Part6:CPR Techniques and Devices
O ver the past25years a variety of alternatives to standard manual CPR have been developed in an effort to improve ventilation or perfusion during cardiac arrest and ultimately to improve survival.Compared with standard CPR,the techniques and devices typically require more personnel,training,or equipment,or they apply to a specific tting.Maximum benefits are reported when adjuncts are begun early in the treatment of cardiac arrest,so that the u of the alternatives to CPR is often limited to the hospital tting.To date no adjunct has consistently been shown to be superior to standard manual CPR for out-of-hospital basic life support,and no device other than a defibrillator has consis-tently improved long-term survival from out-of-hospital car-diac arrest.The data reported here is limited to clinical trials, so most animal data is excluded from this ction.
CPR Techniques
High-Frequency Chest Compressions
High-frequency(Ͼ100per minute)manual or mechanical chest compressions have been studied as a technique for improving resuscitation from cardiac arrest.1–4The spar animal and human data available show mixed results.One clinical trial of9patients showed that high-frequency(120 per minut
e)chest compressions improved hemodynamics over standard CPR(LOE4).5The u of high-frequency chest compressions for cardiac arrest by adequately trained rescue personnel can be considered,but there is insufficient evidence to recommend for or against its u(Class Indeterminate). Open-Chest CPR
No prospective randomized studies of open-chest CPR for resuscitation have been published.Four relevant human studies were reviewed:2were performed to treat in-hospital cardiac arrest following cardiac surgery(LOE46;LOE57), and2were performed after out-of-hospital cardiac arrest (LOE48;LOE59).The obrved benefits of open-chest cardiac massage were improved coronary perfusion pressure9 and incread return of spontaneous circulation(ROSC).8 Open-chest CPR should be considered(Class IIa)for patients with cardiac arrest in the early postoperative period after cardiothoracic surgery or when the chest or abdomen is already open(eg,in trauma surgery).For further information about trauma resuscitation,e Part10.7:“Special Resusci-tation Situations:Cardiac Arrest Associated With Trauma.”Interpod Abdominal Compression
The interpod abdominal compression(IAC)-CPR technique us a dedicated rescuer to provide manual compression of the abdomen(midway between the xiphoid and the umbili-cus)during the relaxation pha of chest compression.The purpo is to enhance venous return during CPR.10,11
When IAC-CPR performed by trained providers was compared with standard CPR for cardiac arrest in the in-hospital tting, IAC-CPR improved ROSC and short-term survival in2 randomized trials(LOE1)12,13and improved survival to hospital discharge in1study.13The data from the studies was combined in2positive meta-analys(LOE1).14,15 Evidence from1randomized controlled trial of out-of-hospital cardiac arrest(LOE2),16however,did not show any survival advantage to IAC-CPR.Although there is1pediatric ca report17of complications,no harm was reported in the other studies,which involved a total of426patients.
IAC-CPR may be considered during in-hospital resuscita-tion when sufficient personnel trained in its u are available (Class IIb).There is insufficient evidence to recommend for or against the u of IAC-CPR in the out-of-hospital tting (Class Indeterminate).
“Cough”CPR
“Cough”CPR is not uful for the treatment of an unrespon-sive victim,18–23and it should not be taught to lay rescuers. Human“cough”CPR has been reported only in awake, monitored patients who developed ventricular fibrillation (VF)or rapid ventricular tachycardia(VT).20,22,24Several small ca ries(LOE5)18,20,22,24reporting experiences in the cardiac catheterization suite suggest that repe
ated cough-ing every1to3conds during episodes of VF or rapid VT by conscious,supine,monitored patients trained in the technique can maintain a mean arterial pressure Ͼ100mm Hg and can maintain consciousness for up to90 conds.
The increa in intrathoracic pressure that occurs with coughing generates blood flow to the brain and helps main-tain consciousness.Coughing every1to3conds for up to 90conds after the ont of VF or pulless VT is safe and effective only in conscious,supine,monitored patients previ-ously trained to perform this maneuver(Class IIb).Defibrillation remains the treatment of choice for VF or pulless VT.
CPR Devices
Devices to Assist Ventilation
Automatic and Mechanical Transport Ventilators Automatic transport ventilators(ATVs).One prospective cohort study of73intubated patients,most of whom were in cardiac arrest,in an out-of-hospital urban tting showed no difference in arterial blood gas parameters between tho ventilated with an ATV and tho ventilated with a bag-mask device(LOE4).25Disadvantages of ATVs include the need for an oxygen source and electric power.Thus,providers should always have
a bag-mask device available for manual backup.Some ATVs may be inappropriate for u in children Ͻ5years of age.
(Circulation.2005;112:IV-47-IV-50.)
©2005American Heart Association.
This special supplement to Circulation is freely available at www.circulationaha
开放式浴室DOI:10.1161/CIRCULATIONAHA.105.166555
IV-47
In both the out-of-hospital and in-hospital ttings,ATVs are uful for ventilation of adult patients with a pul who have an advanced airway(eg,endotracheal tube,esophageal-tracheal combitube[Combitube],or laryngeal mask airway [LMA])in place(Class IIa).For the adult cardiac arrest patient who does not have an advanced airway in place,the ATV may be uful if tidal volumes are delivered by a flow-controlled,time-cycled ventilator without positive end-expiratory pressure(PEEP).If the ATV has adjustable output control valves,tidal volume should be adjusted to make the chest ri(approximately6to7mL/kg or500to600mL), with breaths delivered over1cond.U
ntil an advanced airway is in place,an additional rescuer should provide cricoid pressure to reduce the risk of gastric inflation.Once an advanced airway is in place,the ventilation rate should be 8to10breaths per minute during CPR.
Manually triggered,oxygen-powered,flow-limited resus-citators.In a study of104anesthetized nonarrest patients without an advanced airway in place(ie,no endotracheal tube;patients were ventilated through a mask),patients ventilated by firefighters with manually triggered,oxygen-powered,flow-limited resuscitators had less gastric inflation than tho ventilated with a bag-mask device(LOE5).26 Manually triggered,oxygen-powered,flow-limited resuscita-tors may be considered for the management of patients who do not have an advanced airway in place and for whom a mask is being ud for ventilation during CPR.Rescuers should avoid using the automatic mode of the oxygen-powered,flow-limited resuscitator becau it applies contin-uous PEEP that is likely to impede cardiac output during chest compressions(Class III).
Devices to Support Circulation
Active Compression-Decompression CPR
Active compression-decompression CPR(ACD-CPR)is per-formed with a hand-held device equipped
with a suction cup to actively lift the anterior chest during decompression.It is thought that decreasing intrathoracic pressure during the decompression pha enhances venous return to the heart.As of2005no ACD-CPR devices have been cleared by the Food and Drug Administration for sale in the United States. Results from the u of ACD-CPR have been mixed.In4 randomized studies(LOE127,28;LOE229,30)ACD-CPR improved long-term survival rates when it was ud by adequately trained providers for patients with cardiac arrest in the out-of-hospital27,28and in-hospital29,30ttings.In5other randomized studies(LOE131–34;LOE235),however,no positive or negative effects were obrved.In4clinical studies(LOE3)30,36–38ACD-CPR improved hemodynamics over standard CPR,and in1clinical study(LOE3)39did not. Frequent training ems to be a significant factor in achieving efficacy.28
A meta-analysis of10trials involving4162patients in the out-of-hospital tting(LOE1)40and a meta-analysis of2 trials in the in-hospital tting(826patients)40failed to document any early or late survival benefit of ACD-CPR over conventional CPR.The out-of-hospital meta-analysis found a large but nonsignificant worning in neurologic outcome in survivors in the ACD-CPR group,and1small study41showed incread incidence of sternal fractures in the ACD-CPR group.
ACD-CPR may be considered for u in the in-hospital tting when providers are adequately traine
d(Class IIb). There is insufficient evidence to recommend for or against the u of ACD-CPR in the prehospital tting(Class Indeterminate).
Impedance Threshold Device
The impedance threshold device(ITD)is a valve that limits air entry into the lungs during chest recoil between chest compressions.It is designed to reduce intrathoracic pressure and enhance venous return to the heart.In initial studies the ITD was ud with a cuffed endotracheal tube during bag-tube ventilation and ACD-CPR.42–44The ITD and ACD device are thought to act synergistically to enhance venous return during active decompression.
In recent reports the ITD has been ud during conven-tional CPR45,46with an endotracheal tube or face mask. Studies suggest that when the ITD is ud with a face mask, it may create the same negative intratracheal pressure as u of the ITD with an endotracheal tube if rescuers can maintain a tight face mask al.43,45,46
In2randomized studies(LOE1)44,47of610adults in cardiac arrest in the out-of-hospital tting,u of ACD-CPR plus the ITD was associated with improved ROSC and 24-hour survival rates when compared with u of standard CPR alone.A randomized study of230adults documented incread a
dmission to the intensive care unit and24-hour survival(LOE2)45when an ITD was ud during standard CPR in patients in cardiac arrest(pulless electrical activity only)in the out-of-hospital tting.The addition of the ITD was associated with improved hemodynamics during stan-dard CPR in1clinical study(LOE2).46
Although incread long-term survival rates have not been documented,when the ITD is ud by trained personnel as an adjunct to CPR in intubated adult cardiac arrest patients,it can improve hemodynamic parameters and ROSC(Class IIa). Mechanical Piston Device
The mechanical piston device depress the sternum via a compresd gas-powered plunger mounted on a backboard.In 1prospective randomized study and2prospective random-ized crossover studies in adults(LOE2),48–50mechanical piston CPR ud by medical and paramedical personnel improved end-tidal CO2and mean arterial pressure in patients in cardiac arrest in both the out-of-hospital and in-hospital ttings.
Mechanical piston CPR may be considered for patients in cardiac arrest in circumstances that make manual resuscita-tion difficult(Class IIb).The device should be programmed to deliver standard CPR with adequate compression depth at the rate of100compressions per minute with a compression-ven
tilation ratio of30:2(until an advanced airway is in place) and a compression duration that is50%of the compression-decompression cycle length.The device should allow com-plete chest wall recoil.
Load-Distributing Band CPR or Vest CPR
The load-distributing band(LDB)is a circumferential chest compression device compod of a pneumatically or electri-
IV-48Circulation December13,2005
cally actuated constricting band and backboard.Evidence from a ca control study of162adults(LOE4)51docu-mented improvement in survival to the emergency depart-ment when LDB-CPR was administered by adequately trained rescue personnel to patients with cardiac arrest in the out-of-hospital tting.The u of LDB-CPR improved he-modynamics in1in-hospital study of end-stage patients (LOE3)52and2laboratory studies(LOE6).53,54LDB-CPR may be considered for u by properly trained personnel as an adjunct to CPR for patients with cardiac arrest in the out-of-hospital or in-hospital tting(Class IIb).
Phad Thoracic-Abdominal Compression-Decompression CPR With a Hand-Held Device
Phad thoracic-abdominal compression-decompression CPR (PTACD-CPR)combines the concepts of IAC-CPR and ACD-CPR.A hand-held device alternates chest compression and abdominal decompression with chest decompression and abdominal compression.Evidence from1prospective ran-domized clinical study of adults in cardiac arrest(LOE2)55 documented no improvement in survival rates with u of PTACD-CPR for assistance of circulation during advanced cardiovascular life support(ACLS)in the out-of-hospital and in-hospital ttings.Thus,there is insufficient evidence to support the u of PTACD-CPR outside the rearch tting (Class Indeterminate).
Extracorporeal Techniques and Invasive Perfusion Devices
Much of the literature showing the effectiveness of extracor-poreal CPR(ECPR)includes patients with cardiac dia. ECPR is more successful in postcardiotomy patients than in tho with cardiac arrest from other caus(LOE5).56ECPR may be particularly effective for the patients becau they are more likely to have a reversible(ie,surgically correctable or short-term)cau of cardiac arrest,and typically they suffer cardiac arrest without preceding multisystem organ failure.
ECPR for induction of hypothermia has been shown to improve survival rates in a small study of patients who arrived at the ED in cardiac arrest and failed to respond to standard ACLS techniques(LOE5).57
ECPR should be considered for in-hospital patients in cardiac arrest when the duration of the no-flow arrest is brief and the condition leading to the cardiac arrest is reversible (eg,hypothermia or drug intoxication)or amenable to heart transplantation or revascularization(Class IIb).58,59
Summary
A variety of CPR techniques and devices may improve hemodynamics or short-term survival when ud by well-trained providers in lected patients.To date no adjunct has consistently been shown to be superior to standard manual CPR for out-of-hospital basic life support,and no device other than a defibrillator has consistently improved long-term survival from out-of-hospital cardiac arrest.
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