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					The New CPR 2009

• • • • SCA - Sudden Cardiac Arrest CPR – Cardio Pulmonary Resuscitation CC CPR – Chest Compression CPR CCR – Cardio Cerebral Resuscitation

Alternatives to Traditional CPR
• Why are alternatives acceptable? • How are alternatives developed? • Were these piloted and where?

Why are alternatives acceptable?

Oxygen Supply in the Body

• Respiratory Arrest patients have depleted oxygen stores in their blood. • Sudden Cardiac Arrest patients have non circulating oxygen supply in their blood.

Phases of CPR
Phase 1 Phase Name Electrical phase Time from VF arrest Important intervention From time of arrest to about the first 5 min after arrest About 5 min to 10 or 15 min after arrest After about 10 to 15 min Electrical therapy


Circulatory (hemodynamic) phase Metabolic phase

CPR before electrical therapy Possible therapeutic hypothermia or other new concepts


• Cardio Pulmonary Resuscitation = heart, lung resuscitation • During traditional CPR, patients are given both chest compressions and ventilations during resuscitation attempts.

30 - 2
• Thirty Chest Compression to • 2 puffs ( quick puffs of air) you must see the chest rise and fall

Continuous Chest Compresssion CPR (CC CPR)
• This type of CPR is taught to lay people. (non health care providers) • CC CPR emphasizes on hard, fast chest compressions, minimizing interruptions. • During CC CPR, a patient receives chest compressions that circulates oxygenated blood. • Early defibrillation when a device is available.

CPR Jackhammer

Steve Berry

Cardio Cerebral Resuscitation (CCR)
• This type of CPR is taught to healthcare providers, with approval from medical direction. • CCR emphasizes on hard, fast chest compressions, minimizing interruptions, defibrillation, and administration of epinephrine and atropine.. • During CCR, a patient receives chest compressions that circulates oxygenated blood, vital defibrillations, and medications.

CCR is used on patient who have a sudden cardiac arrest DO NOT USE ON: Primary Respiratory Arrest Overdose Arrest Traumatic Arrest Drowning Any patient <8 years old

Why CCR?
• Oxygenated heart is critical to defibrillation • Sudden Cardiac Arrest patients have non circulating oxygen supply in their blood • The medications given help to increase a heart rate

What do we know we do wrong
• We interrupt CPR too frequently to perform other tasks, resulting, on average, in < 60 compressions/min • We don't compress the chest fast enough or deep enough, resulting in low coronary perfusion pressures. • We hyperventilate our pts, which inhibits VR by increasing intrathoracic pressures • Due to poor technique and/or rescuer fatigue, we don't allow the chest to recoil completely, leading to even higher intrathoracic pressures

Decision to start CPR:
• Decision to start CPR is made if a victim is unresponsive and not breathing normally.
• Pulse check is no longer required, and is NOT recommended for lay persons. • Pulse check has been shown to be unreliable, with unacceptably high rates of false positives and negatives.

Chest compressions
• Place hands on the center of the chest, rather than the ‘rib margin’ method. • 100/min for all victims (except newborns). • Allow chest to recoil to normal position after each compression. • Use equal compression and relaxation times. • Limit interruptions in chest compressions, even for rhythm check, shock delivery, advanced airway, or vascular access.

• Breaths are given over 1sec rather than 2sec.

• During the first minutes of CPR, ventilation is probably not as important as compressions. • Ventilation, however, is important for victims of hypoxic arrest and after the first minutes of any arrest.


• During CPR, blood flow to the lungs is much less than normal, so the victim needs less ventilation. • Hyperventilation is not necessary, and may be harmful. • Limit the time used to deliver breaths to reduce interruptions in chest compressions. • Ventilation during CPR increase intra-thoracic pressure, reducing VR and thus blood flow generated by chest compressions.

Universal Compression-to-Ventilation Ratio for All Lone Rescuers
• Ratio of compressions to ventilations is 30:2 for all adult victims of cardiac arrest.
• The 2 initial rescue breaths are omitted, with 30 compressions being given immediately after cardiac arrest is established. • During 2-rescuer CPR with an ETT in place, rescuers no longer stop compressions for ventilation (continuous compressions and 10 breaths/min).

High-Frequency Chest Compressions
• >100/min chest compressions showed mixed results. One clinical trial of 9 pts showed that 120/min chest compressions improved hemodynamics over standard CPR.
• High-frequency chest compressions can be considered, but there is insufficient evidence to recommend for or against its use (Class Indeterminate).

Interposed Abdominal Compression
• IAC-CPR uses a dedicated rescuer to provide manual compression of the abdomen during the relaxation phase of chest compression, to enhance venous return. • IAC-CPR may be considered for in-hospital resuscitation when sufficient trained personnel are available (Class IIb). • There is insufficient evidence to recommend for or against IAC-CPR in the out-of-hospital setting (Class Indeterminate).

• Compression rate is 100/minute

• Ventilation rate is 10 breaths per minute .
• Once an advanced airway is in place, ratios cease to be used and chest compressions are performed nonstop at 100/minute, with breaths delivered at a rate of 10/min without pausing compressions to deliver the ventilations .

Bottom Line
• Perfusion first, defibrillation second. Interruptions to CPR kept to a minimum • In witnessed arrest and AED is immediately available, shock. • Otherwise, CPR for 2 min • Shock-CPR-shock-CPR-shock, instead of shockshock-shock-CPR. • 30:2 for all but newborns • Avoid hyperventilation

Pediatric basic life support
• Lone rescuers in pediatric cardiac arrest start with 5 rescue breaths and continue with the 30:2 ratio • Two rescuers will use the 15:2 ratio in a child up to the onset of puberty. • In an infant (<1yr) the compression technique remains the same: two-finger compression for single rescuers and two-thumb encircling technique for two or more rescuers. Above one yr of age, the one or two hands technique may be used according to rescuer preference.

Summary of BLS for lay rescuers


Summary of BLS for professional rescuers



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