Home > Encyclopedia of Nursing & Allied Health > Cardiopulmonary Resuscitation (CPR)

Definition

Cardiopulmonary resuscitation (CPR) is a procedure to support and maintain breathing and circulation on a person who has stopped breathing (respiratory arrest) and/or whose heart has stopped (cardiac arrest).

Purpose

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. It should be performed if a person is unconscious and not breathing. Respiratory and cardiac arrest can be caused by allergic reactions, an ineffective heartbeat, a heart attack, 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 on infants, children, and adults by trained bystanders or healthcare professionals. It should always be performed by the person on the scene who is most experienced in CPR.

Precautions

CPR should never be performed on a healthy person, since it can cause serious injury to a beating heart.

Description

CPR is part of the emergency cardiac care system designed to save lives. Many deaths can be prevented by prompt recognition of the medical situation and notification of the emergency medical system (EMS). This should be followed by early CPR, defibrillation (which delivers a brief electric shock to the heart in an attempt to get the heart to beat normally), and advanced cardiac life support measures.

CPR must be performed within four to six minutes of the time that breathing stopped in order to prevent brain damage or death. It is a two-part procedure that involves rescue breathing and external chest compressions. To provide oxygen to the person's lungs, the rescuer administers mouth-to-mouth breaths, then helps circulate the 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 isn't strong enough to do both, the external chest compressions should be done alone. Some bystanders are reluctant to initiate CPR because of the possible transmission of infectious disease during mouth-to-mouth breathing or their inexperience with CPR. External chest compressions alone have been found to have similar results when compared to mouth-to-mouth breathing and external chest compressions combined. External chest compressions, as well as CPR that is performed inexpertly, are more effective than no resuscitation attempt.

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.

It must be appreciated, however, that most CPR attempts are not ultimately successful in restoring the victim 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 is traumatic and not a peaceful end of life.

CPR has been practiced for more than 40 years. Each year, it helps save thousands of lives in the United States. More than five million Americans receive training in CPR through the American Heart Association and the American Red Cross courses annually. 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. They recommend that family members or other people who live with patients at risk of

respiratory or cardiac arrest be trained in CPR. A hand-held device called CPR Prompt is available to walk people trained in CPR through the procedure, using American Heart Association guidelines.

In 2000, focus groups from the American Heart Association and the American Red Cross joined forces with international councils in order to create a consistent, single description of resuscitation guidelines. These guidelines have been released and many changes in CPR have been instituted. These changes replace the recommendations from their publications in 1992.

Performing CPR

The basic procedure for CPR is the same for adults, infants, and children, with a few modifications for infants and children to account for their smaller size.

PERFORMING CPR ON AN ADULT. In most cases, the first step is to call the emergency medical system for help by telephoning 911. There are exceptions to calling for help first. The new concept of "phone fast" is being recommended for trauma victims, water submersion victims, and medication/drug overdoses. CPR should be started immediately on these types of victims because the rate of survival increases with early rescue efforts. To start CPR, use the following steps:

• The rescuer opens the 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). He pinches the person's nostrils shut while holding the chin in the other hand. The rescuer places his mouth against the 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 an instant and then repeats. The person's head is repositioned after each mouth-to-mouth breath.
• After two breaths, the rescuer checks for indications of blood circulation (regular respiratory inhalations, vomiting, or any attempt to move). If the rescuer is a health care professional, the person's pulse is checked by moving the hand that was under the person's chin to the artery in the neck (carotid artery). If the person shows no signs of circulating blood, the rescuer continues rescue breathing until help arrives or the person begins breathing spontaneously. If the 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 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 his other hand on top of the one on the chest and interlocks the fingers. He straightens his arms, leans forward to position the shoulders directly above the hands on the person's chest, and presses down, using only the palms, so that the person's breast-bone sinks in about 1¹/₂-2 in (4-5 cm). The rescuer releases without removing the hands, then repeats about 15 times in 10-15 seconds.
• The rescuer tilts the person's head and returns to rescue breathing for one or two quick breaths. Then he alternates breathing and heart presses for one minute, and checks for any signs of blood circulation. If the rescuer finds signs of a heartbeat and breathing, CPR is stopped. If the person is breathing but has no pulse the heart presses are continued; if the person has a pulse but is not breathing, rescue breathing is continued. The number of heart presses has recently increased to 15 heart presses to two breaths for single or double rescuer CPR. The recommended number of heart presses is at least 100 a minute. The rationale for this increase relates to establishing adequate heart and brain circulation.
• For children over the age of eight, the rescuer performs CPR the same as on 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 infant/child's mouth (and nose with infants) to give gentle breaths. The rescuer delivers 20 rescue breaths per minute, taking 1¹/₂-2 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 1-1¹/₂ in (2.5-3.75 cm) for a child and ¹/₂-1 in (1-2.5 cm) for an infant, the rescuer gives at least 100 chest compressions per minute.

New developments in CPR

The use of the automated external defibrillator (AED) has saved many lives and is now considered part of the CPR chain of survival. The AED is a machine that is attached to the unresponsive victim, analyzes the heart rhythm and has the ability to shock the victim with electricity. The AED has two pads that have to be placed on the victim's right upper chest wall and the left lower chest wall. Most cardiac arrest victims have a heart rhythm called ventricular fibrillation and the only way to correct this deadly heartbeat is with electricity. Some airports, airplanes, and shopping malls have automated external defibrillators onsite with user-friendly instructions, and survival rates in these places have increased significantly.

Preparation

If a person suddenly becomes unconscious, the rescuer should call out for help from other bystanders, and then determine if the person is responsive by shaking him or her gently on the shoulder and asking, loudly, if they are OK. Upon receiving no answer, the rescuer should call the emergency medical system with the exception of the "phone fast" victims. The rescuer should check to see whether the person is breathing by kneeling near the person's shoulders, looking at the person's chest, and placing his cheek next to the 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.

Aftercare

Emergency medical care is always necessary after successful CPR. Once the person's breathing and heartbeat have been restored, the rescuer should make him or her 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 the professionals arrive and take over.

Complications

CPR can cause injury to the person's ribs, liver, lungs, and heart. But these risks must be accepted if CPR is necessary to save the person's life. As health care professionals, many complications will be apparent in the acute care setting. Medical and nursing management of these complications will be addressed by prioritizing the most traumatic or deadly first.

Health care team roles

CPR and basic life support are important skills to have for anyone in the health care field. Recognition of the need to initiate CPR and the activation of proper resuscitation can save many lives. The international, universal pneumonic used to prompt health care professionals with the basics of CPR quickly is ABCD. This pneumonic stands for:

• • Airway: Is the person's airway open?
• • Breathing: Is the person breathing?
• Circulation: Does the person have a pulse (health care professional)? Does the person have any signs of blood circulation (layperson)?
• Defibrillation: Where is the defibrillator (AED)?

Legally, health care professionals coming to a person's aid in an emergency situation are covered under the federal Good Samaritan Law. Protection under this law requires that the situation be an emergency, that no monetary compensation for the treatment provided, and that the care provided has to be done "in good faith." In most states, health care professionals have no mandatory obligation to help in an emergency situation, but this law is in place to protect those who do from liability.

Patient education

All health care professionals should emphasize the importance of laypeople in their communities being trained in CPR. Classes are offered through the American Heart Association and the American Red Cross. Many

hospitals and local health departments have classes available for the public.

Training

CPR training is recommended every two years, and most health care institutions require their workers to obtain certification in Basic Cardiac Life Support (BCLS), which covers CPR. Studies have been done on the differences between video aided/practice training and lecture training. Video and practice training has been found to be the most effective.

---

KEY TERMS

---

Automated external defibrillator (AED)—A device that analyzes a person's heartbeat and can automatically deliver an electric shock if needed.

Cardiopulmonary—Relating to the heart and the lungs.

Defibrillation—A procedure to stop the type of irregular heart beat called ventricular fibrillation, usually by using electric shock.

Resuscitation—Bringing a person back to life after an apparent death.

Ventricular fibrillation—An irregular heartbeat where the heart beats very fast but ineffectively. Ventricular fibrillation is fatal if not quickly corrected.

---

Lori Beck