the victim begins to breathe on his or her own, the rescuer looks for signs of circulation, such as coughing or movement. If a healthcare professional has arrived by this time, the pulse will be checked before resuming resuscitation.
• If chest compressions are needed to restart breathing, the rescuer will place the heel of a hand above the lowest part of the victim's ribcage where it meets the middle-abdomen. The other hand will be placed over the heel of the first hand, with fingers interlocked. Keeping the elbows straight, the rescuer will lean his or her shoulders over the hands and press down firmly about 15 times. It is best to develop an up-and-down rhythm, keeping the hands firmly on the victim's chest.
• After the compressions, the rescuer will give the victim two long breaths. The sequence of 15 compressions and two breaths will be repeated until there are signs of spontaneous breathing and circulation or until professional medical help arrives.

Precautions

There are certain important precautions for rescuers to remember in order to protect the victim and get the best result from CPR. These include:

• Do not leave the victim alone.
• Do not give chest compressions if the victim has a pulse. Chest compression when there is normal circulation could cause the heart to stop beating.
• Do not give the victim anything to eat or drink.
• Avoid moving the victim's head or neck if spinal injury is a possibility. The person should be left as found if breathing freely. To check for breathing when spinal injury is suspected, the rescuer should only listen for breath by the victim's mouth and watch the chest for movement.
• Do not slap the victim's face, or throw water on the face, to try and revive the person.
• Do not place a pillow under the victim's head.

The description above is not a substitute for CPR training and is not intended to be followed as a procedure.

Normal Results

Successful CPR will restore breathing and circulation in the victim. Medical attention is required immediately even if successful CPR has been performed and the victim is breathing freely.

Prevention

Loss of consciousness is an emergency that is potentially life threatening. To avoid loss of consciousness and protect themselves from emergency situations, people at risk can follow these general guidelines:

• People with known conditions or diseases, such as diabetes or epilepsy, should wear a medical alert tag or bracelet.
• People with diabetes should avoid situations that will lower their blood sugar level.
• People who feel weak, become dizzy or light-headed, or have ever fainted, should avoid standing in one place too long without moving.
• People who feel faint, can lie down or sit with their head lowered between their knees.
• Risk factors that contribute to heart disease should be reduced or eliminated. People can reduce risks if they stop smoking, lower blood pressure and cholesterol, lose weight, and reduce stress.
• Illegal recreational drugs should be avoided.
• Seeing a doctor regularly and being aware of any disease conditions or risk factors can help prevent or complicate illness, as can seeking and following the doctor's advice about diet and exercise.
• Using seat belts and driving carefully can help avoid accidental injury.
• People with poor eyesight or those who have difficulty walking because of disability, injury, or recovery from illness, can use a cane or other assistance device to help them avoid falls and injury.

Resources

Organizations

American CPR Training. http://www.cpr-training-classes.com.

American Heart Association, National Center. 7272 Greenville Avenue, Dallas, TX 75231. http://www.americanheart.org.

Other

Emergency Cardiovascular Care. [cited April 2003]. http://www.cpr-ecc.org.

Severson, Todd. "Cardiopulmonary Resuscitation." MedlinePlus. April 2003 [cited April 2003]. http://www.nlm.nih.gov/medlineplus.

— L. Lee Culvert

A basic emergency procedure for life support, consisting of artificial respiration and manual external cardiac massage.

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for an infant, child, or adolescent who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Purpose

CPR is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. CPR can be performed by trained laypeople or healthcare professionals on infants, children, adolescents, and adults. CPR should be performed if an infant, child, or adolescent is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, asphyxiation, breathing passages that are blocked, choking, drowning, drug reactions or overdoses, electric shock, exposure to cold, severe shock, or trauma. In newborns, the most common cause of cardiopulmonary arrest is respiratory failure caused by sudden infant death syndrome (SIDS), airway obstruction (usually from inhalation of a foreign body), sepsis, neurologic disease, or drowning. Cardiac arrest in children over one year of age is most commonly caused by shock and/or respiratory failure resulting from an accident or injury.

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of cardiopulmonary arrest and notification of the emergency medical system (EMS), followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in attempt to get the heart to beat normally), and advanced cardiac life support measures. When performed by a layperson, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.

CPR must be performed within four to six minutes after cessation of breathing to prevent brain damage or death. CPR consists of rescue breathing, which delivers oxygen to the victim's lungs, and external chest compressions, which help circulate blood through the heart to vital organs.

CPR technique differs for infants, children, and adolescents. The American Heart Association and the American Red Cross, the two organizations that provide CPR training and guidelines, distinguish infants, children, and adolescents for the purposes of CPR as follows:

• "Infant" includes neonates (those in the first 28 days of life) and extends to the age of one year.
• "Child" includes toddlers aged one year to children aged eight years.
• "Adult" includes children aged eight years and older.

Because infants and children under the age of eight have smaller upper and lower airways and faster heart rates than adults, CPR techniques are different for them than for older children and adults. Children and adolescents aged eight years and older have reached a body size that can be handled using adult CPR techniques and are thus classified as adults for delivery of CPR and life support. CPR is always begun after assessing the victim and contacting EMS.

Performing Cpr on an Infant

For an infant, the rescuer opens the airway using a gentle head tilt/chin lift or jaw thrust, places their mouth over the infant's mouth and nose then delivers gentle breaths so that the infant's chest rises with each breath. Chest compressions are delivered by placing two fingers of one hand over the lower half of the infant's sternum slightly below the nipple line and pressing down about one half inch to one inch. Compressions are delivered at a rate of 100 times per minute, giving five chest compressions followed by one rescue breath in successive cycles.

Performing Cpr on a Child Aged One to Eight

For a child aged one to eight years, the compression rate is the same—five compressions and one rescue breath. Rescue breaths are delivered using a mouth-to-mouth seal, instead of mouth-to-mouth-and-nose. Chest compressions are delivered by placing the heel of one hand over the lower half of the sternum and depressing about one to one and one half inches per compression.

Performing Cpr on a Child Aged Eight and Older

For a child aged eight years and older, and for larger children under age eight, two hands are used for compressions, with the heel of one hand on the lower half of the sternum and the heel of the other hand on top of that hand. The chest is compressed about one and one half to two inches per compression. Rescue breaths are delivered with a mouth-to-mouth seal. The compression rate is 80 to 100 per minute delivered in cycles of 15 compressions followed by two rescue breaths.

Preparation

Before administering CPR to an infant or child, laypeople should participate in hands-on training. More than 5 million Americans annually receive training in CPR through American Heart Association and American Red Cross courses. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but they use different terms. CPR training should be retaken every two to three years to maintain skill level.

Precautions

CPR should not be performed based on the overview contained in this article. To prevent disease transmission during CPR, face masks and face shields are available to prevent direct contact during rescue breathing.

Aftercare

Emergency medical care is always necessary after CPR. Once a person's breathing and heartbeat have been is coming and talk positively until professionals arrive restored, the rescuer should make the person comfortable and stay there until emergency medical personnel arrive. The rescuer can continue to reassure the person that help and take over.

Risks

CPR can cause injury to a person's ribs, liver, lungs, and heart. However, these risks must be accepted if CPR is necessary to save the person's life.

Normal Results

In many cases, successful CPR results in restoration of consciousness and life. Barring other injuries, a revived person usually returns to normal functions within a few hours of being revived.

Abnormal results include injuries incurred during CPR and lack of success with CPR. Possible sites for injuries include a person's ribs, liver, lungs, and heart. Partially successful CPR may result in brain damage. Unsuccessful CPR results in death.

Parental Concerns

Because most cardiopulmonary arrest in infants and children occurs in or around the home and results from SIDS, trauma, drowning, choking, or poisoning, all parents and child caregivers should consider becoming trained in CPR. Training is available at local schools and community centers.

Resources

Books

Knoop, Kevin J., and Lawrence B. Stack. Atlas of Emergency Medicine, 2nd ed. New York: McGraw Hill, 2001.

Larmon, Baxter, et al. Basic Life Support Skills. Toronto, ON: Prentice Hall PTR, 2004.

Periodicals

Babbs, C. F., and V. Nadkarni. "Optimizing chest compression to rescue ventilation ratios during one-rescuer CPR by professionals and lay persons: children are not just little adults." Resuscitation 61, no. 2 (May 2004): 173–81

Kern, K. B., H. R. Halperin, and J. Field. "New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest." Journal of the American Medical Association 285 (2001): 1267–69.

Organizations

American College of Emergency Physicians. PO Box 619911, Dallas, TX 75261–9911. Web site: www.acep.org.

American College of Osteopathic Emergency Physicians. 142 E. Ontario Street, Suite 550, Chicago, IL 60611. Web site: www.acoep.org.

American Heart Association, National Center. 7272 Greenville Avenue, Dallas, TX 75231. Web site: www.americanheart.org.

Web Sites

"Cardiopulmonary Resuscitation." American Heart Association, 2004. Available online at www.americanheart.org/presenter.jhtml?identifier=4479 (accessed October 29, 2004).

"CPR and Emergency Cardiovascular Care." American Heart Association, 2004. Available online at www.americanheart.org/presenter.jhtml?identifier=3011764 (accessed October 29, 2004).

"Infant First Aid for Choking and CPR: An Illustrated Guide." BabyCenter, 2004. Available online at www.babycenter.com/general/9298.html (accessed October 29, 2004).

[Article by: Jennifer E. Sisk, MA]

For more information on cardiopulmonary resuscitation, visit Britannica.com.

An emergency lifesaving procedure used to revive someone who has stopped breathing or whose heart has ceased functioning. CPR uses heart massage and mouth-to-mouth resuscitation to get the heart or lungs working again. More recently, electric stimulation to the heart (using devices called defibrillators) has greatly increased the efficacy of this technique.

"CPR" redirects here. For other uses, see CPR (disambiguation).

CPR being performed on a mannequin used for training

The Wikibook First Aid has a page on the topic of Primary Assessment & Basic Life Support

Cardiopulmonary resuscitation (CPR) is an emergency medical procedure for a victim of cardiac arrest or, in some circumstances, respiratory arrest.^[1] CPR is performed in hospitals, or in the community by laypersons or by emergency response professionals.^[2]

CPR involves physical interventions to create artificial circulation through rhythmic pressing on the patient's chest to manually pump blood through the heart, called chest compressions, and usually also involves the rescuer exhaling in to the patient (or using a device to simulate this) to inflate the lungs and pass oxygen in to the blood, called artificial respiration.^[1][3] Some protocols now downplay the importance of the artifical respirations, and focus on the chest compressions only.^[4][5]

CPR is unlikely to restart the heart, but rather its purpose is to maintain a flow of oxygenated blood to the brain and the heart, thereby delaying tissue death and extending the brief window of opportunity for a successful resuscitation without permanent brain damage. Advanced life support and defibrillation, the administration of an electric shock to the heart, is usually needed for the heart to restart, and this only works for patients in certain heart rhythms, namely ventricular fibrillation or ventricular tachycardia, rather than the 'flat line' asystolic patient although CPR can help bring a patient in to a shockable rhythm.

CPR is generally continued, usually in the presence of advanced life support (such as from a medical team or paramedics), until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared dead.

Contents 1 History 2 Use in cardiac arrest 3 Guidelines 4 Alternative methods 4.1 Compression only (cardiocerebral) resuscitation 4.2 Rhythmic abdominal compressions 4.3 Self-CPR 5 Prevalence and effectiveness 5.1 Chance of receiving CPR 5.2 Chance of receiving CPR in time 5.3 Chance of surviving 5.4 Therapeutic Hypothermia 5.5 Chest compression adjuncts 5.5.1 Timing devices 5.5.2 Manual assist devices 5.5.3 Automatic devices 6 Place in film and television 6.1 Portrayed effectiveness 6.2 Stage CPR 7 Application on animals 8 See also 9 References 10 External links

History

Main article: History of CPR

Sign showing old Silvester and Holger-Nielson methods of resuscitation

In the 19th century, Doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation.^[6] The procedure is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in films made in the early part of the 20th century.

A second technique, called the Holger Neilson technique, described in the first edition of the Boy Scout Handbook in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, resting on the palms of both hands. Upward pressure applied at the patient’s elbows raised the upper body while pressure on their back forced air into the lungs, essentially the Silvester Method with the patient flipped over. This form is seen well into the 1950s (it is used in an episode of Lassie during the Jeff Miller era), and was often used, sometimes for comedic effect, in theatrical cartoons of the time (see Tom and Jerry's "The Cat and the Mermouse"). This method would continue to be shown, for historical purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in 1979. The technique was later banned from first-aid manuals in the UK.

However, it was not until the middle of the 20th century that the wider medical community started to recognize and promote artificial respiration combined with chest compressions as a key part of resuscitation following cardiac arrest. The combination was first seen in a 1962 training video called "The Pulse of Life" created by James Jude, Guy Knickerbocker and Peter Safar. Jude and Knickerbocker, along with William Kouwenhouen had recently discovered the method of external chest compressions, whereas Safar had worked with James Elam to prove the effectiveness of artificial respiration. It was at Johns Hopkins University where the technique of CPR was originally developed. The first effort at testing the technique was performed on a dog. Soon afterwards, the techique was used to save the life of a child. ^[7] Their combined findings were presented at annual Maryland Medical Society meeting on September 16, 1960 in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour they undertook. Peter Safar wrote the book ABC of resuscitation in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s. ^[8]

Artificial respiration was combined with chest compressions based on the assumption that active ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted without comparing its effectiveness with chest compressions alone. However, research over the past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressions alone (see Cardiocerebral resuscitation below).^[4]

Use in cardiac arrest

CPR training: CPR is being administrated while a second rescuer prepares for defibrillation.

The medical term for the condition in which a person's heart has stopped is cardiac arrest^[9] (also referred to as cardiorespiratory arrest). CPR is used on patients in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep vital organs alive.

Blood circulation and oxygenation are absolute requirements in transporting oxygen to the tissues. The brain may sustain damage after blood flow has been stopped for about four minutes^[10][11][12] and irreversible damage after about seven minutes.^[13][14] If blood flow ceases for 1 or 2 hours, the cells of the body die unless they get an adequately gradual bloodflow^{[citation needed]}, (provided by cooling and gradual warming, rarely, in nature [such as in a cold stream of water] or by an advanced medical team). Because of that CPR is generally only effective if performed within 7 minutes of the stoppage of blood flow.^[15] The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperatures as sometimes seen in near-drownings prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay brain death, and allows the heart to remain responsive to defibrillation attempts.

If the patient still has a pulse, but is not breathing, this is called respiratory arrest and artificial respiration is more appropriate. However, since people often have difficulty detecting a pulse, CPR may be used in both cases, especially when taught as first aid.

Guidelines

In 2005, new CPR guidelines^[16][17] were published by the International Liaison Committee on Resuscitation (ILCOR), agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.^[18][19] The primary goal of these changes was to simplify CPR for lay rescuers and healthcare providers alike, to maximize the potential for early resuscitation. The important changes for 2005 were:^[20]

• A universal compression-ventilation ratio (30:2) recommended for all single rescuers of infant (less than one year old), child (1 year old to puberty), and adult (puberty and above) victims (excluding newborns).^[21] The primary difference between the age groups is that with adults the rescuer uses two hands for the chest compressions, while with children it is only one, and with infants only two fingers (index and middle fingers).^[22] While this simplification has been introduced, it has not been universally accepted, and especially amongst healthcare professionals, protocols may still vary.^[23]
• The removal of the emphasis on lay rescuers assessing for pulse or signs of circulation for an unresponsive adult victim, instead taking the absence of normal breathing as the key indicator for commencing CPR.
• The removal of the protocol in which lay rescuers provide rescue breathing without chest compressions for an adult victim, with all cases such as these being subject to CPR.

Research^[16] has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and cannot accurately discern the absence of pulse in about 10%. The pulse check step has been removed from the CPR procedure completely for lay persons and de-emphasized for healthcare professionals.

Alternative methods

Compression only (cardiocerebral) resuscitation

The traditional International Liaison Committee on Resuscitation approach described above has been challenged in recent years by advocates for compression-only CPR, also known as cardiocerebral resuscitation (CCR). This technique is simply chest compressions without artificial respiration. The respiration component of CPR has been a topic of major controversy over the past decade. The CCR method has been championed by the University of Arizona's Sarver Heart Center, and a study by the university,^[24] claimed a 300% greater success rate over standard CPR.^[25] The exceptions were in the case of drowning or drug overdose.

In March 2007, a Japanese study in the medical journal The Lancet presented strong evidence that compressing the chest, not mouth-to-mouth (MTM) ventilation, is the key to helping someone recover from cardiac arrest.^[26] An editorial by Gordon Ewy MD (a proponent of CCR) in the same issue of The Lancet called for an interim revision of the ILCOR Guidelines based on the results of the Japanese study, but the next scheduled revision of the Guidelines was not until 2010. However, on March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that compression-only CPR works as well as, and sometimes better than, traditional CPR.^[27]

The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. It has been claimed that the use of compression only delivery increases the chances of lay person delivering CPR.^[28]

Rhythmic abdominal compressions

Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected to other sites, including the circulation around the heart. Findings published in the September 2007 issue of the American Journal of Emergency Medicine using pigs found that 60 percent more blood was pumped to the heart using rhythmic abdominal compression-CPR than with standard chest compression-CPR, using the same amount of effort. There was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. Avoiding mouth-to-mouth breathing and chest compressions eliminates the risk of rib fractures and transfer of infection.^[29]

Self-CPR

A form of "self-CPR" termed "Cough CPR" was the subject of a hoax chain e-mail entitled "How to Survive a Heart Attack When Alone" which wrongly cited "ViaHealth Rochester General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique.^[30][31]

Rapid coughing has been used in hospitals for brief periods of cardiac arrhythmia on monitored patients. One researcher has recommended that it be taught broadly to the public.^[32][33]

However, “cough CPR” cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness^[34] in which case coughing is impossible, although myocardial infarction (heart attack) may occur to give rise to the cardiac arrest, so a patient may not be immediately unconscious. Further, the vast majority of people suffering chest pain from a heart attack will not be in cardiac arrest and CPR is not needed. In these cases attempting “cough CPR” will increase the workload on the heart and may be harmful. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds.^[35]

The American Heart Association (AHA) and other resuscitation bodies^[36] do not endorse "Cough CPR", which it terms a misnomer as it is not a form of resuscitation. The AHA does recognize a limited legitimate use of the coughing technique:

"This coughing technique to maintain blood flow during brief arrhythmias has been useful in the hospital, particularly during cardiac catheterization. In such cases the patients ECG is monitored continuously, and a physician is present."^[37]

Prevalence and effectiveness

Chance of receiving CPR

Various studies suggest that in out-of-home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14%^[38] and 45%^[39] of the time, with a median of 32%. This indicates that around 1/3 of out-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable, and the studies suggest only around half of bystander CPR is performed correctly.^[40][41]

There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services.^[38][42] It was also found that CPR was more commonly given by a bystander in public than when an arrest occurred in the patient's home, although health care professionals are responsible for more than half of out-of-hospital resuscitation attempts.^[39] This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family.^[43] This is likely because of the shock experienced by finding a family member in need of CPR; it is easier to remain calm - and think clearly - when the person in need of CPR is a complete stranger, as in this case one will not be as frightened.

There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.^[43]

Finally, it has been claimed that there is a higher chance of CPR being performed if the bystander is told to only perform the chest compression element of the resuscitation.^[28]

Chance of receiving CPR in time

CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,^[44] because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 4–6 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge^[45] A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. Hypothermia seems to protect the victim by slowing down metabolic and physiologic processes, greatly decreasing the tissues' need for oxygen.^[46] There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia.^[47]

Chance of surviving

Used alone, CPR will result in few complete recoveries, and those that do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for defibrillation and advanced life support.^[48] However, in the case of "non-shockable" rhythms such as Pulseless Electrical Activity (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 5%-10% of people who receive CPR survive.^[49] The purpose of CPR is not to "start" the heart, but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, the current consensus is to perform CPR on a patient that is not breathing.

Studies have shown the importance of immediate CPR followed by defibrillation within 3–5 minutes of sudden VF cardiac arrest improve survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York City, without those advantages, the survival rate is only 1-2 percent.^[50]

In most cases, there is a higher proportion of patients who achieve a Return of Spontaneous Circulation (ROSC), where their heart starts to beat on its own again, than ultimately survive to be discharged from hospital (see table below). This is due to medical staff either being ultimately unable to address the cause of the arrhythmia or cardiac arrest, or in some instances due to other co-morbidities, due to the patient being gravely ill in more than one way.

Type of Arrest	ROSC	Survival	Source
Witnessed In-Hospital Cardiac Arrest	48%	22%	[51]
Unwitnessed In-Hospital Cardiac Arrest	21%	1%	[51]
Bystander Cardiocerebral Resuscitation	40%	6%	[52]
Bystander Cardiopulmonary Resuscitation	40%	4%	[52]
No Bystander CPR (Ambulance CPR)	15%	2%	[52]
Defibrillation within 3-5 minutes	74%	30%	[48][50]

ROSC = Return of spontaneous circulation

Therapeutic Hypothermia

Main article: Therapeutic hypothermia

In some cases, doctors may choose to induce hypothermia after return of spontaneous circulation (ROSC). This procedure is called therapeutic hypothermia. The first study conducted in Europe focused on people who were resuscitated 5-15 minutes after collapse. Patients participating in this study experienced spontaneous return of circulation (ROSC) after an average of 105 minutes. Subjects were then cooled over a 24 hour period, with a target temperature of 32-34°C (89.6-93.2°F). 55% of the 137 patients in the hypothermia group experienced favorable outcomes, compared with only 39% in the group that received standard care following resuscitation.^[53] Death rates in the hypothermia group were 14% lower, meaning that for every 7 patients treated one life was saved.^[53] Notably, complications between the two groups did not differ substantially. This data was supported by another similarly run study that took place simultaneously in Australia. In this study 49% of the patients treated with hypothermia following cardiac arrest experienced good outcomes, compared to only 26% of those who received standard care.^[54]

Chest compression adjuncts

Several different devices have become available in order to help facilitate rescuers in getting the chest compressions completed correctly. These devices can be split in to three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely.

Timing devices

They can feature a metronome (an item carried by many ambulance crews) in order to assist the rescuer in getting the correct rate. The CPR trainer cited here has timed indicators for pressing on the chest, breathing and changing operators.

Manual assist devices

Studies have shown that audible and visual prompting can improve the quality of CPR and prevent the decrease of compression rate and depth that naturally occurs with fatigue,^{[55][56][57][58][59][60]} and to address this potential improvement, a number of devices have been developed to help improve CPR technique.

These items can be devices to placed on top of the chest, with the rescuers hands going over the device, and a display or audio feedback giving information on depth, force or rate,^[61] or in a wearable format such as a glove.^[62] Several published evaluations show that these devices can improve the performance of chest compressions.^[63][64]

As well as use during actual CPR on a cardiac arrest victim, which relies on the rescuer carrying the device with them, these devices can also be used as part of training programmes to improve basic skills in performing correct chest compressions..^[65]

Certain defibrillation pads are capable of performing similar function, in that they may display rate and depth of compressions. Additionally, a certain algorithm may allow them to monitor electrical activity even during CPR.^[66].

Automatic devices

There are also some devices available which take over the chest compressions for the rescuer. These devices use techniques such as pneumatics to drive a compressing pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed air cylinders or lines available in ambulances or in hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure^[67] and return of spontaneous circulation.^[68]

Another system called the AutoPulse is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation.^[69][70]

Place in film and television

Portrayed effectiveness

CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a person who is not breathing and has no circulation. A 1996 study published in the New England Journal of Medicine showed that CPR success rates in television shows was 75% for immediate circulation, and 67% survival to discharge.^[71][72] This gives members of the public an unrealistic expectation of a successful outcome.^[71] When educated on the actual survival rates, the proportion of patients over 60 years of age desiring CPR should they suffer a cardiac arrest drops from 41% to 22%.^[73]

Stage CPR

Chest compressions are capable of causing significant local trauma. Performing CPR on a healthy person may or may not disrupt normal heart rhythm, but regardless the technique should not be performed on a healthy person because of the risk of trauma.

The portrayal of CPR technique on television and film often is purposely incorrect. Actors simulating the performance of CPR may bend their elbows while appearing to compress, to prevent force from reaching the chest of the actor portraying the victim. Other techniques, such as substituting a mannequin torso for the "victim" in some shots, may also be used to avoid harming actors.

Application on animals

It is entirely feasible to perform CPR on animals like cats and dogs. The principles and practices are virtually identical to CPR for humans. One is cautioned to only perform CPR on unconscious animals to avoid the risk of being bitten^[74] and that animals, depending on species, have a lower bone density than humans causing bones to become weakened after CPR is performed.

See also

• Basic Life Support (BLS)
• Cardiocerebral Resuscitation (CCR), a similar technique.
• CPR mask
• Resusci Anne
• Face shield
• Advanced life support

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External links

• 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
• ERC European Resuscitation Council
• Learn CPR - University of Washington
• Akuttjournalen.com - The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
• How Stuff Works - CPR

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v • d • e Lifesaving and lifeguarding International standards bodies International Lifesaving Federation · International Liaison Committee on Resuscitation National societies DLRG · Royal Life Saving Society Australia · Royal Life Saving Society of Canada · Royal Life Saving Society UK · Royal Life Saving Society Commonwealth · Surf Life Saving Australia · Surf Life Saving New Zealand · United States Lifesaving Association · Wasserwacht Topics Lifesaving · Lifeguard · Surf lifesaving · First aid · Cardiopulmonary resuscitation · Drowning chain Awards Bronze Medallion · Bronze Cross · National Lifeguard Service Equipment Lifebuoy · Rescue buoy · Throw bag · Life saving reel · IRB · Surf ski

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