Cardiopulmonary Resuscitation (CPR): Procedure, Steps and Types

Cardiopulmonary resuscitation (CPR) is a life-saving emergency procedure performed when someone's heart or breathing has stopped. The full name of CPR is cardiopulmonary resuscitation. CPR stands for Cardiopulmonary Resuscitation. It is an organised sequential procedure done when someone's heart stops beating. The process requires speed ,efficiency and proper application therefore Proper training and awareness should be spread all over the world. The effectiveness of the process depends on the quality of CPR provided and the amount of damage which has already been done to the patient.

What is CPR?

Cardiopulmonary resuscitation is a life-saving emergency procedure performed when someone's heart or breathing has stopped. The goal of CPR is to manually restore blood circulation and oxygenation to the body's vital organs until advanced medical help can be provided.

During Cardiopulmonary Resuscitation chest compressions and rescue breaths are performed in a specific sequence to mimic the functions of the heart and lungs. chest compressions involve pressing down on the center of the chest with enough force to create blood flow. Rescue breaths involve providing mouth-to-mouth or mouth-to-nose breaths to supply oxygen to the person's lungs.

Cardiopulmonary Resuscitation can be performed by anyone who has been trained including healthcare professionals. It is typically used in situations such as cardiac arrest, drowning, suffocation, or any other event that causes the heart to stop or impairs breathing.

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What Are the Uses Of CPR?

CPR is necessary for anyone unconscious, not breathing, or who only sometimes gasps in pain since they are most likely going into cardiac arrest. If an individual is not breathing but still has a pulse, artificial ventilation can be more suitable (respiratory arrest).

 It can be difficult for general citizens to accurately determine whether someone is breathing or not, hence CPR guidelines recommend providing healthcare professionals the option to check a person's pulse rather than instructing non-professionals to do so. 

CPR is recommended even though it is considered useless in situations of trauma-related cardiac arrest. Treating the underlying cause of pericardial tamponade or tension pneumothorax, for example, may be helpful.

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What Is The Pathophysiology Of CPR?

CPR is given to a person who is experiencing cardiac arrest to sustain cardiac output and oxygenate their blood, therefore saving their vital organs. Both oxygenation and blood circulation are necessary for delivering oxygen to the tissues. Several systems must cooperate to produce a pressure gradient between the venous and arterial vascular beds to carry out Cardiopulmonary Resuscitation. The absence of blood flow may cause harm to the brain after about four minutes, and irreparable damage after about seven minutes. If blood flow is disrupted for one to two hours, body cells typically perish. Therefore, the best results from CPR usually come from starting it within seven minutes of the blood flow stopping. 

The heart's ability to maintain a steady rhythm also rapidly declines. The brain can survive longer at low body temperature, as has occasionally been seen in near-drownings. In the event of cardiac arrest, effective CPR delays brain stem death by allowing enough oxygen to reach the brain and maintaining the heart's responsiveness to defibrillation attempts.

 If the incorrect compression rate is used during Cardiopulmonary Resuscitation, it is possible to lower the volume of blood that is returned to the heart from the veins, which goes against the established guidelines of the American Heart Association, which recommend between 100 and 120 compressions per minute. For example, the victim's chances of survival may be adversely affected if CPR is performed with a continuous compression rate of greater than 120 beats per minute.

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How To Perform CPR?/ CPR Procedure/ Steps of CPR

Performing CPR is an important life-saving process and it can help in emergencies to provide basic life support. We can perform CPR by following the steps:

• Step 1- Assess the Scene: Ensure that the area is safe for the victim. Look for any potential dangers or hazards before approaching the person in need.
• Step 2- Check Whether the Patient is Responding or Not: Gently tap the patient and ask out loud whether the patient is fine and then check for the signs of any response such as a movement or a response.
• Step 3- Call for Help:  If the patient is unresponsive or having difficulty breathing immediately call for emergency medical services.
• Step 4- Open the Airway: Tilt the patient's head backward by slightly lifting the chin with one hand and pushing down on the forehead with the other hand. This process helps in opening up the airways.
• Step 5- Check for Breathing: carefully examine the patient by trying to look or feel the breathing of the patient. Place your ear close to the patient's mouth and watch out for the movements of the chest and look for the patient's breathing for at least 10 minutes.
• Step 6- Begin Chest Compressions: If the chest is in a gasping condition or if not breathing then start chest compressions. Place the heel of one hand on the top of the other and interlock the fingers. The elbow should be straight and the shoulders should be positioned directly over the hands.
• Step 7- Compress the Chest: Push the chest hard at the rate of 100-120 compressions per minute. Depress the chest at least 2 inches with each compression allowing the full chest to recoil in between these compressions.
• Step 8- Give Rescue Breaths: After 30 compressions, 2 resume breaths should be provided. Maintain the open airway by tilting the head back and lifting the chin. Pinch the nose of the patient, take a normal breath, and cover the mouth of the patient with yours to create a seal. Give a breath that lasts for about one second and wait for the chest to rise. Continue cycles of compressions and breaths until professional help arrives.

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What are the Different Types of CPR?

Different types of CPR can be used depending on the situation. The main types of CPR are:

• Standard CPR- This is the traditional method of Cardiopulmonary Resuscitation that combines chest compressions and rescue breaths. It involves performing cycles of 30 chest compressions followed by 2 rescue breaths.
• Hands-only CPR-This technique, also known as compression-only CPR, focuses only on chest compressions without providing rescue breaths. The goal is to provide continuous chest compressions at a rate of 100 -120 compressions per minute.
• Pediatric CPR-This technique is specially used for infants and children. The rate of compression to rescue breaths is 15 compressions followed by 2 rescue breaths.
• Hands-only CPR with an  AED- Automated external defibrillator devices are used to deliver an electric shock to the heart during cardiac arrest. Hands-only Cardiopulmonary Resuscitation can be performed till the time AED is being prepared.

AHA 2020 Update On CPR Guidelines In Adults

1. Double Sequential Defibrillation
   • A patient has been given 3 DC shocks. The patient is still in Ventricular fibrillation.
   • The patient is Hooked to 2 defibrillators.
   • The following two steps should be performed.

1st

• One paddle has to be placed on the Right upper sternal border.
• One paddle has to be placed on the Left Cardiac apex.

2nd

• Medial to paddles of 1
• Should not be in contact to avoid damaging circuits.
• 1 paddle can be placed posteriorly
• Double sequential defibrillation is not supported.

2. Epinephrine Use in case of CPR

• In pediatrics, within 5 minutes of CPR initiation
• Epinephrine in Ventricular fibrillation or ventricular
• Tachycardia Enhances coronary perfusion (decreases ischemia)
• In Non-Shockable Rhythm Give ASAP.
• In Ventricular fibrillation, Continue CPR give Epinephrine with 2nd shock, It increases Electro shock responsiveness

AHA 2020 Update On CPR Guidelines In Pediatrics

• Both in Infants and children Choose cuffed ETT oveR Uncuffed (Reduces chances of aspiration)
• Cuffed ETT: High Volume, Low pressure is chosen to reduce subglottic stenosis,
  • Cuff pressure < 20 cm H O 2
• Cricoid pressure is not recommended as it does not reduce the chance of aspiration
• Advanced airway (After intubation)
  • Older guidelines: 1 breath / 5-6 Sec i.e. 10-12 breaths/minute
  • New guidelines: 1 breath / 2-3 Sec i.e. 20-30 breaths/minute

AHA 2020 Update On CPR Guidelines For Usage Of Steroids

1. Used successfully in COVID-19 Pneumonia
2. Used for pediatric septic shock which is non-responsive to fluid or vasopressor.
   • Vasopressors that can be used are:Epinephrine, Nor epinephrine: Preferred in septic shock and Dopamine.

In Case Of Return Of Spontaneous Circulation (ROSC)

• 1st 24 hours: Targeted temperature management: Therapeutic Hypothermia
  • Lower temp of brain
  • Metabolism of energy needs of neurons reduces they can survive better.
• Next 24 hours: Rewarming is done.
• And then controlled normothermia is ensured after rewarming.
• Biomarker: increase in Neuron Specific Enolase: a marker of dying neurons
• EEG: Somato Sensory Evoked Potential returns (When Heading toward Brain death, burst suppression Pattern is seen, followed by Silence)
• First 24 hours: CT is recommended
• After 24 hours: MRI is recommended.

Cardiac Arrest in Pregnancy

Cause of Cardiac Arrest in Pregnancy

• A - Anaesthesia
• B - Bleeding
• C - CVS (Pre-existing)
• D - Drugs
• E - Embolism
• F - Fever
• G - General Anaesthesia: 5H and 5T
• H - HTN

Maternal Intervention Needed in CPR

• Airway management is the first step
• 100% O2
• IV Line above the diaphragm
• Mg So stopped (Antidote is CaCl ) 4 2

Fetal Intervention

• Perimortem C Section (If no return of circulation within 5 mins)
• Early CPR For Presumed Cardiac Arrest
• IF CPR is withheld in Outside Hospital Cardiac Arrest, the risk for damage is high.
• Use of audio: visual feedback during training for CPR to increase performance in Real-time scenarios.
• Return of spontaneous circulation (ROSC): ET CO ≥ 20 mm Hg, there is a Higher Chance of 2
• ROSC, DBP, and CV O2 saturation is strictly monitored.
• I.V. access is better than IO (intraosseous).

Also Read: The Wolff-Parkinson-White (WPW) Syndrome

Frequently Asked Questions

1. What is CPR?

   - CPR stands for Cardiopulmonary Resuscitation. It's a life-saving technique used in emergencies when someone's breathing or heartbeat has stopped.

2. When should CPR be performed?

   - CPR should be performed if a person is unresponsive and not breathing normally or if their heart has stopped beating.

3. What are the basic steps of CPR for adults?

   - The basic steps include checking for responsiveness, calling for emergency help, starting chest compressions, providing rescue breaths if trained, and continuing until help arrives.

4. How do you perform chest compressions?

   - Place your hands, one on the other, on the center of the person's chest. Push hard and fast at a rate of 100-120 compressions per minute, with a depth of about 2 inches.

5. What is the ratio of chest compressions to rescue breaths in CPR?

   - For adults, the ratio is 30 chest compressions to 2 rescue breaths.

6. How do you give rescue breaths?

   - Tilt the person’s head to the back slightly, pinch their nose, and cover their mouth with yours to create an airtight seal. Give 2 breaths, each lasting about 1 second and making the chest rise.

7. Should CPR be different for children and infants?

   - Yes, the techniques are adjusted for size and age. For children (ages 1-8), use one or two hands for compressions and perform them at a depth of about 1.5 inches. For infants (under 1 year), use two fingers for compressions at a depth of about 1.5 inches.

8. How long should you continue CPR?

   - Continue CPR until emergency medical personnel arrive, the person starts to show signs of life, or you are too exhausted to continue.

9. What is the "CAB" sequence in CPR?

   - The CAB sequence refers to Compressions, Airway, and Breaths. Start with chest compressions, open the airway, and give rescue breaths.

10. What is Hands-Only CPR?

    - Hands-only CPR involves chest compressions without rescue breaths. It's recommended for untrained bystanders or if you're unsure about giving breaths.

11. How can you determine if someone needs CPR?

    - Check if the person is unresponsive and not breathing or not breathing normally. If in doubt, start CPR and call for emergency help.

12. Is CPR effective for drowning victims?

    - Yes, CPR is effective for drowning victims. Begin with chest compressions and rescue breaths immediately.

13. What should you do if you’re alone with an adult needing CPR?

    - Call emergency services first if possible, then start CPR. If you’re unable to make the call first, start CPR and then call for help.

14. Can CPR be performed on pregnant women?

    - Yes, perform CPR on pregnant women using the same techniques. If the woman is in advanced stages of pregnancy, you may need to adjust the position to prevent pressure on the abdomen.

15. What precautions should you take when performing CPR?

    - Ensure the scene is safe, use proper technique to avoid causing harm, and avoid hesitation. Personal protection, like gloves, is ideal but not always necessary.

16. How can I learn proper CPR techniques?

    - Take a CPR certification course from organizations like the American Heart Association (AHA) or the Red Cross. Courses offer hands-on training and are recommended for everyone.

17. Can you perform CPR if the person has a pacemaker or defibrillator?

    - Yes, you can perform CPR on individuals with pacemakers or defibrillators. Avoid placing hands directly over these devices, but continue with chest compressions.

18. What are the potential risks of performing CPR?

    - While CPR can save lives, it may cause rib fractures or other injuries. The benefits of CPR in saving lives typically outweigh the risks.

19. How often should I refresh my CPR skills?

    - It's recommended to refresh CPR skills every 1-2 years to stay current with best practices and guidelines.

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