Physiology and Techniqeus of CPR

Time is critical in cases of cardiac or pulmonary arrest. If breathing stops first, the heart often continues
to pump blood for several minutes. When the heart stops, oxygen in the lungs and bloodstream is not
circulated to vital organ. The patient whose heart and breathing have stopped for less than 4 minutes
has an excellent chance for recovery if cardiopulmonary resuscitation (CPR) is administered immediately
and followed by advanced cardiac life support (ACLS) within 4 minutes. By four to six minutes, brain
damage may occur, and after 6 minutes, brain damage almost always occurs. The initial goal of CPR
therefore are

1) Delivering oxygen to the lungs

2) Providing a means of circulating it to the vital organs (via closed-chest compression);followed by
3) ACLS, with restoration of the heart as the mechanism of circulation

Delivery of oxygen is achieved by positioning the patient, opening the airway, and performing rescue
breathing. In the absence of muscle tone, the tongue and epiglottis frequently obstruct the airway. The
head-tilt with the chin-lift maneuver (figure 29-1 and 29-2) or the jaw thrust maneuver (figure 29-3) may
provide airway access. If foreign material appears in the mouth, it should be removed either manually or
with active suction if available. If air does not enter the lungs with rescue breathing, reposition the head
and repeat the attempt at rescue breathing. Persistent obstruction requires the sequence of chest
thrusts, finger sweeps, and rescue breathing outlined in Table 29-1. Airway obstruction may occur in a
choking victim as well as a patient experiencing a cardiopulmonary arrest. With only partial airway
obstruction, the conscious woman should be allowed to attempt to clear the obstruction herself, and
finger sweeps by the rescue are avoided. Finally, failure of nonsurgical procedures to relieve the airway
obstruction is an indication for emergency cricothyroidotomy or jet-needle insufflation if appropriate
equipment is available.

Chest thrusts in a conscious sitting or standing victim require placing the thumb side of the fist on the
middle of sternum, avoiding the xiphoid and the ribs. The rescuer then grabs his or her own fist with the
other hand and performs chest thrusts until either the foreign object dislodges or the patient lose
consciousness (figure 29-4). The unconscious patient requires chest compressions. The rescuers hand
closest to the patients head is placed two finger-breadths above the xiphoid. The long axis of the
sternum (figure 29-5). The other hand lies over the first, with fingers either extended or interlaced. The
elbows are extended and the chest compressed 11/2 to 2 inches (figure 29-6).

External chest compressions cause a rise in intrathoracic pressure, which is distributed to all
intrathoracic structures. Competent venous valves prevent transmission of this pressure to extrathoracic
veins, whereas the arteries transmit the increased pressure to extrathoracic arteries, creating an arterial
venous pressure gradient and forward blood flow. The mitral and tricuspid valves remain open during
CPR, supporting the concept of the heart as a passive condult rather than a pump during a CPR.

Basic life support (BLS) guidelines call for a ratio of two ventilation to 15 compressions in a one-person
CPR and a 1:5 ratio in two rescuer CPR, with a total of 80-100 compressions per minute in both
circumstances. ACLS involves the addition of electrical and pharmacologic therapy, invasive monitoring,
and therapeutic techniques to correct cardiac arrhythmias, metabolic imbalances, and other causes of
cardiac arrest. Standard algorithms recommended by the American Heart Association (AHA) are
reviewed in Appendix 2.

The Effect of Pregnancy on CPR

Pregnancy produces physiologic changes that have a potentially dramatic effect on cardiopulmonary
resuscitation. Upward displacement of the diaphragm by the enlarging uterus leads to a decrease in the
functional residual capacity (FRC) of the lungs. The decrease in FRC combines with the increase in
oxygen demand to predispose the pregnant woman to a decrease in arterial and venous oxygen tension
during periods of decreased ventilation. The pregnant uterus exerts pressure on the inferior vena cava,
iliac vessels, and abdominal aorta. In the supine position, such uterine compression may lead to
sequestration of up to 30% of circulating blood volume. For the patient in the latter half of pregnancy,
aortacaval compression by the gravid uterus renders resuscitation more difficult than in her non
pregnant counterpart. It does so by decreasing venous return, causing supine hypotension, and
decreasing the effectiveness of thoracic compressions. Furthermore, the enlarged uterus poses am
obstruction to forward blood flow, particularly when arterial pressure and volume are decreased, as in a
cardiac arrest.

Changes in the gravid womans response to drugs and alterations in the maternal gastrointestinal
system also hinder effective resuscitation. Vasopressors used in ACLS, especially alpha adrenergic or
combined alpha and beta agents, are capable of producing uteroplacental vasoconstriction, leading to
decreased fetal oxygenation and CO2 exchange. Decreases in gastrointestinal motility and relaxation of
the lower esophageal sphincter lead to an increased risk of aspiration prior to or during endotracheal
intubation.

Modification of BLS and ACLS in Pregnancy

The anatomic and physiologic changes of pregnancy require several modifications in emergency cardiac
care (ECC). Most important to effect an increase in venous return and reduce supine hypotension, the
uterus must be displaced to the left. This can be attempt in several ways. Left lateral displacement can
be achieved by 1) manual displacement of the uterus by a member of the resuscitation team, 2)
positioning the patient on an operating room table that can be tilted laterally, or 3) positioning a wedge
under the patients right hip.

It must also be kept in mind that sodium bicarbonate only very slowly crosses the placenta. Accordingly,
with rapid correction of maternal metabolic acidosis, the patients respiratory compensation will cease
with normalization of her partial pressure of carbon dioxide (Pco2). If the maternal Pco2 increase from
20 to 40 mm Hg as a result of bicarbonate administration, the fetal Pco2 will also increase. However, the
fetus will not receive the benefit of the bicarbonate. If the fetal pH was 7.00 before maternal
bicarbonate administration, the normalization of maternal pH will be achieved at the expense of
increasing the fetal Pco2 by 20 torr, with a resultant fall in a fetal pH to approximately 6.48. Accordingly,
the merits of such treatment must be questioned, especially in light of the fact that the AHA is
deemphasizing the use of sodium bicarbonate in the acute arrest situation.
Figure 29-1

Opening the airway. Top: airway obstruction produced by the tongue and the epiglottis. Bottom: Relief
via head-tilt and shin-lift maneuvers. (Reproduced with permission. Instructors manual for basic life
support. American Heart Association. 1987)

Figure 29-2

Head-tilt/chin-lift maneuver. Perpendicular line reflects proper neck extension. (i.e. a line along the edge
of the jaw bone should be perpendicular to the surface on which the victim is lying)

Figure 29-3

Jaw-thrust maneuver

Figure 29-4

Top: chest thrust administered to a conscious (standing) victim of foreign-body airway obstruction.
Bottom: chest thrust administered to an unconscious (lying) victim of foreign body airway obstruction.

Figure 29-5

External chest compressions: locating the correct hand position on the lower half of the sternum.

Figure 29-6

Proper position of rescuer: shoulders directly over victims sternum : elbow locked.

Table 29-1

Management of a foreign-body obstruction

Conscious Victim

1. Perform chest thrust

2. Repeat until obstruction is relieved or victim is unconscious

Unconscious Victim

1. Turn on back
2. Perform tongue-jaw lift and finger sweep
3. Open airway with head-tilt and chin-lift maneuvers. Attempt rescue breathing
4. Perform chest thrusts
5. Perform tongue-jaw lift and finger sweep
6. Open airway with head-tilt and chin-lift maneuvers. Attempt rescue breathing
7. Repeats steps 4-6 until the obstruction is relieved