Cardiopulmonary
Resuscitation
Peizhi Huang
Zhongshan Hospital
Diagnosis of cardiac and
respiratory arrest
Traditional methods,
1,Carotid pulse check by lay rescuers
2,Loss of consciousness
3,Pupil dilation
4,Respiratory arrest
Guideline 2000
? Elimination of the pulse check for lay
rescuers
? Evaluate for signs of circulation in 10
seconds
breathing,coughing,movement in
response to
rescue breath
Assess for a pulse
?Time is too longer
?Accurate rate 75 %
?Sensibitity 90%
?Specificity 60%
Rate of false- positive(40%)
Results
Pulseless Pulse
Mistakenly loss the saving
opportunity
Rate of false-negative (10 %)
Results
Pulse Pulseless
Unnecessarily do CPR
Electrocardiogram changes
of Cardiac arrest
? Ventricular fibrillation
? A flat line or only atrial wave
? Pulseless Electrical Activity,PEA
The chain of Survival
? Early access
? Early CPR
? Early Defibrillation
? Early advanced life support
* patient with Coma （ immediately do CPR,
not clear obstructed airways at first）
Basic Life Support
--- the first ABCD
? Airway A
? Breathing B
? Circulation C
? Defibrillation D
Airway
? Tilt the head backwards
? Lift the jaw
? Open the mouth
? Clearing obstructed airways
from choking
? Subdiaphragmatic abdominal
thrust (Heimlich maneuver)
Breathing
? Mouth to mouth or mouth to nose
? Mouth to oropharyngeal tube
? Mouth to shield
? Mouth to mask(compressing the cricoid cartilage
in order to decrease gastric distention and
prevent gastric reflu)
? Bag-mask ventilation challenged endotracheal
intubation – resuscitation’s,gold standard”
Circulation
— external chest compression
?High-frequency（ 100 compressions per min）
aortic pressure ↑myocardial perfusion
pressure↑ cardiac outputs ↑ rise survival rate
?Reduce interrupted compression ( compression –
ventilation ratio simplified to 15:2)
?Compression-only CPR,unwilling
or unable to perform mouth to
mouth or cardiogenic cardiac arrest
Circulation
— Compression-only CPR
? Research suggests,
① Survival rate with compression-only CPR
in first 6~12 minutes is 40.8%
② Survival rate with chest compression add
artificial ventilation is 34.1%,because artificial
ventilation may be result in respiratory
alkalosis,
Mechanism of
external chest compression
? Chest pump
- sequential increased and decreased pressure
in the thoracic cavity
- valves maintaining forward direction of flow
? Cardiac pump
-sequential filling and emptying of cardiac
chambers
-valves maintaining forward direction of flow
Circulation
? Thump version from 20-25 cm high to chest
? Cough Version in 10-15 second
? Intermittent abdominal compression-
cardiopulmonary resuscitation（ IAC-CPR)
? Activated compression-decompression（ ACD-CPR)
? Phased－ Chest and Abdominal ACD-CPR
（ Life-stick Resuscitation）
increase mean pressure,coronary and cerebral perfusion
pressure,left ventricular and cerebral blood flow
Automated external defibrillator
--- AED
① Ventricular fibrillation, may be used by 200J*3
times) or 200J,200-300J,300J
② If polymorphic ventricular tachycardia can not be
clearly distinguished from ventricular fibrillation
(VF),treatment would refer to be as VF
③ Atrial fibrillation,100-200J synchronized
④ Atrial flutter or supraventricular tachycardia
50- 100J synchronized
⑤ Ventricular tachycardia 100J synchronized
Biphasic waveform defibrillation
?A compensated defibrillation for
the second time in limited time
?Low-energy levels（ 150J
correspond to 200-300J）
?Reduce the myocardial injury
Advanced Life Support
--- the second ABCD
? Endotracheal intubation (A)
? Mechanical ventilation and oxygen therapy (B)
? Intravenous injection (C)
? electrocardiogram and blood pressure monitoring,
resuscitation drug,open chest cardiac
compression (C)
? Differential diagnosis (D)
Confirmation of
Endotracheal tube placement
? Mark estimated depth
? Breath sounds by auscultation at 5 locus
? Thorax rise as inspiration
? increase of SaO2
? Steam in canal of artificial ventilation device
? Use a specific technique or device to
prevent tube dislodgment
Mechanical ventilation
? Low tidal volume 6-7ml/kg（ 400-600ml）
? Hyper ventilation High airway pressure
and endogenous PEEP Intracranial
hypertension;
? High tidal volume Distension
? Too low tidal volume hypoxia and
CO2 retention
Epinephrine EN --(1)
? α-adrenergic receptor stimulating
? Peripheral arterial vasoconstriction(not
cerebral and coronary arterioles)
mean arterial pressure↑ myocardial
and cerebral blood flow ↑
Epinephrine EN --(2)
? Recommended dosage, 1.0mg(0.01-0.02mg/kg )
iv every 3-5 minutes,then 1mg + GS 250ml iv gtt,
1μg/min→3-4μg/min,or 1mg,3mg,5mg iv
? Compared high dosage,0,1-0.2mg/kg
? High dosage (>0.2mg/kg) may be harmful
? Endotracheal administration,
NS 20ml + 2~2.5 time recommended dose
? Intracardiac injection,only in heart operation or
chest trauma
Vasopressin
? Act by direct stimulation of smooth muscle V1
receptors vasoconstriction
? No increased myocardial oxygen consumption
? Half-life is 10 ~20 minute,longer than EN
? Applicable to VF or prolonged cardiac arrest,
and with PEA（ pulseless electrical activity） or
with asystole
? Effective in patients who remain in cardiac arrest
after treatment with epinephrine
? Usage,40IU iv
Amiodarone(1)
? Persistent VT or VF after defibrillation and
epinephrine in cardiac arrest
? Hemodynamically stable VT
? polymorphic VT
? wide-complex tachycardia
? Ventricular rate control of rapid atrial
arrhythmias with impaired LV function when
digitalis ineffective
Amiodarone(2)
? Initially 300mg iv diluted in 20-30 ml in cardiac arrest
? Initial dose of 150mg iv（ over 10 min),followed by 1
mg/min infusion for 6 h,then 0.5mg/min
? Supplementary 150mg iv repeatedly for recurrent or
resistant arrhythmias or hemodynamically unstable
VT
? Maximum total dose,2g／ 24h
? adverse effects,hypotension and bradycardia
Magnesium sulfate
? Torsades de pointes
? Arrhythmias caused by magnesium
deficiency
? Loading dose,1～ 2g /50-100ml iv (over 5-
60 minutes)
? Followed by an infusion of 0.5-1.0g/h
Sodium Bicarbonate（ 1）
? Only after the confirmed interventions are
ineffective
? Preexisting metabolic acidosis,
hyperkalemia,tricyclic or phenobarbitone
overdose
? Protracted arrest or long resuscitative
efforts
Sodium Bicarbonate（ 2）
? Acid-base balance, chest compressions
ROSC adequate alveolar ventilation
and restoration of tissue perfusion
? CO2 more freely diffusible than HCO3 - into
myocardial and cerebral cells intracellular
acidosis
? Initial dosage,5%NaHCO3 1mEq /kg iv gtt
( 1ml≌ 0.6mEq )
Etiological factors
（ 5Hs,5Ts)
? Hypovolemia
? Hypoxia
? Hydrogen ion (acidosis)
? Hyperkalemia
or Hypokalemia
? Hyperthermia
or Hypothermia
? Tablets (drug)
? Tamponade
? Tension Pneumothorax
? Thrombosis coronary
? Thrombosis
pulmonary
Optimal response
to resuscitation
? Awake
? Responsive
? Breathing spontaneously
? restoration of spontaneous circulation
(ROSC)
Prolong Life Support
? Postresuscitation care
- Prevent and treatment SIRS and MODS
? organs function support
? Cerebral resuscitation
Postresuscitation syndrome
? Reperfusion failure
? Reperfusion injury
? Cerebral intoxication from ischemic
metabolites
? Coagulopathy
Postresuscitation syndrome
--- 4 phases
? Cardiovascular dysfunction in the hours
after ROSC in 24 hours
? SIRS leads to MODS over 1 to 3 days
? Serious infection occurs and the patient
declines rapidly
? Death
Dopamine
? A potent adrenergic receptor agonist and a strong
peripheral dopamine receptor agonist,
? Effects are dose-dependent,5 ～ 20μg／ min／ kg
? Low-dose (2 ~ 4 μg／ min／ kg) is no longer used
for acute oliguric renal failure,because
occasionally diuresis no improve renal
glomerular filtration rate,
? Middle dosage,5~10μg／ min／ kg,positive
inotropic effect
? High dosage,10~20 μg／ min／ kg,
vasoconstriction
Sodium Bicarbonate
? immediately after ROSC
? Guided by the partial pressure of CO2
Cerebral resuscitation
? Maintain relative high blood pressure during CPR
? Hemodilution and mild hypothermia （ 32－ 34℃ ）
for 12 h during CPR
? thrombolysis for ameliorate hypercoagulable state
? Antioxidant, free radical scavenger
? Emergency hypothermia CPB
? Hyperbaric oxygen,suitable for persistent
vegetative state
Ethical and legal
considerations of CPR
? When withdrawal or withhold of life support？
? DNAR（ do not attempt resuscitation) orders
? Transporting patient proceed CPR must be
continue CPR
? Patient is in a persistent vegetative state or
terminal condition certified by 2 physicians,
including 1 with special expertise in evaluation
cognitive function
Resuscitation
Peizhi Huang
Zhongshan Hospital
Diagnosis of cardiac and
respiratory arrest
Traditional methods,
1,Carotid pulse check by lay rescuers
2,Loss of consciousness
3,Pupil dilation
4,Respiratory arrest
Guideline 2000
? Elimination of the pulse check for lay
rescuers
? Evaluate for signs of circulation in 10
seconds
breathing,coughing,movement in
response to
rescue breath
Assess for a pulse
?Time is too longer
?Accurate rate 75 %
?Sensibitity 90%
?Specificity 60%
Rate of false- positive(40%)
Results
Pulseless Pulse
Mistakenly loss the saving
opportunity
Rate of false-negative (10 %)
Results
Pulse Pulseless
Unnecessarily do CPR
Electrocardiogram changes
of Cardiac arrest
? Ventricular fibrillation
? A flat line or only atrial wave
? Pulseless Electrical Activity,PEA
The chain of Survival
? Early access
? Early CPR
? Early Defibrillation
? Early advanced life support
* patient with Coma （ immediately do CPR,
not clear obstructed airways at first）
Basic Life Support
--- the first ABCD
? Airway A
? Breathing B
? Circulation C
? Defibrillation D
Airway
? Tilt the head backwards
? Lift the jaw
? Open the mouth
? Clearing obstructed airways
from choking
? Subdiaphragmatic abdominal
thrust (Heimlich maneuver)
Breathing
? Mouth to mouth or mouth to nose
? Mouth to oropharyngeal tube
? Mouth to shield
? Mouth to mask(compressing the cricoid cartilage
in order to decrease gastric distention and
prevent gastric reflu)
? Bag-mask ventilation challenged endotracheal
intubation – resuscitation’s,gold standard”
Circulation
— external chest compression
?High-frequency（ 100 compressions per min）
aortic pressure ↑myocardial perfusion
pressure↑ cardiac outputs ↑ rise survival rate
?Reduce interrupted compression ( compression –
ventilation ratio simplified to 15:2)
?Compression-only CPR,unwilling
or unable to perform mouth to
mouth or cardiogenic cardiac arrest
Circulation
— Compression-only CPR
? Research suggests,
① Survival rate with compression-only CPR
in first 6~12 minutes is 40.8%
② Survival rate with chest compression add
artificial ventilation is 34.1%,because artificial
ventilation may be result in respiratory
alkalosis,
Mechanism of
external chest compression
? Chest pump
- sequential increased and decreased pressure
in the thoracic cavity
- valves maintaining forward direction of flow
? Cardiac pump
-sequential filling and emptying of cardiac
chambers
-valves maintaining forward direction of flow
Circulation
? Thump version from 20-25 cm high to chest
? Cough Version in 10-15 second
? Intermittent abdominal compression-
cardiopulmonary resuscitation（ IAC-CPR)
? Activated compression-decompression（ ACD-CPR)
? Phased－ Chest and Abdominal ACD-CPR
（ Life-stick Resuscitation）
increase mean pressure,coronary and cerebral perfusion
pressure,left ventricular and cerebral blood flow
Automated external defibrillator
--- AED
① Ventricular fibrillation, may be used by 200J*3
times) or 200J,200-300J,300J
② If polymorphic ventricular tachycardia can not be
clearly distinguished from ventricular fibrillation
(VF),treatment would refer to be as VF
③ Atrial fibrillation,100-200J synchronized
④ Atrial flutter or supraventricular tachycardia
50- 100J synchronized
⑤ Ventricular tachycardia 100J synchronized
Biphasic waveform defibrillation
?A compensated defibrillation for
the second time in limited time
?Low-energy levels（ 150J
correspond to 200-300J）
?Reduce the myocardial injury
Advanced Life Support
--- the second ABCD
? Endotracheal intubation (A)
? Mechanical ventilation and oxygen therapy (B)
? Intravenous injection (C)
? electrocardiogram and blood pressure monitoring,
resuscitation drug,open chest cardiac
compression (C)
? Differential diagnosis (D)
Confirmation of
Endotracheal tube placement
? Mark estimated depth
? Breath sounds by auscultation at 5 locus
? Thorax rise as inspiration
? increase of SaO2
? Steam in canal of artificial ventilation device
? Use a specific technique or device to
prevent tube dislodgment
Mechanical ventilation
? Low tidal volume 6-7ml/kg（ 400-600ml）
? Hyper ventilation High airway pressure
and endogenous PEEP Intracranial
hypertension;
? High tidal volume Distension
? Too low tidal volume hypoxia and
CO2 retention
Epinephrine EN --(1)
? α-adrenergic receptor stimulating
? Peripheral arterial vasoconstriction(not
cerebral and coronary arterioles)
mean arterial pressure↑ myocardial
and cerebral blood flow ↑
Epinephrine EN --(2)
? Recommended dosage, 1.0mg(0.01-0.02mg/kg )
iv every 3-5 minutes,then 1mg + GS 250ml iv gtt,
1μg/min→3-4μg/min,or 1mg,3mg,5mg iv
? Compared high dosage,0,1-0.2mg/kg
? High dosage (>0.2mg/kg) may be harmful
? Endotracheal administration,
NS 20ml + 2~2.5 time recommended dose
? Intracardiac injection,only in heart operation or
chest trauma
Vasopressin
? Act by direct stimulation of smooth muscle V1
receptors vasoconstriction
? No increased myocardial oxygen consumption
? Half-life is 10 ~20 minute,longer than EN
? Applicable to VF or prolonged cardiac arrest,
and with PEA（ pulseless electrical activity） or
with asystole
? Effective in patients who remain in cardiac arrest
after treatment with epinephrine
? Usage,40IU iv
Amiodarone(1)
? Persistent VT or VF after defibrillation and
epinephrine in cardiac arrest
? Hemodynamically stable VT
? polymorphic VT
? wide-complex tachycardia
? Ventricular rate control of rapid atrial
arrhythmias with impaired LV function when
digitalis ineffective
Amiodarone(2)
? Initially 300mg iv diluted in 20-30 ml in cardiac arrest
? Initial dose of 150mg iv（ over 10 min),followed by 1
mg/min infusion for 6 h,then 0.5mg/min
? Supplementary 150mg iv repeatedly for recurrent or
resistant arrhythmias or hemodynamically unstable
VT
? Maximum total dose,2g／ 24h
? adverse effects,hypotension and bradycardia
Magnesium sulfate
? Torsades de pointes
? Arrhythmias caused by magnesium
deficiency
? Loading dose,1～ 2g /50-100ml iv (over 5-
60 minutes)
? Followed by an infusion of 0.5-1.0g/h
Sodium Bicarbonate（ 1）
? Only after the confirmed interventions are
ineffective
? Preexisting metabolic acidosis,
hyperkalemia,tricyclic or phenobarbitone
overdose
? Protracted arrest or long resuscitative
efforts
Sodium Bicarbonate（ 2）
? Acid-base balance, chest compressions
ROSC adequate alveolar ventilation
and restoration of tissue perfusion
? CO2 more freely diffusible than HCO3 - into
myocardial and cerebral cells intracellular
acidosis
? Initial dosage,5%NaHCO3 1mEq /kg iv gtt
( 1ml≌ 0.6mEq )
Etiological factors
（ 5Hs,5Ts)
? Hypovolemia
? Hypoxia
? Hydrogen ion (acidosis)
? Hyperkalemia
or Hypokalemia
? Hyperthermia
or Hypothermia
? Tablets (drug)
? Tamponade
? Tension Pneumothorax
? Thrombosis coronary
? Thrombosis
pulmonary
Optimal response
to resuscitation
? Awake
? Responsive
? Breathing spontaneously
? restoration of spontaneous circulation
(ROSC)
Prolong Life Support
? Postresuscitation care
- Prevent and treatment SIRS and MODS
? organs function support
? Cerebral resuscitation
Postresuscitation syndrome
? Reperfusion failure
? Reperfusion injury
? Cerebral intoxication from ischemic
metabolites
? Coagulopathy
Postresuscitation syndrome
--- 4 phases
? Cardiovascular dysfunction in the hours
after ROSC in 24 hours
? SIRS leads to MODS over 1 to 3 days
? Serious infection occurs and the patient
declines rapidly
? Death
Dopamine
? A potent adrenergic receptor agonist and a strong
peripheral dopamine receptor agonist,
? Effects are dose-dependent,5 ～ 20μg／ min／ kg
? Low-dose (2 ~ 4 μg／ min／ kg) is no longer used
for acute oliguric renal failure,because
occasionally diuresis no improve renal
glomerular filtration rate,
? Middle dosage,5~10μg／ min／ kg,positive
inotropic effect
? High dosage,10~20 μg／ min／ kg,
vasoconstriction
Sodium Bicarbonate
? immediately after ROSC
? Guided by the partial pressure of CO2
Cerebral resuscitation
? Maintain relative high blood pressure during CPR
? Hemodilution and mild hypothermia （ 32－ 34℃ ）
for 12 h during CPR
? thrombolysis for ameliorate hypercoagulable state
? Antioxidant, free radical scavenger
? Emergency hypothermia CPB
? Hyperbaric oxygen,suitable for persistent
vegetative state
Ethical and legal
considerations of CPR
? When withdrawal or withhold of life support？
? DNAR（ do not attempt resuscitation) orders
? Transporting patient proceed CPR must be
continue CPR
? Patient is in a persistent vegetative state or
terminal condition certified by 2 physicians,
including 1 with special expertise in evaluation
cognitive function
