Guidelines for Cardiopulmonary 
Resuscitation: Update
By
Dr Mohamed Ezzat Moemen

Physicians may meet patients with cardiac arrest inside the hospitals. Bystanders may meet patients with cardiac arrest outside the hospitals. In both situations cardiopulmonary resuscitation is mandatory.

Introduction:
Cardiac arrest is defined as “inability of the heart to maintain an adequate cerebral circulation, not due to progressive and irreversible disease”.
Etiology:

• Inability of the heart to fill in the normal way.
• Inability of the heart to empty in the normal way.

Cardiac arrest should be diagnoses within 30 seconds. Diagnosis depends on absence of pulse in big vessels as the carotids and femorals, together with the presence of signs of cerebral hypoxia, namely; unconsciousness, apnea with or without cyanosis, and widely dilated pupils.
Definitive diagnosis of cardiac arrest needs an electrocardiogram. However, quick diagnosis should not depend or auscultating the heart or doing electrocardiography, to save time. Diagnosis should be based clinically on the sudden collapse of the patient with unconsciousness and absence of pulse in big vessels. There is no substitute for a rapid clinical diagnosis, if emergency management is to be instituted promptly and effectively.
Guidelines for Cardiopulmonary
Resuscitation (CPR)
The European Resuscitation Council has recently published the 2005 guidelines for CPR. These denote modifications of the previous guidelines, published in 2000.

The Chain of Survival
The actions linking the victim of sudden cardiac arrest with survival are named “the Chain of Survival”. It includes four links. The first link indicates the importance of recognising those at risk of cardiac arrest, and calling for help in the hope that early treatment can prevent arrest. The second link indicates early CPR to buy time for the effectiveness of the third link. This third link indicates early defibrillation to restart the heart. The fourth link indicates post-resuscitation care to restore the quality of life.

The universal algorithm:
The universal algorithm for CPR in adults and paediatrics includes Basic Life Support (BLS), and Advanced Life Support (ALS).

Basic Life Support (BLS):
BLS should be started early. It aims to keep the brain alive until professional help through providing equipment and drug therapy, is available.

• BLS starts by making sure that the rescuer and the victim are in a safe environment.
• The victim should be checked for response. The rescuer gently shakes the victim’s shoulders and asks him loudly “Are you all right?”
• If the victim does not respond, the rescuer should “shout for help”.
• At the same time the rescuer opens the victim’s airway by head tilt and chin lift manoeuver.
• Then, the victim should be checked for breathing, through the triad of look, listen, and feel: Looking for chest movement, Listening at the victim’s mouth for breath sounds, and feeling for air on the rescuer’s cheek.
• If the victim is breathing normally, he should be turned into the recovery position and checked for continuous breathing, till the called ambulance reaches to carry him to the hospital.
• If the victim is not breathing normally, chest compressions should be started at a rate of about 100/minute: a little less than 2 compressions/ second.
• The ratio of chest compressions to ventilations should be 30: 2.
• The rescuer continues BLS in this described sequence until:
• Qualified help arrives and takes over.
• The victim starts to breath normally.
• The rescuer becomes exhausted. Another rescuer takes over, if possible.

Advanced Life Support (ALS):

• ALS starts by rhythm assessment to differentiate between:
• Shockable rhythm (VF, Pulseless VT)
• Non-shockable rhythm (Asystoly, Pulseless Electrial Activity)
• Shockable rhythm needs one shock of 360 Joule delivered from the defibrillator, while every-body is away from the patient, followed by CPR for two minutes (30 chest compressions: 2 ventilations). Then, rhythm is checked and another 360 joule shock is delivered.
• Adrenaline 1 mg is given iv if the shockable rhythm persists. This is repeated every 3-5 minutes there-after if VF/ VT persists.
• A third shock is delivered and amiodarone 300 mg is given iv. This can be replaced by iv lidocaine 1mg/kg. The maximum lidocaine dose is 3mg/kg during the first hour.
• For non-shockable rhythm, CPR is continued, and adrenaline 1 mg is given iv, and repeated every 3-5 minutes there-after until return of spontaneous circulation is achieved.

Post-Resuscitation Care:
The unconscious victim needs mild hypothermia. He should be cooled to 32-34°C for 12-24 hours. Anyhow, he is cared for in the intensive care unit.