Tag: cpr

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Important Things to Know About CPR (Cardio-Pulmonary Resuscitation)

Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)
Sunrise at Haleakala Volcano Summit in Maui, Hawaii. (Dr. Noorali Bharwani)

“Bystander CPR is the most important predictor of survival from cardiac arrest,” says an article in the Canadian Medical Association Journal (CMAJ January 9, 2017).

The article is titled “Five Things to Know About Cardio-pulmonary Resuscitation.” Here is the summary.

1. Chest compressions – importance of fast pushes

Chest compressions during CPR should be fast pushes. In adult patients with out-of-hospital cardiac arrest, a large multicentric study has shown patient survival to hospital discharge was highest when compressions were between 100 and 120 per minute.

2. During the use of a defibrillator – importance of peri-shock pauses

During cardiac arrest the heart needs to be shocked with a defibrillator. To do this chest compression has to stop for a brief moment. This is called peri-shock pauses. Peri-shock pauses should be limited to improve survival. High priority is given to minimizing interruptions for chest compressions. It is recommended that total pre-shock and post-shock pauses in chest compressions be as short as possible.

Studies have shown survival is higher for those patients who received pre-shock pauses of less than 10 seconds and total peri-shock pauses of less than 20 seconds during CPR. Peri-shock pauses should be minimized during CPR by performing compressions while the defibrillator is charging.

3. Interrupted or continuous CPR strategy?

Bystander CPR is the most important predictor of survival from cardiac arrest. Any interruptions in chest compressions are associated with reduced blood flow and worse survival.

For this reason, and because ventilation (mouth to mouthing breathing) is a difficult skill to acquire for those who are not health care professionals, the guideline update recommends that members of the public provide uninterrupted continuous chest compressions.

Trained rescuers should provide 30 chest compressions that are interrupted by no more than 10 seconds to provide two ventilations (mouth to mouth breathing).

4. Role of medications during cardiac arrest

Should we use vasopressin or epinephrine during resuscitation? The aim is to improve return of spontaneous circulation and improve survival.

Vasopressin is a hormone. Its two primary functions are to retain water in the body and to constrict blood vessels to raise blood pressure.

Epinephrine, also known as adrenaline, is a hormone. It plays an important role in the fight-or-flight response of the body by increasing blood flow to muscles, output of the heart, pupil dilation, and blood sugar. As a medication it is used to treat a number of conditions, including anaphylaxis, cardiac arrest, and superficial bleeding.

The CMAJ article says vasopressin offers no advantage over epinephrine in cardiac arrest.

There is limited evidence to suggest that vasopressin and epinephrine can improve return of spontaneous circulation. Because simplicity is important during resuscitation efforts, the guideline update specifically recommends that epinephrine be administered as soon as possible following onset of cardiac arrest.

5. Maintain patient’s temperature during cardiac arrest

A target temperature should be maintained in the post-cardiac arrest period.

All adult patients who are comatose with return of spontaneous circulation following cardiac arrest should receive targeted temperature management. The guideline update recommends selecting and achieving a single target temperature between 32°C and 36°C, which should be maintained constantly for at least 24 hours.

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High-Rise Buildings Present Challenge in Cardiac Arrest

Disneyland. (Dr. Noorali Bharwani)
Disneyland. (Dr. Noorali Bharwani)

If there is a life-threatening emergency in a high-rise building then it is longer to rescue the people trapped in the building. In case of fire there are problems related to evacuation, accessibility, smoke movement and fire control.

What happens if you have a heart attack (cardiac arrest) in a high-rise building?

A study shows patients residing on higher floors of high-rise buildings in Toronto had lower survival after out-of-hospital cardiac arrest. Most out-of-hospital cardiac arrests occur in residential areas, and these cases are associated with poorer outcomes than nonresidential cardiac arrests, says an article in the Canadian Medical Association Journal (CMAJ).

Studies have shown that the mean time from ambulance arrival on scene to patient contact was 2.8 minutes for people on the first two floors but 3.1 minutes for those on the 3rd to 9th floors and 3.3 minutes for those on the 10th floor or higher.

Cardiac arrests on higher floors had longer rescue times, which contributed to poorer outcomes.

There are a number of issues which affect access in a high-rise building. For example:

  • Lack of witnesses to provide immediate help, CPR (Cardio Pulmonary Resuscitation) or call to paramedics.
  • There are barriers to elevator access. Studies have shown additional elevator stops happened in 18.6 per cent of high-rise residential calls. Elevators were not easily accessible in 33.9 per cent of all paramedic calls to apartment buildings.
  • Requirement for an entry code to a building (67.6 per cent of all access barriers), lack of directional signs (82.6 per cent) and inability to fit the ambulance stretcher into the elevator (67.9 per cent).
  • CPR in elevators is challenging.

What would help?

  • Train the family members of those at risk to do CPR.
  • Place automated external defibrillators strategically in certain residential locations.
  • Smartphone technology can link residents who are trained first responders to defibrillators in their neighbourhoods and to victims of cardiac arrest in apartments.

Recently another article in CMAJ (January 18, 2016) discussed this subject. During the study period, 7842 cases of out-of-hospital cardiac arrest met the inclusion criteria. Of these 76.5 per cent of patients had cardiac arrest below the third floor and 23.5 per cent of the patients had cardiac arrest on the third floor or higher.

The authors found survival was greater on the lower floors (4.2 per cent v. 2.6 per cent). They also found survival was 0.9 per cent above floor 16, and there were no survivors above the 25th floor. Wow, that can make you nervous!

Their conclusion: “In high-rise buildings, the survival rate after out-of-hospital cardiac arrest was lower for patients residing on higher floors. Interventions aimed at shortening response times to treatment of cardiac arrest in high-rise building may increase survival.” This kind of action can alleviate other disasters like fire.

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New CPR Guidelines Make Resuscitation Technique Easy to Save a Life

It has been 50 years since the introduction of closed chest compression and mouth-to-mouth rescue breathing as the techniques of modern cardiopulmonary resuscitation (CPR). The technique is simple and it has saved many lives of victims of cardiac arrest.

As we know, CPR is an emergency procedure involving chest compressions (pressing down on the chest) and artificial respiration (rescue breathing). It has the power to restore blood flow to someone suffering cardiac arrest, keeping them alive until an ambulance arrives.

The guidelines are reviewed every five years and updated only when evidence is clear that changes will improve survival rates. Over the years it has become clear that high quality chest compressions is vital to proper resuscitation technique.

It is also evident that many people are reluctant to provide mouth-to-mouth resuscitation due to hygienic reasons. The Heart and Stroke Foundation of Canada survey finds that only 40 per cent of Canadians trained in CPR would try to revive someone who has had a cardiac arrest. 

So, it was time for change. The Heart and Stroke Foundation of Canada is co-author of the 2010 Guidelines for CPR and Emergency Cardiovascular Care (ECC) in North America. The Foundation is actively involved in resuscitation science, education and training (http://www.heartandstroke.com). 

Experts looked at all the evidence to see if the technique can be simplified so we can save more lives. The 2010 guidelines are based on input from 356 resuscitation experts from 29 countries.

As indicated earlier, most victims of out-of-hospital cardiac arrest do not receive any bystander CPR. Why? There are probably many reasons for this, but one impediment may be the A-B-C (Airway, Breathing, Chest compressions) sequence, which starts with the procedures that rescuers find most difficult, namely, opening the airway and delivering breaths. Starting with chest compressions might encourage more rescuers to begin CPR.

So, the new guideline has changed the sequence from A-B-C to C-A-B (Chest compressions, Airway, Breathing) for adults, children, and infants (excluding the newly born). Here are some important points from the new guidelines (2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science):

-A chest compression rate of at least 100/min (a change from “approximately” 100/min)
-A chest compression depth of at least 2 inches (5 cm) in adults and a compression depth of at least one third of the anterior-posterior diameter of the chest in infants and children.

-Allow for complete chest recoil after each chest compression
-Minimize interruptions in chest compressions
-Avoid excessive ventilation. There is no change in the recommendation for a compression-to-ventilation ratio of 30:2 for single rescuers of adults, children, and infants

If you are the only person to witness a cardiac arrest, at home or on a street, then start with chest compressions and call for help. If there are two or more rescuers around then one rescuer immediately initiates chest compressions while another rescuer gets an automated external defibrillator (AED), if available, and calls for help. A third rescuer opens the airway and provides ventilations.

Once the heart stops pumping, seconds count. For every minute that passes without help, a person’s chance of surviving drops by about 10 per cent. But if you know how to respond to a cardiac arrest, a person’s odds of survival and recovery may increase by 30 per cent or more.

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Plan Ahead for a Dignified Death

Last week, my friend Evelyn sent me a red rose in memory of my mother. Evelyn also had a question, “Why an elderly lady in a nursing home was denied treatment because her nursing care status was DNR 3?” Let me give you some personal examples to answer the question.

Yesterday (December 1) was my mother’s 88th birthday. But she wasn’t here to celebrate. So the red rose was timely. The red rose and the letters DNR brought back memories of my parent’s last few hours or few days in this world.

In my dad’s case, he had a severe heart attack at home. The paramedics revived him, put him on a breathing machine and transported him to Foothills hospital.

As I was about to leave for Calgary, my dad’s cardiologist phoned me to say that my dad’s chances of recovery were minimal and needed directions regarding resuscitation and how long to prolong his life on a breathing machine. He wanted me to discus the situation with the rest of the family since my dad had not left any written direction regarding such matters. We chose DNR 3.

In my mom’s case the situation was little different. She was diagnosed with terminal cancer. She was given a choice between receiving chemotherapy, with its unpleasantness and no chance of cure vs. tender loving care with no active treatment to avoid unnecessary prolongation of sufferings. My mom was mentally alert and was able to make an informed decision after a family discussion to let nature take its course. That means she elected to be DNR 3.

DNR stands for “do not resuscitate”. DNR provides guidelines for resuscitation levels depending on patient’s condition. Resuscitation care decisions are made by the attending physician in consultation with the patient, if the patient is mentally capable of making that decision. Otherwise the physician has to discuss the situation with the patient’s family members or a legal guardian. If there is no next of kin or a legal guardian then a second physician is consulted.

DNR has three levels: DNR 1, DNR 2 and DNR 3.

Patients on DNR 1 receive total supportive treatment including CPR (cardio-pulmonary resuscitation). The patients receive all aggressive medical, nursing and paramedical intervention including mechanical breathing machine and defibrillation. This status is given to all new patients in acute care unless they have a personal directive which gives clear instructions otherwise.

Patients on DNR 2 have to be deemed to have a poor likelihood of returning to a stable condition after CPR. Patients under this status do not get CPR or mechanical breathing. They receive all other supportive treatment.

Patients on DNR 3 receive comfort measures only as they are deemed to have an illness or condition which does not have a cure or provide a good quality of life. Therefore these patients receive only tender loving care.

The whole purpose of DNR policy is to allow people to die with dignity. That is why it is important to have a personal directive. A personal directive is a legal document you write in case you cannot make your own personal decisions in the future. The document lets you choose another person, an agent, to act on your behalf and make decisions for you when you cannot make them yourself.

You can have a personal directive if you are 18 years or over. Personal Directives Act (December 1, 1997) requires that for a personal directive to be valid, it should be signed, dated and witnessed. For more information you should visit Alberta Seniors and Community Supports (Office of the Public Guardian) website at www.seniors.gov.ab.ca. Their phone numbers: Edmonton office 780-422-1868, Lethbridge office 403-381-5648.

If you do not have a personal directive then you should get one today.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!