Cardiopulmonary Resuscitation (CPR)

• Anybody dying needs to be rescued and resuscitated, including accidents or patients on admission.
• What is then done will depend on the condition, available human, and material resources.

What is CPR?

• Emergency life-saving procedure done when someone's breathing or heartbeat has or is near arrested.
• CPR may combine rescue breathing and chest compressions.
• Rescue breathing provides oxygen to the person's lungs, chest compressions push the blood round the body.

The Purpose of CPR

• Keep oxygenated blood flowing around the body to keep the vital organs alive. The heart, brain, and the adrenal glands are included.
• CPR is effective only if performed within seven minutes of the stoppage of blood flow.
• Compressions may not restart someone’s heart but will keep them alive until a defibrillator arrives.
• A defibrillator is a device which delivers an electrical shock to the heart to restart it.

How can I help someone who has collapsed?

• CVS: Ventricular Fibrillation, Ventricular Tachycardia, Asystole, Myocardial Infarction, Cardiac Arrest, electric shock, congestive heart failure, and bleeding.
• CNS: Head injury, Stroke, drug intoxication, or CNS infection.
• RS: Bronchospasm, foreign body aspiration, Respiratory infection, Drowning.
• GIT: Diarrhea and vomiting leading to dehydration, electrolyte imbalance, and shock.
• Other: Trauma, sepsis, Hypoglycemia, hypocalcemia, heat stroke, etc.
• May involve a patient on admission, an accident victim, or a bystander.

During a heart attack - part of the heart muscle is starting to die. It is caused by a blockage of a coronary artery by cholesterol deposits or a blood clot. Victims are usually fully conscious but feel severe pain. The most critical time is within the first 30 minutes.

Symptoms:

• Pain or pressure in the center of the chest – which lasts more than 3-5 minutes.
• Pain might feel like pressure, fullness, squeezing, or heaviness. It might spread to the shoulder, neck, lower jaw, and down the arm, usually the right.
• Pain might stutter, stop momentarily, but then begin again.
• Lightheadedness, fainting, sweating without fever, nausea, shortness of breath.
• Most victims will downplay symptoms, so you must take action!

What to do:

• Call emergency numbers if available and get the nearest AED (Automated External Defibrillator).
• Have the person rest in a comfortable position where they can breathe easily.
• Place them in an area where you can get them to the floor easily, and where paramedics can easily access them.

• Cardiac arrest occurs when the heart stops beating. It is usually caused by ventricular fibrillation (VF) or ventricular tachycardia (VT), which can begin when the heart muscle is injured.
• Without blood flow and no pulse, the person becomes unconscious, stops breathing, and collapses.
• VF and cardiac arrest may be the only symptom of a heart attack.
• The AED (Automated External Defibrillator) is the only thing that can stop a VF.

• It is a rapid onset of neurological problems like weakness, paralysis in one or more limbs, difficulty speaking, visual problems, intense dizziness, facial weakness, altered consciousness, and severe headache.
• Two causes:
  • Blood vessel to the brain is blocked by a blood clot.
  • Blood vessel to the brain breaks.
• #3 cause of death and #1 cause of serious disability among Americans.
• Most signs are overlooked; three major signs to observe:
  • Facial droop
  • Arm weakness – most obvious when the victim attempts to extend arms with eyes closed – one or both may not move very well
  • Speech difficulties – slurring of words and sentences
• Call emergency numbers immediately if you see signs of stroke.
• Provide CPR if needed.

Usually caused by food, but can be caused by many objects

• Major signs
  • Universal choking signal
  • Poor ineffective coughs
  • Inability to speak
  • High-pitched sounds while inhaling
  • Increased difficulty breathing
  • Blue lips or skin- cyanosis)
  • Loss of consciousness and responsiveness
• Perform the Heimlich maneuver in conscious victims:
  • Stand behind the victim and place your arms around their waist.
  • Make a fist with one hand and place the thumb side against the middle of the victim's abdomen, just above the navel.
  • Grasp your fist with your other hand and give quick, upward thrusts into the abdomen to force air from the lungs and help expel the obstructing object.
  • Repeat thrusts until the object is expelled or the victim can breathe or cough forcefully.
• Perform CPR in unconscious victims

• Basic life support (BLS):
  • Includes actions that can be taken by bystanders or at the roadside.
• Advanced life support (ALS):
  • Includes life support provided by trained individuals, often in a hospital setting.
  • Encompasses primary, secondary, and tertiary life support.
• Both involve an orderly sequence of the A, B, C, D, E, and F principles of resuscitation and more:
  • A = Airway clearance
  • B = Breathing
  • C = Circulating blood
  • D = Drug use
  • E = Emergency care
  • F = Follow-up

Five Links in the Chain of Survival

Each year, more than 250,000 Americans die from sudden cardiac arrest. According to medical experts, the key to survival is timely initiation of a "chain of survival,” including CPR.

The five links in the adult chain of survival are:

1. Immediate recognition of cardiac arrest and activation of the emergency response system
2. Early cardiopulmonary resuscitation (CPR) with an emphasis on chest compressions
3. Rapid defibrillation
4. Effective advanced life support
5. Integrated post-cardiac arrest care

American Heart Association

The term Chain of Survival provides a useful metaphor for the elements of the ECC systems concept.

http://www.heart.org/HEARTORG/CPRAndECC/WhatisCPR/AboutUs/Chain-of-Survival_UCM_307516_Article.jsp

Step One

Make sure the place is safe.

Check unresponsiveness: Tap and shout – “Are you alright?”
If no response – call emergency services or send someone directly to call.

Get AED or send someone to get it.

Do not delay. Someone collapsing is not likely to give optimal response.

A = Airway and Spinal Immobilization

• Feel for movement of air in expiration
• Adequacy of inspiratory effort
• Appropriate chest rise
• Signs of increased work of breathing like snoring, gurgling, stridor, gasping
• Tracheal centrality
• Airway is patent and clear

If patient is breathing, position of comfort or recovery position.

Clean the face, allow free flow of air.

Supplemental O2 (face mask, nasal prongs preferred) in advanced setting.

If not breathing with a clear airway, start CPR.

When airway is patent but spontaneous respiratory effort is inadequate (roadside):

• Mouth to mouth breathing
• Ensure no foreign body in the mouth
• Use clean handkerchief to cover the mouth
• Good mouth cover, a good chest rise, maintain a tight seal
• Reduce gastric distension by: cricoid pressure, little gastric pressure

B – Breathing

Assess the adequacy of minute ventilation (respiratory rate and tidal volume).

Inspect: skin color, mental status, work of breathing.

Auscultate: air entry, symmetry, abnormal breath sounds.

Pulse oximetry probe - assess oxygenation.

If airway is patent, minute ventilation appears adequate:
Give high flow oxygen pending objective assessment of arterial gases.

All seriously ill and injured patients should receive supplemental oxygen.

For airway is patent but spontaneous resp. effort is inadequate (advanced):

Positive pressure ventilation: AMBU bag with oxygen reservoir.

Indications include: Poor color or bradycardia unresponsive to supplemental oxygen. Gasping, periods of apnea. Progressive respiratory distress, appearance of respiratory fatigue.

If not successful, check equipment.

If ventilation by bag-valve-mask is not successful, go on to endotracheal intubation.

Partial or complete airway obstruction:

• Repositioning: Put in the sniff position using chin lift; jaw thrust (in trauma patient)
• Don’t hyperextend the neck
• Manually remove the foreign body, clean the face
• Suctioning: Blood, secretions, gastric contents
• An oral or nasal airway if above maneuvers fail in primary and secondary settings
• Orotracheal intubation may be required if the above BLS maneuver is not successful
• May need to breathe for the patient using AMBU bag or respirator

C- Circulation

• Early signs:
  • Tachycardia only
  • Cold, clammy extremities
  • Mottled or pale skin color
  • Delayed capillary refill time
  • Effortless tachypnea
  • Weak or absent peripheral pulses
  • Altered mental status and hypotension
• Trauma: Identify and control bleeding.
• Tie above the cut using clean means.
• Elevate the lower limbs.
• Prevent heat loss.
• If in shock, perform chest compression.

Chest Compressions:

Chest compressions: Perform chest compressions synchronized with ventilation.

Use a cardiac resuscitation board.

Pause periodically for return of heart rate, pulse, and respirations.

C – Circulation, advance

Initial priority in the treatment of shock:

• Restoring adequate perfusion of vital organs.
• Control of hemorrhage.
• Volume resuscitation in hypovolemic shock.
• Use of pressors should largely be reserved for cardiogenic, septic, or neurogenic shock.

Isotonic crystalloid, 20ml/kg as rapid as possible.

Further fluid of up to 60ml/kg if needed.

0.01 unit of adrenaline.

1-2mmol of HC03/kg in double dilution.

Begin CAB's

C = Circulation

• If not breathing or seeing abnormal breathing, begin chest compressions.
• Agnal breathing – gasps that occur at the beginning of cardiac arrest – not efficient – act as if they are not breathing.
• No checking for pulse or signs of circulation, just go straight to CPR.
• Place one palm on the chest between the nipple line.
• Interlock your other hand on top of the hand on the chest.
• Bring your shoulder over the top.
• Ensure you have a wide base (knees spread just outside your shoulders).
• Press down 1 ½ - 2 inches at a rate of 100 compressions per minute – hard and fast.
• Ensure the chest recoils completely.
• Complete 30 compressions and then give two breaths.
• Do not stop unless an AED is available, victim moves, or you are substituted out (if two rescuers are available – switch every five cycles of 30:2 – approx two minutes) – reduces fatigue.

Step Two

During the beginning stages of cardiac arrest, chest compressions are more important than breaths. Oxygen levels will stay high for the first few minutes, but blood is not moving due to the heart not pumping.

• Breathing becomes as important as the length of CPR continues.

Very important to limit interruptions of chest compressions.

Be mindful not to give too many breaths, too much breath, or too forceful – it may cause gastric filling and resultant complications, and/or diminish blood flow and reduce survival.

Vomiting/Other Breathing

• If someone does throw up – do not panic.
• Roll victim towards you. Use your body to hold them.
• Clean out the mouth – roll back and continue.

Mouth to nose: Use when it is impossible to use the mouth due to injury.

Face shields and masks – may be used:

• Very little chance of transfer of bodily fluids if performing mouth-to-mouth without a mask.
• Using shield or mask can slow down the CPR process.
• “Chest compression only” CPR is more beneficial than no CPR at all.

Recovery Position

If victim begins breathing and having a pulse, then turn the victim to their side with the lower arm in front.

No position is perfect - just make sure they are stable, near a true lateral position, and there is no pressure on the chest to impair breathing.

Endotracheal Intubation

Uncuffed endotracheal tube (age < 8 years)

• Size = age in years / 4 + 16 = inner diameter in mm

Difficult intubation secondary to severe facial or neck trauma OR complete upper airway obstruction.

Secure IV access

Get equipment ready: bag-mask ventilation

Equipment for intubation

Cricothyrotomy tray

Most intubations will be emergent, thus a rapid sequence induction with Sellick maneuver is preferred

It's possible to intubate without sedation and analgesic

Recommended to use analgesia to reduce metabolic stress

Pretreat children > 1 month with sedative and analgesia

Diazepam, midazolam, lorazepam

Opiates - fentanyl, remifentanil

Vecuronium, rocuronium, pancuronium

Needle Cricothyrotomy

Airway is obstructed and intubation has not succeeded

• Needle cricothyrotomy: a 12-14 gauge IV catheter with stylet.
• Inclined inferiorly at about 45 degrees
• Oxygen flushed through the catheter @ 10-15L/min
• This supports a child, even one with little or no respiration
• Plan for a more secured airway

Surgical Cricothyrotomy

Rarely necessary

• Performed by an experienced surgeon
• Complications include pneumothorax, bleeding, airway obstruction

Spinal Immobilization

In pediatric trauma patients

• Immobilize cervical spine in:

High velocity injury

Evidence of multiple trauma

Significant injury above the level of the clavicle

Part of prehospital care

Immobilize on a backboard

A = Airway

Head tilt and chin lift

B = Breathing

• If you do not detect normal breathing – give two breaths lasting 1 second each (may use barrier)
• Watch chest rise, allow exhalation before next breath.
• If breaths do not go in – reposition head and try again.

Practice

Potential Neck Injury

• If two or more responders:

One stabilizes the neck – they will be in charge if victim needs to be moved

Place hands on the sides of the head and neck, using your hands to cup around the neck.

Place pressure on the head with forearms near the ears

Elbows should be on the ground, wrists in ulnar deviation so that they come in contact with the head.

If movement is necessary then move the body as one.

Signs of end-organ perfusion:

Skin color, warmth, mental status, and urine output

The production of 1-2 ml/kg/hr of urine is indicative of adequate fluid resuscitation

Transfusion with packed cells may be necessary if an injured child fails to respond to 60 ml/kg of normal saline or lactated Ringer's solution.

Compression Rate and Depth

Age	Compression Rate (per minute)	Respiration Rate (per minute)	Tube Inner Diameter	Compression Depth (inches)
Newborn	100	20-24	3.5-4mm	2.5 inches
Child	80	16-20	4.5-6mm	2.0 inches
Teen	60	12-18	6-7.5mm	1.5 inches

• Airway clearance
• Breathing – self-inflating bag, bag and mask ventilation, or a mechanical ventilator.
• Circulation – chest wall compression HR <60bpm, 1:3 done synchronously. In extreme cases, support with adrenaline
• Drugs –
  • Reverse acidosis by giving a buffer i.e. HCO3, do not give in close circuit. Ensure the baby is ventilated or ventilating him/herself to prevent CO2 accumulation. 8.4% solution of NaHCO3 at a dose of 1-2mEq/kg initial dose.
  • In preterms, dilute HCO3 to 4.2% solution
  • Naxolone to reverse the effect of narcotic analgesic.
  • IV adrenaline if HR falls below 60
• E – institution of any emergency care e.g. transfusion, correct hypoglycemia – 200mg/kg/dose
• F – follow up care

What is Defibrillation?

• Electric shock to the heart
• Stops uncoordinated rhythm
• Allows return of regular rhythm and pulse
• Only definitive treatment for VF

Principles of Resuscitation

• Prompt and effective resuscitation
• Preventing further hypoxia, hypercapnia, and acidosis
• Post-resuscitation monitoring and O2 therapy
• Fluid and electrolyte therapy (restrict fluid – SIADH)
• Provision of calories
• Treatment of seizures – initially with phenobarbital 15-20mg/kg stat, then maintenance of 8mg/kg/12hr
• Monitor with seizure chart
• Monitor weight and other anthropometry
• Adequate nursing care
• Good family support and understanding
• Long-term care
• Prevention of recurrence in subsequent pregnancy

Decision to Continue Resuscitation or Not

To Continue:

• Intubate
• Administration of ionotropic agents
• Initiation of Mechanical Ventilation
• Drugs that can be administered endotracheally
• Epinephrine
• Atropine
• Naloxone
• Lidocaine

About 98% of pediatric patients undergoing resuscitation recover to a substantial degree.

Rates of discharge from hospital for children with prehospital cardiopulmonary arrest range from 0-21%.

Good neurologic outcome with rapid resuscitation in the field, arriving in the ED with a perfusing rhythm.

Patients who continue to be apneic and pulseless on arrival at the ED, though aggressive pharmacologic therapy may re-establish a perfusing cardiac rhythm, brain death or survival with serious neurologic impairment is the rule.

• Most injuries are preventable.
• Early recognition and treatment of many illnesses can prevent the need for emergency care.
• Education for parents and caregivers on the importance of first-aid training, recognizing signs and symptoms of serious illnesses or significant injury, and when to seek immediate medical care.
• Providing standard handouts and diagnosis-driven discharge instructions, along with verbal communication during first-aid/CPR classes.
• Office preparedness:
  • CPR needs are relatively infrequent in an office setting.
  • Primary health providers and staff should be prepared for patients with impending shock, respiratory failure, seizures, or deteriorating conditions while waiting.
  • Staff training and education.
  • Established policies and procedures for emergency intervention.
  • Readily available appropriate equipment.
  • Knowledge of local EMS resources and a working relationship with area emergency departments.
• Training of staff and continuing education:
  • Recognizing children with altered mental status, shock, or respiratory distress/failure.
  • Awareness of appropriate action plans for rapid intervention.
  • Nurses and physicians should be trained in a systematic approach to pediatric medical and trauma resuscitation.
  • Pre-assigned roles for all personnel.
• Policies and Procedures:
  • Standardized protocols for telephone triage of seriously ill or injured children.
  • Prefer ambulance transport over private car transport.
  • Written policies for managing common emergencies.
• Resuscitation Equipment:
  • Equipment should be available, routinely checked, and accessible to all staff.
• Transport to hospital, district emergency department, or regional emergency department:
  • Patients requiring aggressive airway or cardiovascular support, altered consciousness, or potential to deteriorate en-route should prefer ambulance transport, regardless of proximity to the hospital.
  • An aeromedical team may be essential.

Paediatric prehospital care involves emergency assistance provided by trained emergency medical personnel before a child reaches a fixed medical facility.

Access to EMS:

• In the US, the 911 system is commonly used, whether enhanced or not enhanced.

EMS (Emergency Medical Services) can be provided by volunteers or paid professionals.

There are different levels of service:

• Basic: First responders such as law enforcement officers, firefighters, and community volunteers.
• Advanced: Emergency medical technicians (EMTs) with approximately 40 hours of training.
• Emergency Medical Team: Paramedics, who have the highest level of training and provide Advanced Life Support (ALS).