Cardiopulmonary resuscitation: What is new in 2017

Abstract

A timely and effective cardiopulmonary resuscitation (CPR) is crucial for saving lives of the individuals who suffer sudden cardiac arrest. Different relevant authorities have published guidelines for educating the caregivers in delivering effective CPR. The present report summarizes the recent changes in the CPR guidelines.

Full text

147
© 2017 Journal of Clinical and Preventive Cardiology | Published by Wolters Kluwer - Medknow
A timely and effective cardiopulmonary resuscitation (CPR) is crucial for saving lives of the
individuals who suffer sudden cardiac arrest. Different relevant authorities have published
guidelines for educating the caregivers in delivering effective CPR. The present report
summarizes the recent changes in the CPR guidelines.
Keywords: Cardiac arrest, debrillation, sudden cardiac death
Cardiopulmonary Resuscitation: What is New in 2017
ST Yavagal1, DM
Access this article online
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Website: www.jcpconline.org
DOI: 10.4103/JCPC.JCPC_24_17
Address for correspondence: Dr. ST Yavagal, DM,
1782, 34th Cross, 14th Main, BSK 2nd Stage, Bengaluru - 560 070,
Karnataka, India.
E-mail: styavagal@yahoo.co.in
Recently, the American Heart Association (AHA) has updated
the guidelines for CPR and Emergency Cardiac Care (ECC).[4]
There are several suggested changes including the system care,
continuous quality improvement, education and continuous
updating of guidelines. The AHA ECC committee has set an
impact goal of doubling bystander CPR rate and doubling
the cardiac arrest survival by 2020. In total, there are 315
recommendations which are discussed in 15 sections.
Evolution of cardiopulmonary resuscitation
In 1960, Kouwenhoven (retired, engineer), Jude (surgical
resident), and Kriscker Bocker (engineer) published an
article titled - “survival of a patient with closed chest cardiac
massage” from John Hopkins Hospital. This was based on their
experience in animal studies. In 1960, a combination of closed
chest compression with rescue breathing was introduced.
In 1962, DC debrillator was introduced. In 1966, the CPR
guidelines were developed by the AHA and periodically these
guidelines are updated.[5] During the past 50 years, early
recognition and activation of emergency medical system, early
CPR, and early debrillation has saved many lives around the
world. In 1970, trained ambulance personnel started treating
OHCA. Today, trained lay persons have started initiating the
treatment for OHCA.[6]
PArt 2: evIdence revIew And guIdelIne
develoPMent
In 2015 guidelines – Scientic Evidence Evaluation and
Review System – a web-based resource which will be
continuously updated has been introduced instead of periodical
review. The International Liaison Committee on Resuscitation
and International Consensus on CPR and ECC science with
Review Article
IntroductIon
Today, medical profession and media have educated
the public regarding coronary artery disease and
hypertension. However, the most neglected eld is sudden
cardiac death (SCD). Thousands of people are dying outside
the hospital due to SCD. In India, survival rate following
SCD is <1%. Thus, there is a need for updating ourselves
with the recent changes in the concept of cardiopulmonary
resuscitation (CPR) and to create awareness about performing
high-quality CPR.
sudden cArdIAc deAth
SCD is the leading cause of death globally, and the incidence
of SCD is increasing in India also. The global incidence of
out-of-hospital cardiac arrest (OHCA) is 62/10,000. Estimated
survival to hospital discharge is 8% and not much has changed
for many years. In the USA alone, 275,000 sudden deaths per
year occur as OHCA. Unfortunately, often the rst sign of
cardiovascular disease (CVD) is the last sign in SCD. Nearly
50% of all deaths in ST‑elevation myocardial infarction and
50% of all CVD deaths are due to SCD. Nearly 80% of all
SCDs are due to ventricular arrhythmias.[1] Obviously, OHCA
is a major public health problem that has not been addressed
adequately. The survival rate can be improved if high-quality
CPR is attempted.[2] In-hospital cardiac arrests (IHCAs) occur
in 3–6/1000 hospital admissions. These are often secondary to
hypotension and shock which is the end result of physiological
deterioration from the underlying medical conditions such as
infections, renal failure, anemia, toxins, electrolyte imbalance,
hypoxia, drugs, and trauma. In these cases, the best approach is
treating the underlying disease to prevent cardiac arrest. These
patients tend to have a better survival to discharge (37%).
PArt 1: executIve suMMAry
In 2010 guidelines, the new approach to primary cardiac
arrest (PCA) was cardio-cerebral resuscitation (CCR). Classic
CPR should be reserved for secondary cardiac arrest (SCA).[3]
1Department of Cardiology,
Kempegowda Institute of
Medical Sciences, Bengaluru,
Karnataka, India
Received: June, 2017.
Accepted: June, 2017.
AbstrAct
How to cite this article: Yavagal ST. Cardiopulmonary resuscitation: What
is new in 2017. J Clin Prev Cardiol 2017;6:147-53.
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148 Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 4 ¦ October-December 2017
treatment recommendations were used in 2015 AHA update.
They categorized the recommendations as Class I, II, III and
level of evidence as a, b, c.
Class (strength of recommendation)
• I – Strong
• IIa – Moderate
• IIb – Weak
• IIIa – No benet
• IIIb – Harmful.
Level (quality) of evidence
a. High-quality evidence from randomized clinical trials
and meta-analysis
b. R – moderate-quality evidence from randomized trials
NR - moderate-quality evidence from nonrandomized
trials
c. Poor - expert opinion based on clinical experience.
Thus, 2015 guidelines are evidence-based recommendations.
OHCA and IHCA care must function differently. The
education of both lay rescuers and health-care providers must
be targeted.
Cardiac arrest
There are two types of cardiac arrest – primary and secondary.
Primary cardiac arrest
It is an unexpected, witnessed (seen or heard) collapse
in a person who is not responsive. Gasping occurs in
majority (55%) of patients in OHCA and is often interpreted
as breathing. Here, heart suddenly stops pumping blood and
the arterial blood is oxygenated at the time of the arrest. About
70%–80% of patients with OHCA have PCA.[7]
Secondary cardiac arrest
SCA is secondary to severe hypoxia often from drowning,
respiratory failure, drug overdose, or hypotension due to shock
or hemorrhage. Classic CPR should be reserved for SCA.
PArt 3: ethIcAl Issues
Ethical issues related to CPR are discussed. However, no
clear-cut recommendations are made.
PArt 4: systeM cAre And QuAlIty
IMProveMent
The AHA 2015 guidelines suggest that OHCA and IHCA care
must function differently. For OHCA, a cardiac resuscitation
center (CRC) such as a hospital with all facilities should be
recognized. The contact number of CRC should be known
to all people in that area. When a cardiac arrest occurs, the
bystander needs to inform the CRC. It is expected that the
person at the CRC – (1) will ask the bystander to start chest
compressions at a rate of 100–120/min, (2) will arrange
to send the ambulance with all facilities, and (3) using the
available technologies, will summon the nearest CPR-trained
person to the rescue spot (Class IIb). With this approach,
bystander initiation of CPR has been shown to increase to
62% versus 48% in control group.[8] Use of debrillator by
lay person continues to improve survival. Dispatcher should
provide compression-only-CPR (CO-CPR) instruction to
caller (Class I).
For IHCA, the medical emergency team or rapid response
team should be formed at institution level which can include
trained experts in advance life support. In the event of a
cardiac arrest in the indoor patient ward, the available staff
can initiate the treatment and simultaneously send the call
to the rapid response team. Implementation of these systems
and methods can improve the survival rate in both OHCA and
IHCA.
PArt 5: Adult bAsIc lIfe suPPort
In 2015, the AHA published CPR guidelines that included
major changes as compared to the earlier guidelines.[4,9]
In the earlier guidelines, the recommendations included the
initial sequence of steps known as, A B C; where A = airway,
B = breathing, and C = chest compression. The current
guidelines now recommend the sequence as, C A B, except in
newborns. “Look, listen, and feel” is no longer recommended,
instead here is an increased focus on methods to ensure
high‑quality CPR. Rapid identication of potential cardiac
arrest is important. An unconscious person with an abnormal
or absent breathing or agonal gasp is a sign of cardiac
arrest (Class IIa). Rescuer should activate emergency response
system without leaving the victim. CPR should be started
before the rhythm is identied and should be continued.
1. Chest compressions of adequate rate (100–120/min)
(Class IIa)
2. Chest compression of adequate depth. In adults, at least
2 inches (5 cm); in children, about 2 inches (5 cm); and
in infants, depth of 1/3rd of the anteroposterior (AP)
diameter of the chest are recommended
3. Allowing complete chest recoil after each compression
4. Minimizing interruptions in compression
5. Avoiding excessive ventilation
6. Emergency cardiac treatment such as routine atropine,
cricoid pressure, and airway suctioning is no longer
recommended
7. If multiple rescuers are available, they should rotate the
task of compressions every 2 min.
Indications of cardiopulmonary resuscitation
CPR should be performed immediately on any person who
has become unconscious and is found to be pulseless. Loss of
effective cardiac activity is generally due to the spontaneous
initiation of a nonperfusing arrhythmia, sometimes
referred to as malignant arrhythmias. The most common
being ventricular brillation (VF), pulseless ventricular
tachycardia (VT), pulseless electrical activity, asystole, and
pulseless bradycardia.
Contraindications of cardiopulmonary
resuscitation
The only absolute contraindication to CPR is a “do not
resuscitate” order. A relative contraindication is if a clinician
justiably feels that the intervention would be medically futile.
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Standard cardiopulmonary resuscitation
procedure
CPR should be started before the rhythm is identied and
should be continued. In its full standard form, CPR comprises
three steps:
• Chest compression
• Airway
• Breathing.
Chest compression
It is not cardiac massage but a compression and decompression
maneuver. Each compression is in accordance with the
patient’s heart beat. If the chest compressions are interrupted
for any reason, blood ow to the heart and brain essentially
stops, decreasing the chance for neurologically intact survival.
Idris et al.[10] observed in their study that the highest rate of
return to spontaneous circulation is at a chest compression
rate of about 125/min. Other studies further showed that
the compression depth becomes shallow if it is done at a
rate more than 120/min. Thus, on the basis of the available
evidence, the optimum compression rate as recommended
should be 100–120/min.[11] Depth of at least 2 inches or 5 cm
for an average adult is needed while avoiding excessive chest
compression depth (>2.4 inches or 6 cm) (Class I). However,
this is challenging without a feedback device. The key thing
to keep in mind while doing CPR is “push hard and push
fast.” Matlock[12] demonstrated that singing, humming, or
listening to songs during CPR improved the compliance,
predictable return of spontaneous circulation (ROSC), and
imparted neurologically intact survival; however, this is not
recommended in the guidelines.
Compression-only-cardiopulmonary
resuscitation versus standard
cardiopulmonary resuscitation
In CO-CPR, the provider delivers only chest compressions at
a rate of 100–120/min with a depth of 2 inches without pause
until the arrival of the medical team. Chest compressions
should be continued through debrillation or resumed
immediately without any postshock pulse check since ROSC
is not instantaneous even after successful debrillation.
The initiation of bystander resuscitation, especially when
begun within 1 min of arrest, markedly improves the survival.
In the study by Becker et al.,[13] survival was more than
four times greater in patients who received early bystander
resuscitation. Further, a meta-analysis of several observational
studies showed higher survival rate in CO-CPR compared to
standard CPR.[14] CO-CPR is clearly better than no CPR and
this should be the primary message to be conveyed to all
health-care professionals and general population.
PArt 6: AlternAtIve technIQues
Automated cardiopulmonary resuscitation
Three types of automated compressors are available:
1. Pneumatically driven piston compressors
2. Active compression-decompression device (LUCAS)
3. Load-distributing band compression (AutoPulse)
These devices improve coronary perfusion pressure during
IHCA compared to manual compression. ASPIRE study
showed that survival to discharge was better with AutoPulse
than manual CPR.[15] LINC[16] and PARAMEDIC[17] trials are
large ongoing randomized trials evaluating the prehospital use
of mechanical compression-decompression devices. Routine
use of these mechanical devices is not recommended at
present. They can be used in hospital settings where standard
CPR is difcult, for example, during transport or when
access to patient is limited such as CPR during percutaneous
coronary intervention (PCI). If these devices are used, it is
important to provide training to minimize interruptions in
chest compression during the use of the device. Most of the
studies did not demonstrate the superiority of mechanical
chest compressions over conventional CPR. Thus, manual
chest compression remains the standard of care.
Ventilation
Present guidelines have repositioned airway and breathing
below circulation in SCA from a cardiac cause. SCA from
pulmonary cause, for example, drowning, choking, and
respiratory failure in whom oxygen reserve is likely to
be depleted, the airway and breathing should be restarted
as quickly as possible. If patient is not breathing, two
ventilations are given through providers’ mouth or bag-valve
mask. This can be challenging to perform correctly and
is best done by two trained rescuers. It is recommended
that tidal volume of 500 ml should be delivered in 1 s.
In effective mouth-to-mouth ventilation, chest should
rise with each ventilation. If not, it indicates inadequate
mouth seal or airway occlusion. Two ventilations should
be given in sequence after 30 compressions (30:2). When
breaths are completed, compressions are restarted. If
available, a barrier device (pocket mask or face shield)
should be used. Ventilations should be provided every 6–8 s
(8–10 breaths/min). Ambu bag is sufcient. Higher ventilation
rate can increase intrathoracic pressure resulting in diminished
venous return and reduced cardiac output. It can also cause
gastric ination which increases the risk of aspiration and can
impede ventilation further by elevating the diaphragm and
restricting the lung expansion. Endotracheal tube placement
should be done when possible. If possible, it should be
conrmed by continuous wave capnography and should
be connected to the ventilator (Class I). Ultrasound is an
additional method. “Death by Hyperventilation,” an editorial
by Aufderheide and Lurie,[18] stresses that frequent forcible
ventilation decreases survival. 100% oxygen can be used.
The use of maximal feasible inspired oxygen during CPR is
strengthened. This recommendation applies only while CPR is
ongoing and does not apply to care after ROSC.
Gasping is a sign of cardiac arrest with an adequate perfusion to
the brain. Untreated gasping lasts for 4–5 min. If compressions
are initiated while patient is gasping or soon after gasping
stops, the patient is likely to continue or resume gasping.
Gasping results in ventilation with a negative intrathoracic
pressure and is associated with increased survival. In Arizona
study,[7] survival of patients with OHCA was 9% when CPR
was applied and patient was not gasping, but 39% if patient
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was gasping during CPR. Gasping is more physiological than
any form of positive ventilation. Positive ventilation increases
intrathoracic pressure, intracerebral pressure and decreases
venous return to the thorax and subsequent cardiac output.[19]
Debrillation
Early debrillation is critical to survival after SCA. The
most frequent initial rhythm in OHCA is VF. The chance of
successful debrillation diminishes over time. Two high‑quality,
population-based cohort studies showed that the use of these
devices by bystanders doubles the survival after OHCA. It is
an effective treatment for VF or pulseless VT associated with
cardiac arrest. No specic training is required. The rescuer
simply follows the audiovisual instructions when the device
is switched on. It is very important to reduce the pauses in
chest compression during debrillation. One cycle of chest
compression is to be resumed immediately after shock without
waiting to look for pulse or rhythm. Even the interruptions in
the compression while preparing for debrillation result in a
drop in coronary perfusion pressure. Hence, every effort should
be made to minimize the interruption in compression (Class I).
Several studies[20] have shown that it is completely safe for
a rescuer wearing standard examination gloves to continue
chest compressions during the use of a biphasic debrillator
and self-adhesive pads. Automated external cardioverter
debrillator (AECD) is used in more intensively monitored
areas. They provide continuous monitoring with two pads
placed over the patient’s chest and automatically debrillate
a shockable rhythm. Ali et al.[21] in a prospective study of
55 patients at risk of pulseless VT/VF reported that the average
interval between onset of arrhythmia and rst debrillation
was 33 s and resulted in 94% of ROSC. AECD is safe and
likely results in early debrillation than standard telemetry
monitoring. However, its routine use is not recommended.
PArt 7: Adult AdvAnced cArdIovAsculAr
lIfe suPPort
Role of drugs in cardiopulmonary
resuscitation
Adrenaline (epinephrine)
Current guidelines recommend that adrenaline should be given
intravenously (IV) every 3–5 min during cardiac arrest (adult
1 mg, children 10 mcg/kg) (Class I). It increases the aortic
relaxation (diastolic) pressure and the rate of ROSC. However,
no difference in survival/hospital discharge was observed.
Large randomized trials are needed to resolve this uncertainty.
Regarding timing of administration, for nonshockable rhythm,
adrenaline gets priority. For shockable rhythm, debrillation
gets the priority.
Vasopressin, steroid, and epinephrine combo
Treatment with vasopressin, steroid, and epinephrine (VSE)
during CPR is found to be benecial (Class IIb). Spyros
et al. (2013)[22] in their randomized trial in patients with IHCA
observed that treatment with VSE followed by treatment of
survivors with daily steroids increased the frequency of being
discharged with a neurologically favorable outcome compared
to the patients receiving standard care with epinephrine
alone. VSE patients also had improved hemodynamic and
central venous oxygen saturation as well as less organ
dysfunction.[18,22]
Other drugs
Vasopressin is removed from the advanced cardiovascular
life support (ACLS) cardiac arrest algorithm. It simplied
the approach. IV atropine, brinolysis, routine uid loading,
and articial pacing have no effect on outcome. Sodium
bicarbonate is only to be used in prolonged resuscitation.
Delivery of drugs through a tracheal tube is no longer
recommended. Precordial thump recommendation is neither
for for nor against. Not recommended for OHCA.
Prognostication during cardiopulmonary
resuscitation
Low partial pressure of end-tidal carbon dioxide in intubated
patients after 20 min of CPR is associated with failure of
CPR. This should not be used in isolation and in nonintubated
patients.
Return of spontaneous circulation not rapidly
achieved - other options
Other options include mechanical CPR device, endovascular
assist device, intra-aortic balloon counter pulsation, and
extracorporeal CPR. Role of these options either alone or in
combination is not well understood.
PArt 8: PostresuscItAtIon cAre
The principles of postarrest care are:
1. To identify and treat the underlying etiology
2. To mitigate ischemia–reperfusion injury and prevent
secondary organ injury
3. To make accurate estimates of prognosis to guide the
clinical team and to inform the family when selecting
goals of continued care.
Apart from timely and effective CPR, optimal postresuscitation
care is also crucial for good outcomes. The two important
pillars of postresuscitation care are coronary angiogram (CAG)
and therapeutic hypothermia. Specic management includes
avoiding and immediately correcting hypotension and
hypoxemia.
Coronary angiogram/percutaneous coronary
intervention
A number of studies have documented the high prevalence of
acute coronary occlusion in patients resuscitated from OHCA.
Hence, CAG and coronary intervention should be performed
as an emergency (rather than late in the hospital or not at all)
for all OHCA even in comatose patients. In a retrospective
study[23] in survivors of IHCA caused by VF, 27% underwent
CAG, 17 patients had PCI, and 13 showed ST segment
elevation myocardial infarction (STEMI) or new left bundle
branch block. Patients who underwent CAG or PCI were
more likely to survive than those who did not. Survivors of
OHCA were treated with therapeutic hypothermia and CAG
was done. At least one signicant lesion in 58% of patients
without ST elevation was observed.[24] Thus, there is a need
for liberal use of CAG and stent or surgery PCI following
cardiac arrest.
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Therapeutic hypothermia
All comatose (i.e., lack of meaningful response to verbal
commands) adult patients with ROSC after cardiac arrest should
have targeted temperature management to select and maintain a
constant temperature between 32°C and 36°C for at least 24 h.
One should try to prevent fever. Routine cooling of patients after
ROSC using rapid infusion of cold saline is not recommended.
The use of mild (32°C–36°C) therapeutic hypothermia for
comatose postresuscitated cardiac arrest victims is accepted
by many resuscitation scientists. Two large randomized
prospective trials[25] showed improved survival and improved
neurologic function of survivors when therapeutic hypothermia
was used for comatose victims of OHCA. The AHA and
European Society of Cardiology recommend that induced
hypothermia may be considered for comatose adult patients
with ROSC after IHCA of any initial rhythm.
The different methods available for therapeutic hypothermia
include:
i. IV infusion of cold saline
ii. External cooling methods such as:
a. Cooling blankets
b. Icepacks to groin, axilla, and neck
c. Wet towels and fanning
d. Cooling helmet
e. Intravascular heat exchange device.
Hypothermia improves neurological outcome after ROSC. It
reduces metabolic rate. It suppresses many chemical reactions
associated with reperfusion injury and reduces mitochondrial
damage and apoptosis (programmed cell death). Possible
adverse effects of hypothermia are arrhythmias, infection,
and coagulopathy. Contraindications for hypothermia include
severe cardiogenic shock, life-threatening arrhythmias,
pregnancy, and patients with primary coagulopathy.
Postresuscitation care includes the use of amiodarone,
beta-blockers, and full cardiac evaluation which includes
electrocardiogram (ECG), echocardiogram, CAG, and
implantable cardioverter debrillator in selected cases.
Organ donation
All cardiac arrest persons who progress to death or brain death
should be evaluated as potential organ donators in settings
where program exists.
PArt 9: Acute coronAry syndroMe
It addresses prehospital and emergency department phase only.
Prehospital ECG recording (Class I) and computer-assisted
interpretation (Class 2b) or transmission of ECG to emergency
department physician (Class 2a) by trained staff in ambulance
is recommended. This will help in prearrival notication to
the hospital and/or prehospital activation of cath lab. If there
are no signs of STEMI on ECG, measurement of hs-cTnI or
hs-TnT can be done. Heparin and aspirin can be started at
prehospital level (Class 2b). Supplementary oxygen can be
given. Aim should be for primary PCI (Class I). If delay is
anticipated, thrombolysis should be given and the patient
should be shifted to PCI center (Class 2b).
PArt 10: sPecIAl cIrcuMstAnces
a. Opioid overdose: Naloxone administration by
nonhealth-care provider in opioid overdose is a new
recommendation
b. Drug toxicity: IV lipid emulsion in cardiac arrest due to
drug toxicity when CPR is failing is recommended
c. Cardiac arrest in later half of pregnancy: Left uterine
displacement to be done during CPR to avoid aortocaval
compression
d. Perimortem cesarean delivery (PMCD): PMCD should
be considered after 4 min after maternal cardiac arrest
when there is no ROSC (Class 2a).
PArt 11: PedIAtrIc bAsIc lIfe suPPort
Algorithm for one and two health-care providers has been
separated. CAB (Class 2b) not compression-CPR (Class 1)
is recommended. Rate of chest compression should be
100–120/min. Depth should be 1/3rd of AP diameter (Class 2a)
or 1.5 inches (4 cm) for infants and 2 inches (5 cm) for
children. Rescue breathing is required because of asphyxial
nature of the cardiac arrest. If unwilling or unable to deliver
breath, CO-CPR (Class 1) is recommended.
PArt 12: PedIAtrIc AdvAnced lIfe suPPort
Aggressive volume replacement/increase is not recommended.
Titrated uid therapy is indicated. There is limited survival
benet for routine use of atropine. Titration of CPR should
be done to achieve the BP target. Amiodarone/lignocaine is
acceptable for shock refractory VT/VF. Fever in comatose
children should be avoided. Hypothermia or normothermia
is equally benecial in comatose children. If hemodynamic
instability is present after cardiac arrest, patients should be
treated actively with uids/inotropes/vasopressin to maintain
systemic blood pressure.
PArt 13: neonAtAl resuscItAtIon
This is primarily for newborn infants. Guidelines remain
unchanged from 2010. There is increased focus on umbilical
cord management, maintaining normal temperature, accurate
determination of heart rate, and optimizing oxygen use. There
is de-emphasis on routine suctioning of meconium. Etiology is
always asphyxia. Hence, effective ventilation is critical.
PArt 14: educAtIon
Even today, there is low survival rate both in OHCA and IHCA.
High-quality training is needed for both lay public and health-care
professionals. Use of high‑delity manikins are recommended for
advanced life support training. It is benecial to use audiovisual
feedback devices during CPR training (Class IIb). More frequent
training instead of 2-year retraining cycle is useful. To reduce
the time taken for debrillation is needed. Communities may
consider training of bystanders in CO-CPR.
PArt 15: fIrst AId
First aid means helping behavior and initial care provided for
acute illness or injury. Training should include early recognition
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of stroke, hypoglycemia, how to manage chest wound without
no occlusive dressing, and dental avulsion. Trained persons
should be able to recognize symptoms of anaphylaxis.
Cardio-cerebral resuscitation
A new approach for patients with PCA has shown signicantly
increased survival. After introducing CCR program, which
stressed upon CO‑CPR, lay rescuer CPR increased from 28%
to 40% and resulted in 300% improvement (3.7%–17.6%) in
survival to hospital discharge [Figure 1].[26]
Community
• Recognition
PCA is an unexpected witnessed (seen or heard)
collapse in a person who is not responsive.
• Calling: 108
• CO-CPR:
• Place the person on hard surface
• Compression for 100–120/min of 2” depth, with
complete release after each compression.
Prehospital
PCA prohibits early intubation, advocates passive ventilation,
minimal interruption of chest compression, and encourages
early administration of epinephrine [Figure 2].
Hospital
In the past, comatose patients following OHCA were often
“medically abandoned.” Today, improved survival rate is
reported with the aggressive postresuscitation care which
includes:
1. Therapeutic mild hypothermia
2. Early CAG to open occluded coronary artery
3. With aggressive management of blood glucose,
ventilation to avoid hyperoxemia and hemodynamic
control, survival rate improves from 34% to 59% and
favorable neurological outcome from 39% to 55%.[27]
No new recommendations are added to the existing guidelines.
But there are few things that have been observed. Andersen
et al.[28] have reported that there is no benet with early
intubation within 15 minutes in IHCA. Survival benets
with intubation was 16% as against 19% in persons without
intubation. Reynolds et al.[29] have reported that shorter the
duration of resuscitation to get ROSC more favourable will
be the outcome. Rajan et al.[30] have reported that shorter the
ambulance response time better will be the prognosis.
conclusIon
Currently recommended initial sequence of steps in CPR
is no longer ABC. It is CAB. High-quality CPR with
minimum interruption should be our goal. Role of routine
use of drugs is unclear. However, epinephrine has got
some benets. After successful resuscitation, the focus
should shift to postresuscitation care which includes
maintenance of cardio-cerebral perfusion pressure, achieving
therapeutic hypothermia and early CAG. The four Cs of
CPR (compression, cardioversion, cooling, and cardiac
catheterization) are the only interventions which improve
survival rate in both OHCA and IHCA.
suMMAry
Guidelines now have changed from periodical review to
continuous update. Recommendations have AHA class
and level of evidence. There is tremendous potential for
increasing the survival in CA. Success in CPR depends on
prompt rescuer action, high-quality CPR, optimized ACLS,
and post-CA care. Thus, there is a need for high-quality
training for everyone.Figure 1: Components of cardio-cerebral resuscitation[6]
Figure 2: The prehospital component of cardio-cerebral resuscitation[6]
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Yavagal: CPR-What is new
153
Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 4 ¦ October-December 2017
Financial support and sponsorship
Nil.
Conicts of interest
There are no conicts of interest.
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