Resuscitation

resuscitation

In a race against time, when every second counts, each step in resuscitation must be exactly right first time. 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 120,00 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 guide and support the rescuer in every stage of resuscitation, whether ventilation or defibrillation. 

What indications can necessitate resuscitation?

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. 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.1
  • 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 thorax or open skull wounds, can trigger cardiovascular failure.2
  • 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.

What is cardiopulmonary resuscitation?

A cardiac arrest is a medical emergency in which the heart stops beating and immediate treatment is required. In such cases, cardiopulmonary resuscitation (CPR) is a life-saving measure. It must be initiated immediately and comprises chest compression and ventilation so as to maintain blood flow to the vital organs and bring oxygen into the lungs.4

CPR can be supplemented with the following treatment measures: 

  • Advanced Cardiac Life Support (ALS): Advanced life support measures5 are specialized procedures performed by trained medical personnel. They consist of the administration of medication, ECG evaluations, defibrillation and intubation.
  • DefibrillationDefibrillation is used in the event of a life-threatening cardiac arrhythmia – such as pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF) – and must be performed as quickly as possible. 
  • Treating the underlying cause: The objective is to identify and treat reversible causes of the cardiac arrest.

Unlike ALS measures, CPR can and should also be performed by laypersons if no medical personnel are present at the scene. In this case, any help is better than none and increases the chances of survival.

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. 

Chain of Survival

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

  • 1. Immediate detection of a cardiac arrest and promptly calling the emergency services.
  • 2. Early cardiopulmonary resuscitation (CPR) with emphasis on chest compressions
  • 3. Prompt defibrillation.
  • 4. Advanced life support by emergency medical services and other medical specialists, including ventilation.
  • 5. Aftercare following cardiac arrest to stabilize the patient and monitoring of vital functions.
  • 6. Recovery as long-term treatment, observation and rehabilitation of the patient.

Guideline recommendations for resuscitation

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), represented in Germany by the German Resuscitation Council (GRC) sets out the guidelines for resuscitation measures.2 The following guidelines apply to BLS:

  • 1. Check: Determine whether cardiopulmonary resuscitation is required.
  • 2. Call: Notify the emergency medical services.
  • 3. Press: Start chest compressions.
  • 4. AED: Find a defibrillator and follow the device instructions.
  • 5. Learn: Further training on performing CPR.

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: These techniques are at the forefront of improving the survival rate after a cardiac arrest. 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.
  • 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: 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. Intubation should only be performed by users with a high success rate (over 95% within two 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 form of ventilation (manual or mechanical) are given.
  • 4. Adrenalin for non-shockable rhythms: The recommendation includes early administration of adrenalin for non-shockable rhythms.
  • 5. Extracorporeal CPR (eCPR): If conventional ALS is unsuccessful, eCPR is recommended as a possible option.

Resuscitation in 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 guidelines for airway management and ventilation during CPR

There are specific ERC guidelines for airway management 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 as it takes (over 1 second) for a clear chest lift to become visible. Ventilation should not interrupt chest compression for longer than ten seconds.

For endotracheal intubation, chest compression should be interrupted for as short a time as possible, ideally less than 5 seconds. The choice between video and direct laryngoscopy for intubation depends on local protocols and the experience of the first responder. Capnography should be used to confirm the position of the endotracheal tube. 

After inserting the endotracheal tube or a supraglottic airway (SGA), ventilation is performed at a rate of 10/min and chest compression is continued without pausing during ventilation. If an SGA leak 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.

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 a best possible patient outcome.

MEDUMAT Standard

The intuitive MEDUMAT Standard2 ventilator features the innovative CCSV (Chest Compression Synchronized Ventilation) function. This pressure-controlled ventilation function optimizes the ventilation and perfusion of 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.

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MEDUVENT Standard

MEDUVENT Standard guarantees a reliable oxygen supply thanks to the turbine. The integrated MEDUtrigger guarantees 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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MEDUMAT EasyCPR

MEDUMAT EasyCPR is an ideal entry-level device for mechanical ventilation. The MEDUtrigger allows manual ventilation breaths to be triggered on a ventilation mask in CPR mode. Once the airway has been secured, the rescuer can simply change to continuous IPPV ventilation by pressing a button.

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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

2 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

3 Larsen R. Notfallbehandlung von Schwerverletzten. Anästhesie und Intensivmedizin für die Fachpflege. 2016 Jun 14:448–59. German. doi: 10.1007/978-3-662-50444-4_31. PMCID: PMC7531416.

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

5 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

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

https://www.cprguidelines.eu/

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

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