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Review Article
Cardiopulmonary Resuscitation: What is New in 2017
ST Yavagal1, DM
Department of Cardiology,
1
A timely and effective cardiopulmonary resuscitation (CPR) is crucial for saving lives of the
Abstract
Kempegowda Institute of individuals who suffer sudden cardiac arrest. Different relevant authorities have published
Medical Sciences, Bengaluru, guidelines for educating the caregivers in delivering effective CPR. The present report
Karnataka, India summarizes the recent changes in the CPR guidelines.
DOI: 10.4103/JCPC.JCPC_24_17 How to cite this article: Yavagal ST. Cardiopulmonary resuscitation: What
is new in 2017. J Clin Prev Cardiol 2017;6:147-53.
© 2017 Journal of Clinical and Preventive Cardiology | Published by Wolters Kluwer - Medknow 147
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treatment recommendations were used in 2015 AHA update. lay person continues to improve survival. Dispatcher should
They categorized the recommendations as Class I, II, III and provide compression‑only‑CPR (CO‑CPR) instruction to
level of evidence as a, b, c. caller (Class I).
Class (strength of recommendation) For IHCA, the medical emergency team or rapid response
• I – Strong team should be formed at institution level which can include
• IIa – Moderate trained experts in advance life support. In the event of a
cardiac arrest in the indoor patient ward, the available staff
• IIb – Weak
can initiate the treatment and simultaneously send the call
• IIIa – No benefit
to the rapid response team. Implementation of these systems
• IIIb – Harmful. and methods can improve the survival rate in both OHCA and
Level (quality) of evidence IHCA.
a. High‑quality evidence from randomized clinical trials
and meta‑analysis
Part 5: Adult Basic Life Support
b. R – moderate‑quality evidence from randomized trials In 2015, the AHA published CPR guidelines that included
NR ‑ moderate‑quality evidence from nonrandomized major changes as compared to the earlier guidelines.[4,9]
trials In the earlier guidelines, the recommendations included the
c. Poor ‑ expert opinion based on clinical experience. initial sequence of steps known as, A B C; where A = airway,
B = breathing, and C = chest compression. The current
Thus, 2015 guidelines are evidence‑based recommendations.
guidelines now recommend the sequence as, C A B, except in
OHCA and IHCA care must function differently. The
newborns. “Look, listen, and feel” is no longer recommended,
education of both lay rescuers and health‑care providers must
instead here is an increased focus on methods to ensure
be targeted.
high‑quality CPR. Rapid identification of potential cardiac
Cardiac arrest arrest is important. An unconscious person with an abnormal
There are two types of cardiac arrest – primary and secondary. or absent breathing or agonal gasp is a sign of cardiac
arrest (Class IIa). Rescuer should activate emergency response
Primary cardiac arrest system without leaving the victim. CPR should be started
It is an unexpected, witnessed (seen or heard) collapse before the rhythm is identified and should be continued.
in a person who is not responsive. Gasping occurs in 1. Chest compressions of adequate rate (100–120/min)
majority (55%) of patients in OHCA and is often interpreted (Class IIa)
as breathing. Here, heart suddenly stops pumping blood and 2. Chest compression of adequate depth. In adults, at least
the arterial blood is oxygenated at the time of the arrest. About 2 inches (5 cm); in children, about 2 inches (5 cm); and
70%–80% of patients with OHCA have PCA.[7] in infants, depth of 1/3rd of the anteroposterior (AP)
Secondary cardiac arrest diameter of the chest are recommended
SCA is secondary to severe hypoxia often from drowning, 3. Allowing complete chest recoil after each compression
respiratory failure, drug overdose, or hypotension due to shock 4. Minimizing interruptions in compression
or hemorrhage. Classic CPR should be reserved for SCA. 5. Avoiding excessive ventilation
6. Emergency cardiac treatment such as routine atropine,
Part 3: Ethical Issues cricoid pressure, and airway suctioning is no longer
Ethical issues related to CPR are discussed. However, no recommended
clear‑cut recommendations are made. 7. If multiple rescuers are available, they should rotate the
task of compressions every 2 min.
Part 4: System Care and Quality Indications of cardiopulmonary resuscitation
Improvement CPR should be performed immediately on any person who
The AHA 2015 guidelines suggest that OHCA and IHCA care has become unconscious and is found to be pulseless. Loss of
must function differently. For OHCA, a cardiac resuscitation effective cardiac activity is generally due to the spontaneous
center (CRC) such as a hospital with all facilities should be initiation of a nonperfusing arrhythmia, sometimes
recognized. The contact number of CRC should be known referred to as malignant arrhythmias. The most common
to all people in that area. When a cardiac arrest occurs, the being ventricular fibrillation (VF), pulseless ventricular
bystander needs to inform the CRC. It is expected that the tachycardia (VT), pulseless electrical activity, asystole, and
person at the CRC – (1) will ask the bystander to start chest pulseless bradycardia.
compressions at a rate of 100–120/min, (2) will arrange
to send the ambulance with all facilities, and (3) using the Contraindications of cardiopulmonary
available technologies, will summon the nearest CPR‑trained resuscitation
person to the rescue spot (Class IIb). With this approach, The only absolute contraindication to CPR is a “do not
bystander initiation of CPR has been shown to increase to resuscitate” order. A relative contraindication is if a clinician
62% versus 48% in control group.[8] Use of defibrillator by justifiably feels that the intervention would be medically futile.
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Standard cardiopulmonary resuscitation These devices improve coronary perfusion pressure during
procedure IHCA compared to manual compression. ASPIRE study
CPR should be started before the rhythm is identified and showed that survival to discharge was better with AutoPulse
should be continued. In its full standard form, CPR comprises than manual CPR.[15] LINC[16] and PARAMEDIC[17] trials are
three steps: large ongoing randomized trials evaluating the prehospital use
of mechanical compression‑decompression devices. Routine
• Chest compression
use of these mechanical devices is not recommended at
• Airway
present. They can be used in hospital settings where standard
• Breathing.
CPR is difficult, for example, during transport or when
Chest compression access to patient is limited such as CPR during percutaneous
It is not cardiac massage but a compression and decompression coronary intervention (PCI). If these devices are used, it is
maneuver. Each compression is in accordance with the important to provide training to minimize interruptions in
patient’s heart beat. If the chest compressions are interrupted chest compression during the use of the device. Most of the
for any reason, blood flow to the heart and brain essentially studies did not demonstrate the superiority of mechanical
stops, decreasing the chance for neurologically intact survival. chest compressions over conventional CPR. Thus, manual
Idris et al.[10] observed in their study that the highest rate of chest compression remains the standard of care.
return to spontaneous circulation is at a chest compression Ventilation
rate of about 125/min. Other studies further showed that
Present guidelines have repositioned airway and breathing
the compression depth becomes shallow if it is done at a
below circulation in SCA from a cardiac cause. SCA from
rate more than 120/min. Thus, on the basis of the available
pulmonary cause, for example, drowning, choking, and
evidence, the optimum compression rate as recommended
respiratory failure in whom oxygen reserve is likely to
should be 100–120/min.[11] Depth of at least 2 inches or 5 cm
be depleted, the airway and breathing should be restarted
for an average adult is needed while avoiding excessive chest
as quickly as possible. If patient is not breathing, two
compression depth (>2.4 inches or 6 cm) (Class I). However,
ventilations are given through providers’ mouth or bag‑valve
this is challenging without a feedback device. The key thing
to keep in mind while doing CPR is “push hard and push mask. This can be challenging to perform correctly and
fast.” Matlock[12] demonstrated that singing, humming, or is best done by two trained rescuers. It is recommended
listening to songs during CPR improved the compliance, that tidal volume of 500 ml should be delivered in 1 s.
predictable return of spontaneous circulation (ROSC), and In effective mouth‑to‑mouth ventilation, chest should
imparted neurologically intact survival; however, this is not rise with each ventilation. If not, it indicates inadequate
recommended in the guidelines. mouth seal or airway occlusion. Two ventilations should
be given in sequence after 30 compressions (30:2). When
Compression‑only‑cardiopulmonary breaths are completed, compressions are restarted. If
resuscitation versus standard available, a barrier device (pocket mask or face shield)
cardiopulmonary resuscitation should be used. Ventilations should be provided every 6–8 s
(8–10 breaths/min). Ambu bag is sufficient. Higher ventilation
In CO‑CPR, the provider delivers only chest compressions at
rate can increase intrathoracic pressure resulting in diminished
a rate of 100–120/min with a depth of 2 inches without pause
venous return and reduced cardiac output. It can also cause
until the arrival of the medical team. Chest compressions
gastric inflation which increases the risk of aspiration and can
should be continued through defibrillation or resumed
impede ventilation further by elevating the diaphragm and
immediately without any postshock pulse check since ROSC
is not instantaneous even after successful defibrillation. restricting the lung expansion. Endotracheal tube placement
should be done when possible. If possible, it should be
The initiation of bystander resuscitation, especially when confirmed by continuous wave capnography and should
begun within 1 min of arrest, markedly improves the survival. be connected to the ventilator (Class I). Ultrasound is an
In the study by Becker et al.,[13] survival was more than additional method. “Death by Hyperventilation,” an editorial
four times greater in patients who received early bystander by Aufderheide and Lurie,[18] stresses that frequent forcible
resuscitation. Further, a meta‑analysis of several observational ventilation decreases survival. 100% oxygen can be used.
studies showed higher survival rate in CO‑CPR compared to The use of maximal feasible inspired oxygen during CPR is
standard CPR.[14] CO‑CPR is clearly better than no CPR and strengthened. This recommendation applies only while CPR is
this should be the primary message to be conveyed to all ongoing and does not apply to care after ROSC.
health‑care professionals and general population.
Gasping is a sign of cardiac arrest with an adequate perfusion to
Part 6: Alternative Techniques the brain. Untreated gasping lasts for 4–5 min. If compressions
are initiated while patient is gasping or soon after gasping
Automated cardiopulmonary resuscitation stops, the patient is likely to continue or resume gasping.
Three types of automated compressors are available: Gasping results in ventilation with a negative intrathoracic
1. Pneumatically driven piston compressors pressure and is associated with increased survival. In Arizona
2. Active compression‑decompression device (LUCAS) study,[7] survival of patients with OHCA was 9% when CPR
3. Load‑distributing band compression (AutoPulse) was applied and patient was not gasping, but 39% if patient
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was gasping during CPR. Gasping is more physiological than central venous oxygen saturation as well as less organ
any form of positive ventilation. Positive ventilation increases dysfunction.[18,22]
intrathoracic pressure, intracerebral pressure and decreases
Other drugs
venous return to the thorax and subsequent cardiac output.[19]
Vasopressin is removed from the advanced cardiovascular
Defibrillation life support (ACLS) cardiac arrest algorithm. It simplified
Early defibrillation is critical to survival after SCA. The the approach. IV atropine, fibrinolysis, routine fluid loading,
most frequent initial rhythm in OHCA is VF. The chance of and artificial pacing have no effect on outcome. Sodium
successful defibrillation diminishes over time. Two high‑quality, bicarbonate is only to be used in prolonged resuscitation.
population‑based cohort studies showed that the use of these Delivery of drugs through a tracheal tube is no longer
devices by bystanders doubles the survival after OHCA. It is recommended. Precordial thump recommendation is neither
an effective treatment for VF or pulseless VT associated with for for nor against. Not recommended for OHCA.
cardiac arrest. No specific training is required. The rescuer
simply follows the audiovisual instructions when the device
Prognostication during cardiopulmonary
is switched on. It is very important to reduce the pauses in resuscitation
chest compression during defibrillation. One cycle of chest Low partial pressure of end‑tidal carbon dioxide in intubated
compression is to be resumed immediately after shock without patients after 20 min of CPR is associated with failure of
waiting to look for pulse or rhythm. Even the interruptions in CPR. This should not be used in isolation and in nonintubated
the compression while preparing for defibrillation result in a patients.
drop in coronary perfusion pressure. Hence, every effort should
Return of spontaneous circulation not rapidly
be made to minimize the interruption in compression (Class I).
Several studies[20] have shown that it is completely safe for achieved ‑ other options
a rescuer wearing standard examination gloves to continue Other options include mechanical CPR device, endovascular
chest compressions during the use of a biphasic defibrillator assist device, intra‑aortic balloon counter pulsation, and
and self‑adhesive pads. Automated external cardioverter extracorporeal CPR. Role of these options either alone or in
defibrillator (AECD) is used in more intensively monitored combination is not well understood.
areas. They provide continuous monitoring with two pads
placed over the patient’s chest and automatically defibrillate Part 8: Postresuscitation Care
a shockable rhythm. Ali et al.[21] in a prospective study of The principles of postarrest care are:
55 patients at risk of pulseless VT/VF reported that the average 1. To identify and treat the underlying etiology
interval between onset of arrhythmia and first defibrillation 2. To mitigate ischemia–reperfusion injury and prevent
was 33 s and resulted in 94% of ROSC. AECD is safe and secondary organ injury
likely results in early defibrillation than standard telemetry 3. To make accurate estimates of prognosis to guide the
monitoring. However, its routine use is not recommended. clinical team and to inform the family when selecting
goals of continued care.
Part 7: Adult Advanced Cardiovascular
Life Support Apart from timely and effective CPR, optimal postresuscitation
care is also crucial for good outcomes. The two important
Role of drugs in cardiopulmonary pillars of postresuscitation care are coronary angiogram (CAG)
resuscitation and therapeutic hypothermia. Specific management includes
Adrenaline (epinephrine) avoiding and immediately correcting hypotension and
Current guidelines recommend that adrenaline should be given hypoxemia.
intravenously (IV) every 3–5 min during cardiac arrest (adult Coronary angiogram/percutaneous coronary
1 mg, children 10 mcg/kg) (Class I). It increases the aortic
relaxation (diastolic) pressure and the rate of ROSC. However,
intervention
no difference in survival/hospital discharge was observed. A number of studies have documented the high prevalence of
Large randomized trials are needed to resolve this uncertainty. acute coronary occlusion in patients resuscitated from OHCA.
Regarding timing of administration, for nonshockable rhythm, Hence, CAG and coronary intervention should be performed
adrenaline gets priority. For shockable rhythm, defibrillation as an emergency (rather than late in the hospital or not at all)
gets the priority. for all OHCA even in comatose patients. In a retrospective
study[23] in survivors of IHCA caused by VF, 27% underwent
Vasopressin, steroid, and epinephrine combo CAG, 17 patients had PCI, and 13 showed ST segment
Treatment with vasopressin, steroid, and epinephrine (VSE) elevation myocardial infarction (STEMI) or new left bundle
during CPR is found to be beneficial (Class IIb). Spyros branch block. Patients who underwent CAG or PCI were
et al. (2013)[22] in their randomized trial in patients with IHCA more likely to survive than those who did not. Survivors of
observed that treatment with VSE followed by treatment of OHCA were treated with therapeutic hypothermia and CAG
survivors with daily steroids increased the frequency of being was done. At least one significant lesion in 58% of patients
discharged with a neurologically favorable outcome compared without ST elevation was observed.[24] Thus, there is a need
to the patients receiving standard care with epinephrine for liberal use of CAG and stent or surgery PCI following
alone. VSE patients also had improved hemodynamic and cardiac arrest.
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of stroke, hypoglycemia, how to manage chest wound without reported with the aggressive postresuscitation care which
no occlusive dressing, and dental avulsion. Trained persons includes:
should be able to recognize symptoms of anaphylaxis. 1. Therapeutic mild hypothermia
2. Early CAG to open occluded coronary artery
Cardio‑cerebral resuscitation
3. With aggressive management of blood glucose,
A new approach for patients with PCA has shown significantly
ventilation to avoid hyperoxemia and hemodynamic
increased survival. After introducing CCR program, which
control, survival rate improves from 34% to 59% and
stressed upon CO‑CPR, lay rescuer CPR increased from 28%
to 40% and resulted in 300% improvement (3.7%–17.6%) in favorable neurological outcome from 39% to 55%.[27]
survival to hospital discharge [Figure 1].[26] No new recommendations are added to the existing guidelines.
But there are few things that have been observed. Andersen
Community
et al.[28] have reported that there is no benefit with early
• Recognition intubation within 15 minutes in IHCA. Survival benefits
PCA is an unexpected witnessed (seen or heard) with intubation was 16% as against 19% in persons without
collapse in a person who is not responsive. intubation. Reynolds et al.[29] have reported that shorter the
• Calling: 108 duration of resuscitation to get ROSC more favourable will
• CO‑CPR: be the outcome. Rajan et al.[30] have reported that shorter the
• Place the person on hard surface ambulance response time better will be the prognosis.
• Compression for 100–120/min of 2” depth, with
complete release after each compression. Conclusion
Prehospital Currently recommended initial sequence of steps in CPR
is no longer ABC. It is CAB. High‑quality CPR with
PCA prohibits early intubation, advocates passive ventilation,
minimum interruption should be our goal. Role of routine
minimal interruption of chest compression, and encourages
use of drugs is unclear. However, epinephrine has got
early administration of epinephrine [Figure 2].
some benefits. After successful resuscitation, the focus
Hospital should shift to postresuscitation care which includes
In the past, comatose patients following OHCA were often maintenance of cardio‑cerebral perfusion pressure, achieving
“medically abandoned.” Today, improved survival rate is 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
Figure 1: Components of cardio‑cerebral resuscitation[6] training for everyone.
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