Cpr Needs Resuscitation & Resuscitation Needs Cpr

CPR, otherwise known as Cardio Pulmonary Resuscitation, is universally accepted as the emergency procedure of choice for people who have stopped breathing or whose heart has stopped beating. But at the same time it remains underutilized and at the same time misunderstood.

Contrary to popular belief, CPR is not meant to and is unlikely to restore a heartbeat. The objective of CPR is to keep the blood circulating, similar to ‘priming the pump’, until an effective heartbeat and breathing can be restored. CPR is just a part of the continuum of the medical management of cardiac arrest. If heart function is restored, it is usually by trained medical personnel with a medical device such as a defibrillator.

CPR training experts are concerned that CPR, as shown in the media including films and TV, has given the public an erroneous view of CPR. With the popularity of medical soaps, CPR, especially hands-only has become a common feature. However, its portrayal is still far from correct. For one thing, CPR survival rates on screen are abnormally high compared to reality. Second, actors do not perform CPR properly, not because of lack of knowledge but for safety reasons. When performed on otherwise healthy people, CPR can interfere with normal breathing and heart function. Thus, in films, CPR is performed without the necessary force to avoid injuries to the actors or is done on mannequins.

A 1996 study of the TV shows, ER, Chicago Hope and Rescue 911, reports that “the survival rates in our study are significantly higher than the most optimistic survival rates in the medical literature, and the portrayal of CPR on television may lead the viewing public to have an unrealistic impression of CPR and its chances for success.”

Sudden Cardiac Arrest remains a deadly disease. Here are some numbers and figures on CPR to ponder upon.

7 to 10% – decrease in the chances of survival for every minute of delay until defibrillation, if CPR is not applied.

95% – cardiac arrest victims who die before reaching the hospital.

49 to 75% – survival rates in adults when CPR plus defibrillation within 3 to 5 minutes of collapse is performed.

294,851 – number of EMS-treated out-of-hospital cardiac arrests in the US each year.

100 – number of compressions per minute to be delivered during CPR. To facilitate counting, the American Heart Association (AHA) trains people to time compressions to the tune of “Stayin’ Alive” which has the right tempo.

80% – fraction of all out-of-hospital cardiac arrests that occur in private homes.

2% to 10% – survival rates in children who develop out-of-hospital cardiac arrest.

14 to 38% – incidence of CPR attempt by bystanders in out-of-home cardiac arrests.

Unfortunately, because of confusion and the lack of knowledge about CPR, very few people are capable or willing to perform CPR during emergencies. A 2008 online AHA survey on emergency awareness of 1,132 adults gave the following results; 89% of respondents were willing to do something to help if they witnessed a medical emergency, 21% were confident they could perform CPR and 15% believed they could use an automated external defibrillator (AED) in an emergency.

Those who were not willing or felt not able to help cited the following barriers; lack of confidence, fear of doing more harm than good and not surprisely, concern about legal consequences.

CPR underultilization is also related to several other factors including:

(1) The recommended CPR steps and variations in terms of age, vital signs, etc. are too complicated for lay persons and for that matter even healthcare professionals to grasp, much more perform during an emergency. A simplified generic version of the procedure is obviously needed and with more emphasis on chest compressions rather than rescue breathing.

(2) The methodology for CPR continues to change which has created confusion in both the medical and public community. Yes, even the medical community! In 50 years we have gone from laying people on their belly and moving their arms to an emphasis on chest compressions interrelated with breathing and now to the emphasis on mainly chest compressions with a deemphasis on rescue breathing. Huh? In fact, recent studies suggest that the survival rate and neurologic outcome are better in patients who have received minimal ventilation.

As a result, the 2005 guidelines recommends a compression-ventilation ratio (30:2) for all single rescuers of infant, child, and adult victims (excluding newborns). The prior compression – ventilation ratio was 5:1. The guidelines were set by the International Liaison Committee on Resuscitation (ILCOR). ILCOR is an international consortium of representatives from many of the world’s resuscitation councils. The guidelines were implanted in the US as the 2005 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

And to further add to this confusion, different health groups have slight differences in implementing the guidelines. As an example, AHA advocates delivery of 2 rescue breaths when the patient is not breathing. The European Resuscitation Council (ERC) and the Resuscitation Council of the United Kingdom ((RCUK) put more emphasis on immediate application of chest compressions. The AHA also used to advocate following different steps in sequence such as checking first for breathing, then checking for a pulse, all within 10 seconds. The ERC and the RCUK recommend a simultaneous check for breathing and pulse. There are also disagreements about applying CPR on a bed or on the floor.

(3) It is believed that mouth-to-mouth ventilation presents the main barrier to bystander CPR. The act of delivering rescue breaths or mouth-to-mouth ventilation is not an easy thing to accept, even by some EMS workers. For one thing, mouth to mouth contact is an act of intimacy in many cultures. For another, it puts both rescuer and patient at risk of disease and infection transmission. Of significance, a recent observational study by American researchers indicates no evidence of any benefit from mouth-to-mouth ventilation in patients who suffered from out-of-hospital cardiac arrest.

(4) The person administering CPR usually has to make a life-and-death decision without consulting the patient. This is sometimes in conflict with the victim’s religious and cultural beliefs. There are religious groups, for example, which are against the practice of CPR, an act which they believe amounts to reversing death and going against nature. For this reason, the AHA came up with ethical guidelines regarding CPR.

Despite the doom and gloom, there are some heartening developments.

(1) Continued focus by the major advocate organizations on the promotion of bystander CPR. Considering the number of out-of-hospital cardiac arrests and how critical CPR application is between time to of collapse and arrival of EMS to survival, it is very important that bystanders, be they family, friends or complete strangers are able to perform CPR.

Many studies have shown that bystander CPR is effective in improving the chances of survival of a cardiac arrest victim. In 1994 Swedish researchers reported that “cardiopulmonary resuscitation initiated by a bystander maintains ventricular fibrillation and triples the chance of surviving a cardiac arrest outside the hospital. Furthermore, it seems to protect against death in association with brain damage as well as with myocardial damage.”

2) Most experts believe that bystander CPR is an essential component in the continuum of care for Sudden Cardiac Arrest. This management, now called the minimally interrupted cardiac resuscitation (MICR) technique probably produces the best chances for survival. Other terms used in this context are cardiocerebral resuscitation (CCR) or cardiac only resuscitation, or compression-only CPR.

(3) Ongoing simplification of CPR instruction, in terms easily understandable by both lay persons and medical professionals, including the adoption of ‘hands-only CPR’ which helps eliminate one of the major barriers to bystander CPR, mouth to mouth breathing.

(4) Promotion of widespread availability of AEDs, the so-called public access defibrillation. CPR alone cannot restart the heart in almost all cases, other than in the group of people that develop cardiac arrest from respiratory arrest, like near drowning. Defibrillation by applying an electric shock directly to the heart is necessary to reverse the most common cause of cardiac arrest, ventricular fibrillation. This is where the AED comes in. AEDs are portable, battery-operated devices that can be used to administer an electric shock and are designed to be used by lay persons even without prior training. As soon as the AED is activated, visual and audio cues guide the rescuer through the whole procedure. In addition, attempts have been made to extend Good Samaritan legal liability protection to all users of AEDs.

(5) But what is even more promising is anybody can perform CPR, including children, according to a study by Austrian researchers. Kids as young as 9 years old who had received six hours of life support training could perform CPR correctly four months after the training. The study concluded that “students as young as 9 years are able to successfully and effectively learn basic life support skills including AED deployment, correct recovery position and emergency calling. As in adults, physical strength may limit depth of chest compressions and ventilation volumes but skill retention is good.”

The message is clear – CPR Needs Resuscitation and Resuscitation needs CPR. What’s important is, not how well CPR was done, but whether it was done at all!