Cardiopulmonary Resuscitation and Advanced Cardiac Life Support: Common Errors and Current Techniques

Stuart Frank, MD Springfield, Illinois

Competence in the techniques of Advanced Cardiac Life Sup­ port is essential for physicians who are in frequent contact with patients at high risk for cardiac arrest. The methods utilized are complex and rapidly changing. However, a consis­ tent pattern of errors in fundamental concepts or methods emerges. These can be characterized as (1) errors in the gen­ eral management of patients, (2) errors in basic cardiopulmo­ nary resuscitation (CPR) techniques, (3) mistakes in the use or omission of appropriate drugs, (4) errors in the associated nec­ essary techniques which require some technical skills, and (5) errors in management of the patient subsequent to the cardiac arrest. Attention to these details may increase success in man­ agement of patients with cardiac arrest.

An extensive and extremely well-developed life support is excellent but is frequently informal training program in cardiopulmonary resuscitation and unstructured, often neglected, and highly var­ (CPR) for the public has been very well received. iable. There are very few physicians who have The program is effective in teaching fundamental been adequately trained in the complexities of ad­ resuscitation techniques to large numbers of vanced cardiac life support, and fewer still who paramedical or non-medically trained individu­ retain this competence without regular exposure als.1-2 The skills, once mastered, need regular re­ to patients in need of advanced life support. Com­ view to maintain a satisfactory level of compe­ petence requires mastering the subtle aspects tence. This training is directed primarily toward of (a) complex electrocardiography, (b) cardiac out-of-hospital cardiac arrest and resuscitation. It pharmacology, (c) team management, (d) technical follows a simple standard decision tree (Figure 1) procedures including the insertion of venous cut- and ends when the patient enters into a system of downs, pulmonary artery balloon catheters, and advanced cardiac life support (ACLS), the hospi­ temporary pacemakers, and (e) electrical cardio­ tal emergency room, or the intensive care unit. version and defibrillation. In marked contradistinction to the basic cardio­ Despite the wide variation in training and expe­ pulmonary resuscitation, the training of physicians rience of physicians and nurses, it is apparent that and nurses regularly involved in advanced cardiac the same errors, the same misconceptions, and the same inadequacies occur during advanced cardiac life support with surprising regularity at all levels of training and experience. During the observation From the Division of Cardiology, Department of Medicine, of over 500 in-hospital resuscitation efforts, the Southern Illinois University, School of Medicine, Spring- field, Illinois. Requests for reprints should be addressed to most common mistakes and the inadequacies Dr. Stuart Frank, Division of Cardiology, Department of which are most flagrant or potentially most serious Medicine, PO Box 3926, Southern Illinois University, School of Medicine, Springfield, (L 62708. were identified. This paper outlines currently rec- 0094-3509/81 /020213-05$01.25 ® 1981 Appleton-Century-Crofts

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Figure 1. Life support decision tree and entry into system of advanced life support (ALS). (Reprinted with permission American Heart Association)

ommended principles for management of cardiac anyone competent if he is there first or when no arrest; these principles are derived from common one else has assumed control. errors of omission or commission. Someone must review the patient’s history or consult with the patient’s family relatively early and continue communications as frequently as General Management possible. This should ideally, but not necessarily, Someone must take charge, to assign, coordi­ be the patient’s personal physician. Sometimes the nate, and oversee; to avoid omissions and dupli­ decision not to resuscitate is obvious, but often it cation of effort; and to ensure that everything is is not, and occasionally aggressive efforts are done in a reasonably coordinated and proper se­ mandated despite apparent contraindications.3 quence. This will often, but not necessarily, be the Clear the room of unnecessary furniture, addi­ patient’s personal physician but he may not be tional patients, and curious spectators. A success­ early on the scene and the coordinator should be ful resuscitation often demands quick action, and the senior or most experienced individual present. rapid access to complex bulky equipment. Work­ The responsibility can and should be assumed by ing with curtains drawn around a bed to ensure

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privacy is futile. It is often easier to move other Do not massage the mattress. If the crash cart beds and patients out. does not have a bed board, almost anything flat Someone must decide when to discontinue rea­ and rigid will do. Cardiac massage without rigid sonable resuscitation efforts. This decision should support under the patient delivers most of the en­ be made in consultation with the patient’s personal ergy to the mattress and springs. Moving the pa­ physician and with the patient’s family if they are tient carefully onto the floor is an alternative but is immediately available. Currently accepted guide­ rarely necessary and makes it difficult to perform lines state, “The decision to terminate advanced some procedures such as intubation. cardiac life support based on the findings of cardi­ The hands and body must be in the proper posi­ ovascular unresponsiveness is equivalent to defin­ tion. Fracture of the xiphoid, and hepatic lacera­ ing that the heart has died, and there is no purpose tion may result if massage is too low on the ster­ to be served in evaluating the status of the brain.”2 num, but more important is the resulting ineffi­ The use of large doses of barbiturates to minimize cient massage with incomplete compression of the central nervous system damage and cerebral ventricles. Do not press the fingers into the ribs or edema is still experimental and is not routinely costochondral junctions during cardiac massage. recommended at this time.4 The fingers should be hyperextended with the pressure delivered with the heel of both hands. The resuscitater should be properly positioned CPR Techniques with his shoulders directly over the sternum, his Do not forget to hyperextend the neck (Figure elbows straight, and his knees at the level of the 2). Resuscitation of a patient with his head com­ mid chest. Proper cardiac massage is difficult to fortably on a pillow is doomed to failure. The perform optimally standing next to the bed, al­ tongue drops back to occlude the airway and ade­ though it is sometimes necessary. The ideal posi­ quate oxygenation is impossible. tion may sometimes require getting one’s knees Do not forget the precordial thump.2,5 A wet and dirty. Improper position promotes early sharp vigorous blow to the chest delivers about 5 and excessive fatigue and vastly diminishes effi­ or 10 watt seconds of energy which may be enough ciency. to convert ventricular tachycardia or ventricular The cardiac massage must be smooth and fibrillation to sinus rhythm. Current recommenda­ rhythmic with a goal of 50:50 downstroke: up­ tions indicate that the precordial thump should be stroke ratio.2,6,7 Avoid short unsustained “jabs” used for “monitored arrest” only, since it has which may eject small spurts of blood, and may been shown to produce ventricular fibrillation or generate a peripheral pulse but results in minimal asystole on rare occasions. blood flow. Some experts feel that these spas-

THE JOURNAL OF FAMILY PRACTICE, VOL. 12, NO. 2, 1981 215 CARDIOPULMONARY RESUSCITA DON modic motions may be of value in breaking up advanced cardiac life support may require some massive pulmonary emboli, but for the average re­ revision of the technique in the future. Experimen­ suscitation, this is not necessary, it is of doubtful tal studies have shown that cardiac output is max­ value, and the cardiac output generated is in­ imal when the lungs are hyperinflated. Increased adequate. flow is probably related to increased intrathoracic Incomplete sternal relaxation impairs ventricu­ pressure and theoretically, a high airway pressure lar filling and inadequate sternal depression de­ coincident with each chest compression may be creases cardiac output. In an adult the sternum optimal. It should be emphasized, however, that must be depressed at least IV2 to 2 inches toward no changes in traditional techniques are recom­ the spine. mended at this time until the safety of these exper­ Do not interrupt the resuscitation. Standard imental methods has been demonstrated. teaching emphasizes that chest compression and respiration should not and need not be discontin­ Drug Treatment ued for more than 5 seconds except for intubation One cannot resuscitate an hypoxic heart. Ade­ or moving patients, when up to 30 seconds inter­ quate oxygenation is essential. ruption is permitted. Practical considerations One cannot resuscitate an acidotic heart.8 sometimes mandate otherwise. Administration of bicarbonate and frequent eval­ A. It is often necessary to stop cardiac massage uation of arterial blood gases is necessary. for a brief interval to eliminate artifact in the Although prophylactic use of lidocaine after a electrocardiogram and determine what intrinsic myocardial infarction is controversial, most expe­ rhythm is present. These periods of asystole rienced cardiologists would agree that lidocaine should be kept to a minimum. During this and all 100-200 mg intravenously should be given early other necessary interruptions, it probably is wise during the resuscitation in a patient in ventricular to hyperoxygenate the patient just prior to tempo­ tachycardia or fibrillation or a patient who has rary interruption of cardiac massage. been electrically converted from these ventricular B. It is sometimes necessary to interrupt car­ arrhythmias. Lidocaine may be hazardous in an diac massage briefly to insert an endotracheal infrequent patient whose arrest may be the result tube. If this is necessary, it is best to have all of asystole or associated with an idioventricular or equipment ready and checked, and personnel junctional rhythm which might be abolished by properly positioned prior to discontinuation of this drug. massage, so as to facilitate the intubation and If an adequate intravenous route is not imme­ permit as brief a period of asystole as possible. diately available, rapid administration of lido­ C. Although intracardiac injections are rarely caine, epinephrine, or atropine can sometimes be necessary, an injection usually can not be per­ accomplished by injection directly into the formed safely unless cardiac massage is temporar­ trachea via an endotracheal tube. Drugs should be ily discontinued. administrated in a volume of at least 5 cc to D. Current teaching and experience has dem­ enhance pulmonary distribution and uptake. The onstrated that cardiac massage can be successfully epinephrine dose is 1 mg (10 cc of 1:10,000 solu­ continued while moving a patient. Practical expe­ tion), the lidocaine dose is approximately 100 mg rience has indicated that massage sometimes must (5 cc of 20 mg/cc) and atropine should be given as 1 be briefly discontinued when moving a patient up mg diluted to 10 cc.9-10 or down stairs or through a narrow passageway. In Alkalosis is just as hazardous and detrimental some instances it may be wiser not to move the as acidosis.11 It depresses the sensorium, pro­ patient if this will require interrupting the resusci­ motes hypokalemia, and facilitates ectopic beats. tation efforts. Aggressive sodium bicarbonate administration re­ E. It is not necessary to interrupt the cardiac sults in an excessive sodium and volume load, both massage to change personnel. of which are undesirable in a marginally compen­ The chest inflations should be synchronized sated patient. with the cardiac massage. The early part of infla­ Intracardiac injections are seldom necessary tion is best timed with sternal relaxation. This as­ except perhaps to administer epinephrine for per­ pect of both cardiopulmonary resuscitation and sistent asystole. Epinephrine can convert fine ven-

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tricular fibrillation into a coarse fibrillation which temporary cutdown can be quickly performed is usually easier to defibrillate. Complications of over the lesser saphenous vein located between intracardiac injections include laceration of an in­ the lateral malleolus and the Achilles tendon or the tercostal artery or coronary artery, and hemoperi- greater saphenous vein located anterior to the cardium, pneumothorax, or hemothorax. Care medial malleolus. should be exercised to be certain that the epi­ The defibrillator paddles must be pressed firmly nephrine is injected into the ventricular chamber against the chest wall. Twenty-five pounds of itself and not into the myocardium. An intra- pressure can decrease the energy levels necessary myocardial injection could result in intractable for cardioversion and defibrillation. Low resist­ ventricular fibrillation. ance paste or saline pads are necessary. The The generally accepted standard dose of cal­ standard lubricant used for rectal examination, for cium is probably too high, particularly if digitoxic- recording echoes, or for routine electrocardiogram ity is suspected. An ampule (10 cc) of 10 percent recording is not satisfactory. calcium chloride (CaCl2) or calcium gluconate is more than necessary and 5 cc is usually adequate. Post-Resuscitation Care Associated Techniques After a successful resuscitation, do not forget: To order appropriate studies to determine the Do not waste time with sterile techniques or etiology of the arrest. unnecessary concern about hemostasis. To order appropriate continuing medications. Do not ignore increasing gastric dilatation. A To deal with post-resuscitation complications. distended stomach can significantly impair ven­ In the excitement and enthusiasm after a success­ tricular filling by elevating the diaphragm. Early ful resuscitation, the resuscitating team may ne­ insertion of a nasogastric tube can rapidly relieve glect their responsibility to provide for continuing already existing distention but a cuffed endotra­ care until the primary physician responsible for cheal tube should be inserted first to protect the the patient’s care can be informed and can assume airway. The use of an esophageal obturator air­ responsibility. way12,13 or an endotracheal tube can effectively prevent gastric distention. Recent experimental studies have shown that increased intra-abdominal References pressure, which may be achieved with a tight ab­ 1. Carveth SW, Lawbrew CT, McIntyre KM, et al: A Manual for Instruction of Basic Life Support. Dallas, Ameri­ dominal binder, may increase cardiac output sub­ can Heart Association, 1977 stantially. 2. Standards and guidelines for cardiopulmonary re­ suscitation (CPR) and emergency cardiac care (ECC). JAMA Do not spent too much time and effort inserting 244:453, 1980 an endotracheal tube, particularly if experienced 3. Rabkin MT, Gillerman G, Rice NR: Orders not to re­ suscitate. N Engl J Med 295:364, 1976 personnel are not immediately available. Ade­ 4. Safar P: Amelioration of postischemic brain dam­ quate oxygenation is often obtained using a mask age with barbiturates. Curr Cone CV Dis 15:1, 1980 5. Pennington JE, Taylor J, Lown B: Chest thump for properly positioned and supported. An esophageal reverting ventricular tachycardia. N Engl J Med 283:1192, obturator airway is easier to use and provides ex­ 1970 6. McIntyre KM, Parise AF, Benfari R, et al: Patho­ cellent oxygenation while decreasing the risks of physiologic syndromes of cardiopulmonary resuscitation. vomiting and aspiration.12,13 Arch Intern Med 138:1130, 1978 7. Taylor GJ, Tucker WM, Green HL, et al: Importance It is generally wise to avoid early insertion of an of prolonged compression during cardiopulmonary resus­ intravenous line into the subclavian or external citation in man. N Engl J Med 296:1515, 1977 8. Loeb HS: Cardiac arrest. JAMA 232:845, 1975 jugular veins, unless the operator is highly skilled 9. Roberts JR, Greenberg Ml, Baskin SI: Endotracheal and experienced. These routes, although ulti­ epinephrine in cardiorespiratory collapse. J Am Coll Emerg Physicians 8:515, 1979 mately satisfactory, may require unnecessary in­ 10. Elam JO: The interpulmonary route for CPR drugs. terruption of cardiac massage, are more likely to In Safar P, Elam JO (eds): Advances in Cardiopulmonary Resuscitation. New York, Springer-Verlag, 1977, chap 21 induce complications because of the trauma asso­ 11. Bishop RL, Weisfeldt ML: Sodium bicarbonate ad­ ciated with the resuscitative efforts, and once in­ ministration during cardiac arrest: Effect on arterial pH, PC02, and osmolality. JAMA 235:505, 1976 serted are often inaccessible or “in the way.” In­ 12. Don Michael TA, Lambert EH, Mehran A: Mouth-to- lung airway: For cardiac resuscitation. Lancet 2:1329, 1968 travenous cutdowns in the arm are inconvenient or 13. Schofferman J, Dill P, Lewis AJ: The esophageal difficult because of the cardiac massage. An ideal obturator airway: A clinical evaluation. Chest 69:67, 1976

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