Charles H. Brown, MSPharm, RPh, CACP, ACLS, PAL
Delaying CPR can drastically reduce a patient;s chances of surviving a medical emergency. Knowing the American Heart Association's new guidelines ensures a quick and effective response.
One of your regular patients walks up to the pharmacy window to drop off 2 new prescriptions to be filled. While waiting, he suddenly complains of being dizzy, loses consciousness, falls to the floor, and is unresponsive. The pharmacy technician rushes to the patient to help and notices that the individual does not have a pulse, and does not appear to be breathing. Because you are the only pharmacist on duty, what can you immediately do to help your patient and perhaps even save his life? Do you wait 10 to 15 minutes for the paramedics to arrive?
Whether you are a pharmacist, pharmacy technician, or layperson, the idea of performing cardiopulmonary resuscitation (CPR) or administering an automated external defibrillator (AED) on a friend or stranger can be a frightening proposition, especially if it is your first time. After all, one might contract an incurable disease when exposed to a person’s bodily fluid(s), and this alone may make some individuals reluctant to perform CPR. However, this scenario depicts a potential medical emergency, possibly sudden cardiac arrest (SCA), and the individual requires prompt CPR/AED and medical attention for the best outcome.
Some may decide to wait for the paramedics to arrive—they are trained professionals. But any delay can be costly. At the time a cardiac arrest occurs the blood is fully oxygenated, but without adequate cardiopulmonary function the blood oxygen level will be depleted in a matter of a few minutes. When blood flow or breathing stops, seconds count. Permanent brain damage or death can occur quickly. A delay of 4 to 5 minutes in administering CPR/AED decreases a person’s chance of survival by as much as 40%. A delay of 10 minutes or longer results in death 95% of the time.
The provision of bystander CPR significantly improves outcome, but it is generally performed in less than 30% of cases. Each minute defibrillation with an AED is delayed reduces the chance of survival about 10%.1 With ventricular fibrillation, the heart is beating so rapidly it does not have time to fill with blood between beats, and cardiac output decreases to near zero.
SCA is the leading cause of death in adults and accounts for 325,000 annual adult deaths in the United States. SCA can happen to anyone without any warning signs or symptoms; it may also occur as a result of electrocution or near drowning. The person collapses, stops breathing normally, and is unresponsive. Survival rates from SCA outside of the hospital vary across the country from 3% to 15%. Prompt, effective administration of CPR/ AED can mean the difference between life and death.1
The 2005 American Heart Association (AHA) CPR guidelines emphasized the traditional “ABC” procedures—open Airway, check for Breathing, and begin chest Compressions. In 2008, the heart group said untrained bystanders, or those unable or unwilling to do rescue breaths, could do hands-only CPR until paramedics arrive or a defibrillator is used to restore a normal heartbeat. For individuals unable or unwilling to administer mouth-to-mouth resuscitation, administering hands-only CPR was very appealing and it encouraged them to become more involved.
Not only was hands-only CPR generally more appealing, a 7-year study comparing the effects of chest compressions– only versus standard CPR found that survival rates were not significantly different whether or not mouth-to-mouth breaths were given.2,3 By performing resuscitation with only chest compressions—done immediately, forcibly, and rhythmatically, without any interruptions—you establish a more forward blood flow and better circulation for that period of time. It is a simpler CPR technique and it is easier to teach. The old CPR approach also took more time and delayed getting chest compressions started, which keeps the blood circulating. When the rescuers begin with chest compressions (hard and fast) first, they are acting like an artificial heart that carries blood and oxygen to keep vital organs alive until paramedics arrive.
New 2010 Guidelines for CPR
The new 2010 AHA Guidelines for CPR and Emergency Cardiovascular Care switch the steps for CPR from ABC to CAB—chest Compressions, open Airway, and Breath (mouth-to-mouth). These new guidelines changed the old ones that called for rescuers to give 2 breaths first, then alternate with 30 chest compressions. According to the AHA, successful resuscitation following cardiac arrest requires an integrated set of coordinated actions, a so-called “Chain of Survival.”3 The chain links are as follows:
• Immediate recognition of cardiac arrest and activation of the emergency response system.
Prompt emergency activation and initiation of CPR requires rapid recognition of cardiac arrest. The victim’s breathing is absent or is not normal. Pulse detection by the rescuer alone is often unreliable. Consequently, rescuers should start CPR immediately. The old CPR directive of “look, listen, and feel for breathing” to aid recognition is no longer recommended.
• Early CPR with an emphasis on chest compressions—30 compressions, then 2 breaths.
Prompt, effective chest compressions are fundamental aspects of cardiac arrest resuscitation. CPR improves the victim’s chances of survival by providing the heart and brain circulation, and should be performed for all victims in cardiac arrest. Rescuers should focus on providing highquality CPR, which includes providing chest compressions at least 100 per minute to move oxygenated blood to vital organs, and providing chest compressions of adequate depth. For adults, a compression depth of at least 2 in (5 cm) is required. For infants, a compression depth of 1½ in (4 cm) is required, and for children a compression depth of about 2 in (5 cm) is required. Rescuers should allow complete chest recoil after each compression, minimize interruptions in compressions, and avoid excessive ventilation.
Airway and Ventilations
Opening the airway with a head tilt–chin lift or jaw thrust to allow unobstructed passing of air, followed by rescue breaths, can improve oxygenation and ventilation. Ventilations should be provided if the victim has a high likelihood of an asphyxial cause of the arrest (eg, infant, child, or drowning victim). Open the airway and check for breathing or blockage, watch for rise of chest, and listen for air movement.
If an advanced airway is in place, health care providers should deliver ventilations at a regular rate of 1 breath every 6 to 8 seconds (8 to 10 breaths/min), and compressions can be delivered without interruption.
• Rapid defibrillation
Early defibrillation remains the cornerstone therapy for ventricular fibrillation and pulseless ventricular tachycardia. The 4-step automated process is as follows: 1) Apply pads, if possible without interrupting chest compressions; 2) turn the AED on; 3) the AED will analyze the victim’s heart rhythm; and 4) direct the rescuer either to provide a shock (ie, attempt defibrillation) or to continue CPR.
If you find yourself in a similar situation as the pharmacist and pharmacy technician in our Case Study, and you are fearful that your knowledge or abilities are not 100% complete, it is far better to do something than to do nothing at all.
The Table provides a step-by-step approach to performing CPR on an adult. Those individuals untrained in CPR or unable/unwilling to perform CPR can simply do chest compressions until help arrives. Remember, the difference between your doing something and doing nothing could save someone’s life. PT
Mr. Brown is a clinical pharmacist at Clarian Arnett Hospital and professor emeritus of clinical pharmacy at the Purdue University School of Pharmacy in West Lafayette, Indiana.