Chest Compressions

Aka: Chest Compressions, Cardiac Compressions, Active Compression-Decompression devices, ACD-CPR, Closed Chest Cardiac Massage

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II. Indications

  1. Newborn Resucitation
  2. Pediatric Resuscitation
  3. Adult Resuscitation

III. Technique: Compressions

  1. Compressions are the mainstay of Resuscitation and trump all medications in survival benefit
    1. Goal is to increase Coronary Artery perfusion pressure >25 mmHg for improved outcomes
    2. When team leader, ensuring high quality CPR is paramount
  2. Compressions should be started immediately for an unresponsive, apneic patient
    1. Only health care providers should check for pulse (<10 seconds) before CPR
    2. Other rescuers should start compressions without delay
    3. If any doubt about palpable central pulses, begin Cardiac Compressions
  3. Markers of adequate compression
    1. EtCO2 >15 mmHg suggests compressions are generating a perfusion pressure
    2. Arterial Line diastolic pressure >40 mmHg
      1. Read from Arterial Line tracing (not generated diastolic number on machine)
  4. Compressions should be interrupted only briefly (<10 seconds) if at all
    1. EtCO2 is a reliable marker for ROSC (if pulses are difficult to palpate)
    2. Stopping and starting compressions requires 5-10 seconds to return to prior coronary perfusion pressure
      1. Bobrow (2008) JAMA 299(10):1158-65 [PubMed]
    3. Bedside Ultrasound may prolong pulse checks
      1. Restart compressions on 10 second timer instead of per ultrasonagrapher
      2. Huis (2017) Resuscitation 119:95-98 PMID:28754527 [PubMed]
    4. ACD-CPR devices (e.g. Lucas) can maintain superior compressions throughout Resuscitation including Defibrillation
    5. Start charging the Defibrillator before CPR is paused (decreases hands-off time)
      1. Defibrillator fully charged when CPR paused
      2. Immediate shock can be delivered at rhythm check and CPR resumed
      3. Edelson (2010) Resuscitation 81(11):1521-6 +PMID:20807672 [PubMed]
    6. Hands on Defibrillation
      1. Rescuers are testing safely continuing manual compressions through biphasic Defibrillation
        1. Minimal rescuer electricity exposure
        2. Lloyd (2008) Circulation 117(19): 2510-4 [PubMed]
      2. Benefit to patient may not outweigh risk to rescuer
        1. No evidence for added benefit in ROSC for hands-on over 10 second CPR pause
        2. Risk of rescuer Electrocution
        3. Hunter in Majoewsky (2013) EM:Rap 13(2): 3-4
  5. Do not stop Chest Compressions for procedures
    1. Intubation
    2. Central Lines
    3. Defibrillator charging
  6. Compressions should be hard and fast
    1. To avoid Fatigue and maintain adequate compressions, compressor switches with Ventilator every 2 minutes
    2. Allow full chest recoil and decompression
  7. Active Compression-Decompression devices (ACD-CPR, e.g. Lucas ) can be considered where available
    1. However insufficient evidence in 2010 to claim survival benefit (beyond anecdotal report)
    2. ACD-CPR anecdotally can sustain adequate cerebral circulation for patients to alert despite lethal rhythm
    3. ACD-CPR anecdotally may adequately sustain patients in lethal rhythm to transfer inter-hospital to a catheter lab
    4. Lucas training video
      1. https://www.youtube.com/watch?v=EAs1IUpNIGo

IV. Technique: 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
  5. Impedance Threshold Device (e.g. ResQPOD)
    1. Attaches inline between positive pressure device (e.g. ambubag) and mask or ET Tube
    2. Assists in maintaining negative intrathoracic pressure which in turn increases venous return
    3. Associated with increased rate of Return of Spontaneous Circulation
      1. Aufderheide (2005) Crit Care Med 33(4): 734-40 [PubMed]
    4. However more recent studies showed no benefit
      1. Aufderheide (2011) N Engl J Med 365(9): 798-806 [PubMed]

V. Technique: Defibrillation

  1. Attach and use the AED or manual Defibrillator as soon as available
  2. Successful conversion from VF/Pulseless VT 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. Active Compression-Decompression device (ACD-CPR, e.g. Lucas )
      1. May be continued through Defibrillation (need not be paused)

VI. Protocol: 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)

VII. Protocol: 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)

VIII. Protocol: 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)

IX. Protocol: Adults

  1. Sternal Compressions
    1. Use heel of two hands placed above center of chest (superior to xiphoid)
    2. Depress chest at least 2 inches or 5 cm
  2. Compression rate at least 100 times/minute
    1. Compress 30 times within 18 seconds
  3. Compression to Ventilation Ratio
    1. One or two rescuers: 30:2 (compressor switches with Ventilator every 2 minutes)

X. Monitoring: Quantitative Waveform Capnography (PETCO2) - indications of quality compressions

  1. PETCO2 <10 mmHg is associated with poor outcome
  2. PETCO2 should exceed 20 mmHg during diastole (relaxation phase)
  3. PETCO2 should show a pulsatile waveform that coincides with compressions
  4. PETCO2 >40 mmHg (typically abrupt onset) suggests Return of Spontaneous Circulation (ROSC)

XI. Prognosis: Return of Spontaneous Circulation (ROSC) in adults

  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 [PubMed]

XII. Resources

  1. Lucas Device CPR
    1. http://www.youtube.com/watch?v=EAs1IUpNIGo
  2. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org

XIII. References

  1. Weingart and Swaminathan in Herbert (2020) EM:Rap 20(7):8
  2. Orman and Bucher in Herbert (2016) EM:Rap 16(12): 12-3
  3. Mace (2013) Crit Dec Emerg Med 27(1): 11-20
  4. Shinar in Herbert (2012) EM:RAP 12(10): 4
  5. (2010) Guidelines for CPR and ECC [PubMed]
  6. (2005) Circulation 112(Suppl 112):IV [PubMed]
  7. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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