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 THE JOURNAL OF FAMILY PRACTICE, VOL. 12 NO. 2: 213-217, 1981 213 CARDIOPULMONARY RESUSCITATION 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 214 THE JOURNAL OF FAMILY PRACTICE, VOL. 12, NO. 2, 1981 CARDIOPULMONARY RESUSCITATION 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