Resuscitation

In Germany, out-of-hospital cardiac arrest is one of the three most common causes of death. The emergency medical services are called out to such cases about 120,000 times a year, and they have to perform resuscitation in about half of them. The survival rate for these emergencies is about 11 %.¹

The innovative devices from WEINMANN support guideline-compliant treatment when administering cardiopulmonary resuscitation (CPR), irrespective of the user’s level of experience. They actively provide guidance and support at every stage of resuscitation, be it ventilation or defibrillation. 

What does ‘to resuscitate’ mean?

Resuscitate means “to revive”. The term originates from the Latin “resuscitāre” and etymologically means “to rouse again, revive”.

Resuscitation is required if a person suffers a sudden cardiac arrest, and they are unresponsive or unconscious. 

Another indication is the absence of normal breathing or the occurrence of abnormal breathing activity, such as gasping (agonal breathing). Furthermore, initial convulsive movements can be an indication of cardiac arrest. 

Resuscitation plays a key role in prehospital emergency medicine, as every minute without resuscitation reduces the chances of survival by 7–10 %.²

What does CPR mean?

In medicine, CPR stands for cardiopulmonary resuscitation and refers to the life support measures initiated in the event of a cardiac arrest. This is when the heart suddenly stops beating and treatment is required without delay.

Cardiopulmonary resuscitation – comprising chest compressions and ventilation – must be initiated immediately so as to maintain blood flow to the vital organs and bring oxygen into the lungs.³

The following treatment measures are relevant when it comes to CPR: 

• Basic Life Support (BLS): CPR can and should also be performed by laypersons if no medical personnel are present at the scene. This is because in an emergency, any help is better than none and increases the chances of survival.
• Advanced Life Support (ALS): Advanced life support measures⁴ are specialized procedures performed by trained medical personnel. They consist of the administration of medication, ECG evaluations, defibrillation and intubation.
• Treating the underlying cause: The objective is to identify and treat reversible causes of cardiac arrest.

Objectives of cardiopulmonary resuscitation

The primary objective of cardiopulmonary resuscitation in the event of respiratory and cardiac arrest is restoring blood circulation as quickly as possible so as to transport sufficient oxygen to the organs and maintain blood flow. Until the cause of the cardiac arrest can be treated, CPR is administered to prevent potentially irreparable damage, in particular to the heart and brain.

What indications can necessitate resuscitation?

If a patient requires resuscitation outside of the hospital setting, this is called an “out-of-hospital cardiac arrest” (OHCA).

The following are possible causes of a cardiac arrest:

• Acute coronary syndrome: Acute coronary syndrome results from the occlusion of a coronary artery.
• Coronary heart disease: With this condition, also known as chronic ischemic heart disease, the coronary blood vessels that supply the heart with oxygen are calcified, and constrictions or blockages develop. This is the most common cause of death in Germany.⁵
• Acute circulation problems (ischemia): Acute ischemia is caused by an embolism. As a result, the surrounding tissue is not supplied with sufficient oxygen and nutrients, while harmful metabolic products cannot be removed.
• Myocarditis: Myocarditis is an inflammation of the heart muscle, which can be triggered by viral, bacterial or autoimmunological factors and can impair the contractile function of the heart.
• Serious trauma: Various traumas, such as penetrating injuries in the neck-torso area, an unstable chest or open skull wounds, can trigger cardiovascular failure.³
• Pulmonary edema: The primary cause of pulmonary edema often lies in the heart, rather than the lungs themselves. If the heart is no longer pumping efficiently, this causes a vascular congestion, and fluid is pressed into the lung tissue. The accumulation of fluid in the lungs causes significant impairment of the gas exchange, which can ultimately lead to hypoxia and a cardiac arrest.

Resuscitation sequence according to Chain of Survival

The Chain of Survival⁶ describes the priority of survival measures that are to be performed during resuscitation. The resuscitation algorithm targets an effective and quick response in the event of a cardiac arrest. 

Resuscitation measures

There are two distinct categories of resuscitation treatment: Basic Life Support, BLS and Advanced Life Support, ALS. While BLS consists of basic first-aid measures that can be performed by laypersons, ALS comprises more complex medical interventions that require specially trained personnel.

The European Resuscitation Council (ERC) sets out the guidelines for resuscitation measures.⁵ The following guidelines apply to BLS:

The BLS measures are primarily designed for people without any medical training. The ALS measures include them, but are performed by trained personnel. 

The European Resuscitation Council (ERC)⁷ and American Heart Association (AHA)⁸ guideline recommendations on advanced resuscitation measures⁹ can be summarized as follows:

1. High-quality chest compression and early defibrillation: Every minute of delay in defibrillation reduces the likelihood of survival by approximately 10 %. Immediate, high-quality chest compression at a rate of 100 to 120 compressions per minute and 5 to 6 cm compression depth, coupled with prompt defibrillation, if indicated, are essential. Defibrillation is used in particular for pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF).

2. Treating reversible causes: An important aspect is early detection and treatment of reversible causes of a cardiac arrest – both in-hospital and prehospital.

3. Airway management and ventilation: Ensuring effective ventilation is a priority in the new guidelines. The highest possible oxygen concentration should be applied during ventilation. The airway is secured by means of basic and advanced airway management.

In the case of an unsecured airway, chest compression and ventilation are performed in a 30:2 ratio. Each breath should last approximately 1 second and produce a visible chest lift. If ventilation is not possible or not desired, continuous compressions at a rate of at least 100/min are acceptable. 

Intubation should only be performed by experienced users with a high success rate (over 95 % within 2 intubation attempts). Once the airway has been secured, ventilation should be performed at a rate of 10 breaths per minute with a tidal volume of 6–7 ml per kg body weight. No specific recommendations on ventilation mode or type of ventilation of ventilation (manual or mechanical) are given. The use of a volume-controlled mode for mechanical ventilation with the highest possible ventilation pressures and the above settings is recommended. However, the evidence remains limited. No recommendation is given for the optimal ventilation strategy during mechanical chest compression. 

4. Adrenaline during resuscitation: 

The recommendation includes:
- 1 mg adrenaline as early as possible for non-shockable rhythm
- 1 mg adrenaline after the third shock in the case of shockable rhythm
- The administration of 1 mg adrenaline should be repeated every 3–5 minutes for as long as the ALS measures are continued.

5. Extracorporeal CPR (eCPR): If conventional ALS is unsuccessful, eCPR is recommended as a possible option.

Resuscitation protocol for children

A sudden collapse as a result of a cardiovascular disease is quite rare in children. In most cases, a persistent respiratory or circulatory problem leads to a respiratory and cardiac arrest.

Similar to adults, ventilation and chest compressions are the priority when it comes to resuscitating children. The ABC protocol is a guide for Pediatric Basic Life Support (PBLS). According to this guide, initial treatment is performed in the following sequence:

A (Airway): Open the airway
B (Breathing): Ventilation
C (Circulation): Chest compressions.

Since a respiratory cause is more likely in children, cardiopulmonary resuscitation starts with five initial breaths. Experienced emergency responders should perform CPR in a 15:2 ratio. Ventilation is usually performed using a bag-valve-mask. If this treatment is ineffective, a supraglottic airway can be inserted.

Special recommendations for airway management and ventilation during CPR

There are specific ERC recommendations for airway management and ventilation during CPR. It should start with basic measures for the airway and, if necessary, be intensified in steps. 

In the case of an unsecured airway, chest compression and ventilation are performed in a 30:2 ratio. During CPR, the highest possible concentration of inspiratory oxygen should be administered. Each breath is performed for as long (over 1 second) as it takes for a clear chest lift to become visible. Ventilation should not interrupt chest compression for longer than five seconds.

For endotracheal intubation, chest compression should be interrupted for as short a time as possible, ideally less than 5 seconds. If video laryngoscopy is available, it should be preferred to direct laryngoscopy. Capnography should be used to confirm the position of the tracheal tube and is mandatory.

After inserting the tracheal tube or a supraglottic airway (SGA), ventilation is performed at a rate of 10/min and a tidal volume of 6–7 ml per kg body weight, and chest compression is continued without pausing during ventilation. If a leak in the SGA leads to insufficient ventilation, the compressions and ventilation are again performed in a 30:2 ratio. 

A detailed description of ventilation techniques during resuscitation, in particular for secured and unsecured airways, can be found in our article on ventilation during resuscitation.

Treatment after resuscitation

Following resuscitation, there is a high risk of post-resuscitation syndrome, which includes neurological deficits and brain damage, among other things.

The post-resuscitation phase therefore requires intensive medical care. This includes stabilizing cardiovascular function,

ventilation and initiating therapeutic hypothermia to prevent secondary brain damage.

Support from WEINMANN for guideline-compliant resuscitation

All WEINMANN devices conform to the ERC standards and enable treatment that complies with the guidelines. They support trained medical staff in performing cardiopulmonary resuscitation and defibrillation, which contributes to the best possible patient outcome.

MEDUtrigger

During resuscitation, it is necessary to trigger the mechanical breaths individually as required. With the unique MEDUtrigger as an alternative to bag-valve mask ventilation, WEINMANN makes this possible for mechanical ventilation as well: it is positioned directly on the mask and connected to the ventilator via a cable. A short press of the button initiates one mechanical breath, while a long press delivers guideline-compliant two breaths – in a maximum of five seconds and with a predefined ventilation pressure and volume.

MEDUMAT Standard² 

The intuitive MEDUMAT Standard² ventilator features the innovative Chest Compression Synchronized Ventilation (CCSV) function. This pressure-controlled ventilation function optimizes the ventilation and perfusion of intubated patients during a cardiac arrest, automatically synchronizing ventilation with chest compression. In the compression phase, a pressure-controlled, small-volume mechanical breath is triggered, while exhalation takes place in the decompression phase. 

This produces an increase in both intrathoracic and arterial pressure during the compression phase, which in turn improves the supply of oxygenated blood to the cardiovascular system.

In the decompression phase, the venous return flow is supported by the exhalation. The ventilator is thus specially optimized for use during resuscitation.

In combination with MEDUtrigger, MEDUMAT Standard²Standard² can thus optimally support the resuscitation process.

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MEDUVENT Standard

MEDUVENT Standard is the ideal ventilation device to have at the scene thanks to its light weight and small size. The integrated MEDUtrigger ensures reliable manual ventilation in 30:2 mode. Once the airway has been secured, the rescuer can simply change to continuous ventilation, thus enabling guideline-compliant ventilation during resuscitation.

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MEDUCORE Standard²

ALS measures can be efficiently implemented with MEDUCORE Standard². The monitor/defibrillator enables detailed patient monitoring, including vital signs and 12-lead ECG. This information enables the user to make informed decisions about the necessity and implementation of defibrillation.

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¹ https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/h/herz-kreislauf-stillstand.html

²www.springermedizin.de/kardiopulmonale-reanimation/kreislaufstillstand/laienreanimation-als-entscheidende-erfolgsmassnahme/11512864

³ Larsen, R. (2012). Kardiopulmonale Reanimation. In: Anästhesie und Intensivmedizin für die Fachpflege. Springer, Berlin, Heidelberg.

⁴ Notfall Rettungsmed 2021 · 24:406–446 doi.org/10.1007/s10049-021-00893-x Approved: April 20, 2021 Published online: June 8, 2021 © European Resuscitation Council (ERC), German Resuscitation Council (GRC), Austrian Resuscitation Council (ARC) 2021, corrected publication 2021; https://cprguidelines.eu/assets/guidelines-translations/ALS_LL_2021.pdf

⁵ https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=10159635&p_sprache=D&p_help=2&p_indnr=516&p_ansnr=68111598&p_version=2&D.000=1&D.001=3&D.002=3&D.003=3

⁶ https://cpr.heart.org/en/resources/cpr-facts-and-stats/out-of-hospital-chain-of-survival

⁷ https://www.cprguidelines.eu/

⁸ https://cpr.heart.org/-/media/cpr-files/cpr-guidelines-files/highlights/hghlghts_2020eccguidelines_german.pdf

⁹ https://www.grc-org.de/files/Contentpages/document/ALSAlgoGRC15.08.2022.pdf