Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation for a
CPR is performed to restore and maintain breathing and circulation and to provide oxygen and blood flow to the heart, brain, and other vital organs. CPR should be performed if a person is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, asphyxiation, breathing passages that are blocked, choking, drowning, drug reactions or overdoses, electric shock, exposure to cold, severe shock, or trauma. CPR can be performed by trained bystanders or healthcare professionals on infants, children, and adults. It should always be performed by the person on the scene who is most experienced in CPR.
CPR should never be performed on a healthy person because it can cause serious injury to a beating heart by interfering with normal heartbeats.
CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the problem and notification of the emergency medical system (EMS), followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in attempt to get the heart to beat normally), and advanced cardiac life support measures.
CPR must be performed within four to six minutes after cessation of breathing so as to prevent brain damage or death. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to a person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate blood through the heart to vital organs by external chest compressions. Mouth-to-mouth breathing and external chest compression should be performed together, but if the rescuer is not strong enough to do both, the external chest compressions should be done. This is more effective than no resuscitation attempt, as is CPR that is performed "poorly."
When performed by a bystander, CPR is designed to support and maintain breathing and circulation until emergency medical personnel arrive and take over. When performed by healthcare personnel, it is used in conjunction with other basic and advanced life support measures.
According to the American Heart Association, early CPR and defibrillation combined with early advanced emergency care can increase survival rates for people with a type of abnormal heart beat called ventricular fibrillation by as much as 40%. CPR by bystanders may prolong life during deadly ventricular fibrillation, giving emergency medical service personnel time to arrive.
However, many CPR attempts are not ultimately successful in restoring a person to a good quality of life. Often, there is brain damage even if the heart starts beating again. CPR is therefore not generally recommended for the chronically or terminally ill or frail elderly. For these people, it represents a traumatic and not a peaceful end of life.
Each year, CPR helps save thousands of lives in the United States. More than five million Americans annually receive training in CPR through American Heart Association and American Red Cross courses. In addition to courses taught by instructors, the American Heart Association also has an interactive video called Learning System, which is available at more than 500 healthcare institutions. Both organizations teach CPR the same way, but use different terms. These organizations recommend that family members or other people who live with people who are at risk for respiratory or cardiac arrest be trained in CPR. A hand-held device called a CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines. CPR has been practiced for more than 40 years.
The basic procedure for CPR is the same for all people, with a few modifications for infants and children to account for their smaller size.
PERFORMING CPR ON AN ADULT. The first step is to call the emergency medical system for help by telephoning 911; then to begin CPR, following these steps:
- The rescuer opens a person's airway by placing the head face up, with the forehead tilted back and the chin lifted. The rescuer checks again for breathing (three to five seconds), then begins rescue breathing (mouth-to-mouth artificial respiration), pinching the nostrils shut while holding the chin in the other hand. The rescuer's mouth is placed against the unconscious person's mouth with the lips making a tight seal, then gently exhales for about one to one and a half seconds. The rescuer breaks away for a moment and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
- After two breaths, the rescuer checks the unconscious person's pulse by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the unconscious person has a heartbeat, the rescuer continues rescue breathing until help arrives or the person
- begins breathing without assistance. If the unconscious person is breathing, the rescuer turns the person onto his or her side.
- If there is no heartbeat, the rescuer performs chest compressions. The rescuer kneels next to the unconscious person, placing the heel of one hand in the spot on the lower chest where the two halves of the rib cage come together. The rescuer puts one hand on top of the other on the person's chest and interlocks the fingers. The arms are straightened, the rescuer's shoulders are positioned directly above the hands on the unconscious person's chest. The hands are pressed down, using only the palms, so that the person's breastbone sinks in about1.5–2 inches. The rescuer releases pressure without removing the hands, then repeats about 15 times per 10–15 second intervals.
- The rescuer tilts the unconscious person's head and returns to rescue breathing for one or two quick breaths. Then breathing and chest compressions are alternated for one minute before checking for a pulse. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the unconscious person is breathing but has no pulse, the chest compressions are continued. If the unconscious person has a pulse but is not breathing, rescue breathing is continued.
- For children over the age of eight, the rescuer performs CPR exactly as for an adult.
PERFORMING CPR ON AN INFANT OR CHILD UNDER THE AGE OF EIGHT. The procedures outlined above are followed with these differences:
- The rescuer administers CPR for one minute, then calls for help.
- The rescuer makes a seal around the child's mouth or infant's nose and mouth to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1.5–2 seconds for each breath.
- Chest compressions are given with only one hand for a child and with two or three fingers for an infant. The breastbone is depressed only 1–1.5 in (2.5–3.8 cm) for a child and 0.5–1 in (1.3–2.5 cm) for an infant, and the rescuer gives at least 100 chest compressions per minute.
New developments in CPR
Some new ways of performing CPR have been tried. Active compression-decompression resuscitation, abdominal compression done in between chest compressions, and chest compression using a pneumatic vest have all been tested but none are currently recommended for routine use.
The active compression-decompression device was developed to improve blood flow from the heart, but clinical studies have found no significant difference in survival between standard and active compression-decompression CPR. Interposed abdominal counterpulsation, which requires two or more rescuers, one compressing the chest and the other compressing the abdomen, was developed to improve pressure and therefore blood flow. It has been shown in a small study to improve survival but more data is needed. A pneumatic vest, which circles the chest of an unconscious person and compresses it, increases pressure within the chest during external chest compression. The vest has been shown to improve survival in a preliminary study but more data is necessary for a full assessment.
If a person suddenly becomes unconscious, a rescuer should call out for help from other bystanders, and then determine if the unconscious person is responsive by gently shaking the shoulder and shouting a question. Upon receiving no answer, the rescuer should call the emergency medical system. The rescuer should check to see whether the unconscious person is breathing by kneeling near the person's shoulders, looking at the person's chest, and placing a cheek next to the unconscious person's mouth. The rescuer should look for signs of breathing in the chest and abdomen, and listen and feel for signs of breathing through the person's lips. If no signs of breathing are present after three to five seconds, CPR should be started.
Emergency medical care is always necessary after successful CPR. Once a person's breathing and heartbeat have been restored, the rescuer should make the person comfortable and stay there until emergency medical personnel arrive. The rescuer can continue to reassure the person that help is coming and talk positively until professionals arrive and take over.
CPR can cause injury to a person's ribs, liver, lungs, and heart. However, these risks must be accepted if CPR is necessary to save the person's life.
In many cases, successful CPR results in restoration of consciousness and life. Barring other injuries, a revived person usually returns to normal functions within a few hours of being revived.
These include injuries incurred during CPR and lack of success with CPR. Possible sites for injuries include a person's ribs, liver, lungs, and heart. Partially successful CPR may result in brain damage. Unsuccessful CPR results in death.
Alton, Thygerson. First Aid and CPR. 4th ed. Sudbury, Massachusetts: Jones & Bartlett Pub, 2001.
Knoop, Kevin J. and Lawrence B. Stack. Atlas of Emergency Medicine. 2nd ed. New York: McGraw Hill, 2001.
National Safety Council. First Aid and CPR for Infants and Children. 4th ed. Sudbury, Massachusetts: Jones & Bartlett Pub, 2001.
Skinner, David B. and Richard Vincent. Cardiopulmonary Resuscitation. 2nd ed. New York: Oxford University Press, 1996.
Davies, N. and D. Gould. "Updating cardiopulmonary resuscitation skills: a study to examine the efficacy of self-instruction on nurses' competence." Journal of Clinical Nursing 9 (2000): 400-410.
Eftestol T., K. Sunde, S. O. Aase, J. H. Husoy, and P. A. Steen. "'Probability of successful defibrillation' as a monitor during CPR in out-of-hospital cardiac arrested patients." Resuscitation 48 (2001): 245-254.
Kern, K. B., H. R. Halperin, and J. Field. "New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest." Journal of the American Medical Association 285 (2001): 1267-1269.
Meyer W. and F. Balck. "Resuscitation decision index: a new approach to decision-making in prehospital CPR." Resuscitation 48 (2001): 255-263.
American College of Emergency Physicians. P.O. Box 619911, Dallas, TX 75261-9911. (800) 798-1822 or (972) 550-0911. Fax: (972) 580-2816. <firstname.lastname@example.org>. <http://www.acep.org/>.
American College of Osteopathic Emergency Physicians. 142 E. Ontario Street, Suite 550, Chicago, IL 60611. (312) 587-3709 or (800) 521-3709. Fax: (312) 587-9951. <http://www.acoep.org>.
American Heart Association, National Center. 7272 Greenville Avenue, Dallas, TX 75231. (877) 242-4277. <http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/heim.html>.
Heimlich Institute. PO Box 8858, Cincinnati, OH 45208. <email@example.com>. <http://www.heimlichinstitute.org/index.htm>.
National Safe Kids Campaign. 1301 Pennsylvania Avenue, Suite 1000, Washington, DC 20004-1707. <http://pedsccm.wustl.edu/All-Net/english/neurpage/protect/drown.htm>.
American Heart Association. <http://www.cpr-ecc.org/> and <http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/cprs.html>.
Columbia Presbyterian Medical Center. <http://cpmcnet.columbia.edu/texts/guide/hmg13_0001.html>.
Learn CPR. <http://www.learn-cpr.com>.
National Registry of Cardiopulmonary Resuscitation. <http://www.nrcpr.org/>.
University of Washington School of Medicine. <http://depts.washington.edu/learncpr/>.
L. Fleming Fallon, Jr., MD, DrPH
Cardiac arrest—Temporary or permanent cessation of the heartbeat.
Cardiopulmonary—Relating to the heart and the lungs.
Resuscitation—Bringing a person back to life after an apparent death or in cases of impending death.
Ventricular fibrillation—An irregular heartbeat where the heart beats very fast but ineffectively. Ventricular fibrillation is fatal if not quickly corrected.