CPR History and Current Guidelines

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Questions and Answers

In the context of cardiac arrest management, which of the following actions during CPR has the most significant impact on coronary perfusion pressure (CPP) and subsequent ROSC?

  • Administering a rapid sequence of rescue breaths to ensure adequate oxygenation.
  • Adjusting the compression-to-ventilation ratio to synchronize with the patient's intrinsic respiratory effort.
  • Ensuring each chest compression reaches a depth of at least 6 cm to maximize stroke volume.
  • Minimizing interruptions in chest compressions to maintain consistent blood flow. (correct)

What is the critical rationale for advocating therapeutic hypothermia in the post-arrest/ROSC management strategy during CPR?

  • To mitigate neurological damage by reducing cerebral metabolic demand and inflammation. (correct)
  • To enhance the effectiveness of thrombolytic agents by slowing down enzymatic reactions.
  • To rapidly lower the patient's core temperature to prevent the onset of shivering.
  • To stabilize blood pressure fluctuations by decreasing peripheral vascular resistance.

Which of the following strategies would be MOST effective in preventing 'compressor fatigue' during prolonged CPR efforts?

  • Ensuring rescuers hydrate adequately to maintain electrolyte balance and muscle function.
  • Administering prophylactic doses of non-steroidal anti-inflammatory drugs (NSAIDs) to rescuers.
  • Implementing a compression-to-ventilation ratio of 15:2 to reduce the physical demand on the rescuer.
  • Rotating chest compressors every two minutes to maintain consistent compression quality. (correct)

In the context of effective CPR, what is the physiological basis for ensuring complete chest wall recoil between compressions?

<p>To create negative intrathoracic pressure, enhancing venous return and myocardial pre-load. (C)</p> Signup and view all the answers

What is the paramount importance of continuous waveform capnography in evaluating the efficacy of CPR?

<p>It estimates cardiac output by correlating end-tidal carbon dioxide levels with pulmonary blood flow. (C)</p> Signup and view all the answers

Considering the three phases of cardiac arrest (electrical, circulatory, and metabolic), what is the MOST appropriate intervention during the circulatory phase to improve patient outcomes?

<p>Providing high-quality CPR with minimal interruptions to enhance coronary perfusion. (D)</p> Signup and view all the answers

What is transthoracic impedance and how does understanding this concept MOST directly influence defibrillation effectiveness?

<p>It represents the resistance to electrical current flow through the chest and it affects the energy delivered during defibrillation. (D)</p> Signup and view all the answers

What is the physiological basis for advocating a single shock strategy followed immediately by CPR, rather than repeated stacked shocks, in current defibrillation protocols?

<p>To minimize myocardial stunning and allow for improved coronary perfusion during CPR. (C)</p> Signup and view all the answers

How does the concept of myocardial stunning directly influence the approach to post-defibrillation care and the need for continued CPR?

<p>It implies the heart may not contract effectively immediately after successful defibrillation, necessitating ongoing CPR. (A)</p> Signup and view all the answers

What is the underlying physiological principle that justifies the recommendation for higher oxygen titration post-ROSC?

<p>To limit the risk of coronary vasoconstriction associated with hyperoxia and optimize myocardial oxygen delivery. (B)</p> Signup and view all the answers

During adult CPR, what is the recommended depth of chest compressions, and why is achieving this depth critical to effective cardiopulmonary resuscitation?

<p>Between 2 and 2.4 inches (5 to 6 cm) to maximize cardiac output and improve survival rates. (D)</p> Signup and view all the answers

For a single rescuer performing CPR on an adult, what is the recommended compression-to-ventilation ratio, and why is it structured as such in current guidelines?

<p>30:2 to prioritize chest compressions while providing adequate ventilation. (D)</p> Signup and view all the answers

How does incorporating real-time feedback devices influence the quality of CPR, and what specific parameters do these devices typically monitor to enhance rescuer performance?

<p>They improve compression depth, rate, and recoil, while minimizing interruptions to chest compressions. (D)</p> Signup and view all the answers

What is the MOST critical difference between managing a hypoxic arrest and a sudden cardiac arrest with ventricular fibrillation (VF), particularly in terms of initial interventions?

<p>Prioritizing ventilation and oxygenation in hypoxic arrest before addressing any underlying cardiac rhythm. (C)</p> Signup and view all the answers

What specific interventions can minimize transthoracic impedance during defibrillation?

<p>Ensuring optimal contact between the pads and skin, selecting appropriate pad size, and avoiding placement over implanted devices. (D)</p> Signup and view all the answers

How does the duration of the peri-shock pause (the time between the last chest compression and the delivery of the defibrillation shock) affect the success of defibrillation?

<p>A shorter peri-shock pause enhances the likelihood of successful defibrillation by maintaining coronary perfusion pressure. (C)</p> Signup and view all the answers

What is the primary goal of defibrillation during cardiac arrest, and how does it relate to the electrical activity of the heart?

<p>To interrupt chaotic electrical activity and allow the heart's natural pacemaker to regain control. (B)</p> Signup and view all the answers

In pediatric defibrillation, what considerations guide the selection of appropriate energy levels, and what is the rationale behind weight-based energy selection?

<p>Weight-based energy selection ensures appropriate electrical dose delivery relative to the child's cardiac mass. (D)</p> Signup and view all the answers

When using a bag-valve-mask (BVM) for ventilations during CPR, what is the recommended duration for each breath, and what is the clinical rationale behind this?

<p>1 second to provide sufficient tidal volume while avoiding hyperventilation. (B)</p> Signup and view all the answers

During CPR with an advanced airway in place, what adjustment should be made to the ventilation strategy compared to CPR without an advanced airway?

<p>Provide asynchronous ventilations at a rate of 8-10 breaths per minute. (C)</p> Signup and view all the answers

What are the key indicators of poor CPR quality, and how do these factors collectively diminish the likelihood of successful resuscitation?

<p>Excessive ventilation rates, shallow compressions, frequent interruptions, and inadequate chest recoil. (A)</p> Signup and view all the answers

According to current guidelines, what is the recommended rate for chest compressions during CPR in adults, and what is the rationale for this specific rate?

<p>100-120 compressions per minute to optimize cardiac output and perfusion pressure. (B)</p> Signup and view all the answers

During CPR, what is the significance of allowing complete chest recoil after each compression, and how does this action impact circulation?

<p>It decreases intrathoracic pressure, facilitating venous return and improving cardiac preload. (B)</p> Signup and view all the answers

How should CPR techniques be modified when the victim is a trauma patient, particularly concerning airway management and potential spinal injury?

<p>Employ a jaw-thrust maneuver without head extension to open the airway and stabilize the cervical spine. (A)</p> Signup and view all the answers

What considerations should be prioritized when performing CPR on pregnant women, particularly concerning chest compression technique and potential interventions?

<p>Maintain standard chest compression techniques, and prepare for potential interventions to relieve aortocaval compression. (C)</p> Signup and view all the answers

In situations where a patient experiences a witnessed out-of-hospital cardiac arrest, what differences exist in the initial approach between emergency responders who arrive within 4 minutes versus those arriving after 8 minutes?

<p>Responders arriving within 4 minutes should focus on immediate defibrillation, while those arriving after 8 minutes should perform CPR first. (B)</p> Signup and view all the answers

What modifications to standard procedures should be considered when performing CPR on an infant compared to an adult, particularly regarding compression depth and hand placement?

<p>Adjust compression depth to approximately 1/3 the depth of the chest, using two fingers or two thumbs encircling the chest. (B)</p> Signup and view all the answers

How do the underlying mechanisms of blood flow during CPR relate to the 'cardiac pump' and 'thoracic pump' models, and what are the implications for optimizing chest compression technique?

<p>The cardiac pump model emphasizes direct heart compression, while the thoracic pump model focuses on changes in intrathoracic pressure; allowing full chest recoil enhances both mechanisms. (B)</p> Signup and view all the answers

What is the effect of hyperventilation on a patient undergoing CPR, and how does it impact cerebral and coronary perfusion pressures?

<p>It decreases both cerebral and coronary perfusion pressures due to increased intrathoracic pressure. (C)</p> Signup and view all the answers

Besides rate and depth, what other parameters related to chest compressions maximize the chances of good outcomes?

<p>Allowing complete chest recoil between compressions. (B)</p> Signup and view all the answers

Which of the following statements BEST describes the significance of end-tidal carbon dioxide (ETCO2) monitoring during CPR?

<p>It provides an indirect measure of cardiac output and pulmonary blood flow. (A)</p> Signup and view all the answers

Which of the following rhythms are treated with defibrillation?

<p>Ventricular fibrillation and pulseless ventricular tachycardia. (C)</p> Signup and view all the answers

What is the recommended chest compression to ventilation ratio for two-rescuer CPR in infants and children?

<p>15:2 (D)</p> Signup and view all the answers

What actions, when performing the head-tilt chin-lift maneuver to open up the airway, should be considered if the patient is a trauma patient?

<p>When trauma has been suspected, the &quot;jaw thrust&quot; approach should be used to reduce the risk of harming the patient (C)</p> Signup and view all the answers

According to the information provided when should you consider that CPR is indicated?

<p>When a patient is unresponsive and not breathing normally. (A)</p> Signup and view all the answers

Which of the following statements BEST describes the importance of therapeutic guidelines for compressions, ventilations and CPR-free intervals?

<p>they recommend target values for compressions, ventilations and CPR-free intervals allowed for rhythm analysis and defibrillation (A)</p> Signup and view all the answers

The delivery of CPR with correctly preformed chest compressions and ventilations, exerts which of the following?

<p>significant survival benefit in both animal and human studies (B)</p> Signup and view all the answers

Flashcards

What is CPR?

CPR stands for Cardiopulmonary Resuscitation. It is the process of chest compressions and ventilations.

Who is Dr. Friedreich Maass?

In 1891, Dr. Friedreich Maass successfully performed external chest compression on a human.

CPR's 3 phases

The electrical phase, circulatory phase, and the metabolic phase.

How does CPR work?

CPR helps circulate blood to vital organs like the heart and brain when the heart stops beating effectively.

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Compression to ventilation ratio for a single rescuer

Universal compression to ventilation ratio for all victims is 30:2 for a single rescuer.

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Key Aspects of Great CPR

Rate, depth, release, ventilation, uninterrupted compression are the five key aspects.

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How do you measure of quality CPR?

ETCO2 and feedback monitoring.

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The management goals of post-resuscitative care

ROSC must be managed to maintain; blood pressure, oxygen saturation, end-tidal CO2, targeted temperature management, and glycemic control.

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How to open the airway of a trauma victim

Use the sniffing position/head tilt-chin-lift to open the airway of a trauma victim, unless a spinal injury is suspected.

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Bag-Valve-Mask Ventilation

The recommended ventilation is given over 1 second (class lla).

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Ventilations every 30 Compressions?

Two effective respirations should be performed for every 30 compressions.

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CPR Important after Defibrillation.

After defibrillation, it takes several minutes for a normal heart rhythm to return and even more time for the heart to create blood flow once VF has been eliminated. CPR can bridge that gap.

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Heart and lungs pressure

Compression of heart & lungs increases intrathoracic pressure during compression.

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Incomplete Chest Recoil

Adequate Depth is Important.

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Pumping Blood During Chest Compressions

During chest compressions, the heart is squeezed between the sternum and the spine, leading to forward blood flow.

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CPR time and depth

The time period of compressions is not delivered 48% of the time, and most compressions are too shallow.

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What does Class lla mean?

It is reasonable to perform procedure/administer treatment or perform diagnostic test/assessment.

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What type of study was performed at U of Chicago

A Prospective observational study of 67 patients who experienced in-hospital cardiac arrest at the University of Chicago Hospitals, Chicago, III.

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Coronary perfusion pressure (CPP)

It is the gradient across the coronary vasculature, which is equal to the difference between the aortic diastolic pressure and the right atrial pressure.

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Study Notes

  • CPR seeks to restore breathing and circulation, improving outcomes for cardiac events

A Little History

  • 1891: Dr. Friedreich Maass successfully performed external chest compressions on a human
  • 1903: Dr. George Crile performed the first successful resuscitation using external chest massage
  • 1950s: Drs. Peter Safar and James Elam proved expired air provided adequate oxygenation
  • 1960: Dr. Kouwenhoven perfected the technique for closed chest massage, which became modern cardiopulmonary resuscitation

Current CPR Stats

  • 95% of out-of-hospital and roughly 80% of in-hospital sudden cardiac arrest victims still die, despite the advancements in Emergency Medical System (EMS)

Recommendations and Evidence Levels

  • Class I: Procedure/treatment or diagnostic test/assessment SHOULD be performed/administered
  • Class IIa: It IS REASONABLE to perform procedure/administer treatment
  • Class IIb: Procedure/Treatment MAY BE CONSIDERED
  • Class III: Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

CPR Quality Findings

  • Out-of-Hospital: In a case series (n=176) in Stockholm, London, Akershus, chest compressions were not delivered 48% of the time, and compressions were too shallow
  • In-Hospital: In a U of Chicago case series (n=67), chest compressions were too slow roughly 38% of compressions were too shallow, and ventilation rates were too high

What Makes CPR Ineffective?

  • Poor ventilation rate
  • Poor interruption
  • Poor chest compression
  • Incorrect body position
  • Poor rate

Compression to Ventilation Ratio

  • The compressions to ventilation ratio is 30:2 if there is a single rescuer present
  • The compressions to ventilation ratio is 15:2 in infants and children if there are two rescuers

CPR Indication and CPR Phases

  • Cardiac arrest due to Ventricular Fibrillation (VF) occurs in three time-dependent phases
  • Electrical Phase: immediate electrical therapy is the best course of treatment
  • Circulatory Phase: good CPR is critical
  • Metabolic Phase: therapeutic hypothermia may be beneficial

Mechanism of Action

  • Blood Flow Theory:
    • Cardiac pump involves squeezing the heart between the sternum and spine, resulting in forward blood flow
    • Thoracic pump model involves the collapse of intrathoracic veins during chest compressions, forcing blood forward through the aorta
    • Central venous circulation refills between compressions

Return of Spontaneous Circulation (ROSC)

  • ROSC directly depends on sufficient myocardial blood flow and coronary perfusion pressure (CPP)
  • A CPP of 15-30 mmHg is required for ROSC
  • CPP reflects the gradient across coronary vasculature and is equal to the difference between the aortic diastolic pressure and right atrial pressure

Coronary Perfusion Pressure (CPP)

  • A major determinant for survival
  • It is highly correlated to ROSC
  • When CPR is paused, CPP decreases quickly
  • When CPR is restarted, there is a delay to reestablish CPP

Important Aspects of Effective CPR:

  • Rate
  • Depth
  • Release
  • Ventilation
  • Continuous compressions

Airway Management

  • Sniffing position/head tilt-chin-lift should be used unless spinal injury is suspected, then use jaw thrust without head extension
  • If the airway remains closed, perform head tilt-chin-lift (Class I)
  • Stabilize with hands

Breathing Considerations

  • Use a bag-valve-mask (BVM)
  • Administer ventilation over 1 second (Class IIa)
  • Ensure volume is sufficient to make the chest rise (Class IIa)
  • Avoid too many, large, or forceful breaths
  • Give 2 ventilations every 30 chest compressions, taking almost 4 seconds
  • Once an advanced airway is inserted, a rate of 8-10 ventilations per minute is recommended, avoiding hyperventilation

Chest Compressions (Class I)

  • "Push Hard and Push Fast" at 100/min (Class IIa)
  • Allow chest recoil (Class IIb)
  • Limit chest compression interruptions (Class IIb)

Compression-Decompression

  • Compression: squeezes the heart & lungs, increased intrathoracic pressure
  • Decompression: involves refilling of the heart & lungs, decreased intrathoracic pressure, negative with full recoil

Defibrillation

  • Administer 1 Shock, then immediate CPR without checking for pulse or rhythm
  • Single Shock equals more CPR
  • CPR should be continued while the machine charges

Rationale Behind Immediate CPR After Shock

  • Initial shock can eliminate VF in greater than 85% of cases
  • If the initial shock is unsuccessful, resuming CPR provides benefit
  • Normal heart rhythm may take several minutes
  • CPR bridges that gap
  • Immediate CPR after defibrillation is not harmful

Possible CPR Complications:

  • Rib fracture
  • Sternal fractures
  • Pneumothorax
  • Cardiac contusions
  • Pericardial hemorrhage
  • Gastroesophageal tears
  • Liver or splenic lacerations

Measuring CPR Quality:

  • Using End-tidal carbon dioxide (ETCO2) levels to measure
  • Feedback monitoring assists with CPR and ventilation, and can be aided by a metronome

Return of Spontaneous Circulation (ROSC)

  • Management goals include:
  • Blood pressure
  • Oxygen saturation
  • End-tidal CO2
  • Targeted temperature management
  • Glycemic control

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