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

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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 an 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).

Frequently Asked Questions:

Q1. What is the full form of CPR in medical terms?

Cardiopulmonary resuscitation (CPR) 

Q2. What does cardiopulmonary resuscitation mean?

Cardiopulmonary resuscitation (CPR) 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.

Q3. How do you perform CPR step by step?

To perform CPR, first check if the area is safe for both you and the victim. If needed, move the person to a safe space. 

Next, check for responsiveness by gently tapping the person’s shoulder and asking loudly if they can hear you. If there’s no response, shout for help to get assistance and activate the emergency response system by calling 108.

After that, check for breathing or gasping and feel for a carotid pulse for not more than 10 seconds. If the person is not breathing and has no pulse, start CPR immediately. 

Start chest compressions by placing the heel of one hand on the lower 1/3rd of the sternum, with the other hand on top, fingers interlocked. Push hard and fast — at least 2 inches deep, 100–120 compressions per minute.

After 30 compressions, give 2 breaths by tilting the head back, lifting the chin, and blowing into the mouth until the chest rises.  Continue ratio of chest compressions to Rescue breath @ 30:2.

When the AED arrives, follow its voice prompts.

 If the rhythm is shockable, give one shock, then resume CPR for 2 minutes before checking again. 

If the rhythm is non-shockable, continue CPR for 2 minutes as instructed. Keep repeating these steps until medical help arrives or the person starts breathing or moving again.

Q4. What are the types of CPR, and when are they used?

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

Standard CPR - This is the traditional method, which involves performing cycles of 30 chest compressions followed by 2 rescue breaths(30:2)

• Basic Life Support (BLS)  - Involves chest compressions, airway management, and rescue breathing, often combined with the use of an Automated External Defibrillator (AED).
• Advanced Cardiac Life Support (ACLS) - It is performed in hospital settings in which CPR, along with advanced interventions like airway management, use of IV medications, e.g., adrenaline, amiodarone, and use of defibrillator,s are done.
  

Hands-only CPR - Also known as compression-only CPR, focuses only on chest compressions at a rate of 100 -120 compressions per minute without providing 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 the AED is being prepared.

Pediatric CPR - Used in infants and children, where the rate of compression to rescue breaths is 15 compressions followed by 2 rescue breaths(15:2)

Neonatal Resuscitation - Done in newborns immediately after birth if breathing or heart rate is inadequate. 

Q5. What is the purpose of giving CPR during cardiac arrest?

In Cardiac arrest, the heart suddenly stops beating effectively, which leads to sudden loss of blood flow to the body. CPR works by mechanically mimicking the heart and lungs. Chest compressions force blood out of the heart into the arteries, and rescue breaths supply oxygen to the blood. This helps to maintain blood circulation and oxygen delivery to vital organs, especially the brain and heart, till the time the heart can be restarted or professional help arrives. 

Q6. How many chest compressions and breaths should be given per minute?

Chest compressions rate is 100-120 per minute, and 2 rescue breaths after every 30 compressions

Ratio of Chest compressions to rescue breaths - 30:2 · 

Q7. What is the correct hand position and technique for CPR?

The correct hand position and technique for adult CPR involves placing the heel of one hand on the lower 1/3rd of the sternum, with the other hand on top, fingers interlocked. The rescuer should keep elbows straight and shoulders directly above the hands. The rescuer should use their upper body weight to compress the chest. Compressions should be 5–6 cm deep at a rate of 100–120 per minute and allow full chest recoil. The hip joint acts as the fulcrum for efficient force application.

Q8. When should CPR be performed, and when should it not be given?

Start CPR when you see an unconscious person with no pulse and not breathing or gasping.

Do not start CPR when a person is conscious & breathing normally, OR the person has a pulse and is breathing but unresponsive (put in left lateral position to prevent aspiration), OR the person has a pulse but is not breathing (give rescue breaths @1 breath every 6 seconds).

Q9. How does adult CPR differ from pediatric CPR?

Adult and pediatric CPR differ mainly in the compression technique, depth, and rescue breath ratio. 

In adults, CPR is done using both hands placed on the center of the chest, pressing at least 2 inches (5 cm) deep. The compression-to-breath ratio is 30:2 for both single and two rescuers.

In children, use one hand for compressions (if a small child) and press about 2 inches (5 cm) deep, while in infants, use two fingers and press about 1.5 inches (4 cm) deep. The compression-to-breath ratio is 30:2 for a single rescuer but 15:2 if there are two rescuers.

In a neonate, the compression-to-breath ratio is 3:1.

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

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