Chest Compressions

1. Indications
   1. Newborn Resucitation
   2. Pediatric Resuscitation
   3. Adult Resuscitation
2. Technique: General
   1. Compressions
      1. Compressions are the mainstay of Resuscitation and trump all medications in survival benefit
      2. Compressions should be started immediately for an unresponsive, apneic patient
         1. Health care providers check for pulse (<10 seconds), but other rescuers start compressions without delay
         2. If any doubt about palpable central pulses, begin cardiac compressions
      3. Compressions should be interrupted only briefly (<10 seconds)
      4. Compressions should be hard and fast
         1. To avoid Fatigue and maintain adequate compressions, compressor switches with Ventilator every 2 minutes
      5. Active Compression-Decompression devices (ACD-CPR, e.g. Lucas ) can be considered where available, however insufficient evidence in 2010
         1. ACD-CPR anecdotally can sustain adequate cerebral circulation for patients to alert despite lethal rhythm
         2. ACD-CPR anecdotally may adequately sustain patients in lethal rhythm to transfer inter-hospital to a catheter lab
   2. Ventilations
      1. Ventilations should last 1 second per breath and demonstrate visible chest rise
      2. Untrained rescuers perform only compressions and no ventilations until EMS arrives
      3. Place Advanced Airway when able
         1. Can maintain airway with 2 intranasal and an Oral Airway until Advanced Airway available
      4. Advanced Airway in position and confirmed
         1. Ventilations every 6-8 seconds (8-10 per minute) asynchronous to compressions
   3. Defibrillation
      1. Attach and use the AED or manual Defibrillator as soon as available
      2. Successful conversion from Ventricular Fibrillation and Pulseless Ventricular Tachycardia is directly related to earliest timing of Defibrillation
      3. Defibrillation requires briefly clearing the patient for each shock
         1. Interruption of compressions should be minimized (<10 seconds)
         2. Use of an Active Compression-Decompression device (ACD-CPR, e.g. Lucas ) may be continued through Defibrillation (need not be paused)
3. Technique: Newborns
   1. Sternal Compressions: Same as for infants except for alternative technique using 2 thumbs
      1. General
         1. Depress one third chest depth (1.5 inches or 4 cm)
         2. Do not lift fingers from chest between compressions
      2. Technique 1: Thumbs depress Sternum
         1. Hands encircle torso
         2. Fingers support spine
         3. Preferred (less tiring)
      3. Technique 2: Two fingers depress Sternum
         1. Use Index, Middle Finger placed below nipple level
         2. Preferred for larger newborns
   2. Compression rate at least 100 times per minute
   3. Compression to ventilation ratio
      1. One rescuer: 30:2
      2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes)
4. Technique: Infants (age under 1 year)
   1. Sternal Compressions
      1. Use Index, Middle Finger placed below nipple level
      2. Depress 1/3 of chest depth (1.5 inches or 4 cm)
         1. Do not lift fingers from chest between compressions
   2. Compression rate ast least 100 times/minute
   3. Compression to Ventilation Ratio
      1. One rescuer: 30:2
      2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes)
5. Technique: Children (1 to 8 years)
   1. Sternal Compressions
      1. Use heel of one hand placed above center of chest (superior to xiphoid)
      2. Depress at least 1/3 of chest depth (2 inches or 5 cm)
   2. Compression rate at least 100 times/minute
   3. Compression to Ventilation Ratio
      1. One rescuer: 30:2
      2. Two health care providers: 15:2 (compressor switches with Ventilator every 2 minutes)
6. Technique: Adults
   1. Sternal Compressions
      1. Use heel of two hands placed above center of chest (superior to xiphoid)
      2. Depress chest 2 inches or 5 cm
   2. Compression rate at least 100 times/minute
   3. Compression to Ventilation Ratio
      1. One or two rescuers: 30:2 (compressor switches with Ventilator every 2 minutes)
7. Monitoring: Quantitative Waveform Capnography (PETCO2) - indications of quality compressions
   1. PETCO2 should exceed 20 mmHg during diastole (relaxation phase)
   2. PETCO2 should show a pulsatile waveform that coincides with compressions
   3. PETCO2 >40 mmHg (typically abrupt onset) suggests return of spontaneous circulation (ROSC)
8. Prognosis: Adults after CPR
   1. Criteria
      1. Witnessed arrest
      2. Initial rhythm
         1. Ventricular Tachycardia or
         2. Ventricular Fibrillation
      3. Pulse regained in first 10 minutes of compression
   2. Interpretation: Any of three criteria above met
      1. Predicts survival to hospital discharge
   3. References
      1. van Walraven (2001) JAMA 285:1602-6
9. References
   1. Cardiopulmonary Resuscitation Guidelines
      1. http://www.circulationaha.org
      2. (2010) Guidelines for CPR and ECC
      3. (2005) Circulation 112(Suppl 112):IV
      4. (2000) Circulation, 102(Suppl I):86-9