Cardiopulmonary resuscitation 66392 226131789 2008-07-16T23:24:48Z TheGerm 610905 Reverted edits by [[Special:Contributions/129.112.109.250|129.112.109.250]] (using [[WP:HG|Huggle]]) {{redirect|CPR}} [[Image:CPR training-04.jpg|thumb|CPR being performed on a [[mannequin]] used for training]] {{wikibookspar|First Aid|Primary Assessment & Basic Life Support}} '''Cardiopulmonary resuscitation''' ('''CPR''') is an emergency medical procedure for a victim of [[cardiac arrest]] or, in some circumstances, [[respiratory arrest]].<ref name=medline>{{cite web|url=http://www.nlm.nih.gov/medlineplus/ency/article/000010.htm|title=US National Library of Medicine Encyclopedia - Definition of CPR|accessdate=2007-06-12}}</ref> CPR is performed in hospitals, or in the community by [[layman|laypersons]] or by emergency response professionals.<ref>{{cite web|url=http://www.redcross.org/services/hss/courses/|title=US Red Cross list of courses for all skill levels|accessdate=2007-06-12}}</ref> CPR has for 50 years consisted of the combination of artificial blood circulation with [[artificial respiration]]<ref name=medline/> i.e., chest compressions and lung ventilation.<ref>{{cite web|url=http://www.resus.org.uk/pages/compCPRs.htm|title=Resuscitation Council UK Comment on Compression Only CPR|accessdate=2007-06-12}}</ref> However, in March 2008 the American Heart Association and the European Resuscitation Council, in an historic reversal, endorsed the effectiveness of chest compressions alone--without artificial respiration--for adult victims who collapse suddenly in cardiac arrest (see Cardiocerebral Resuscitation below).<ref name=Circstatement>{{cite web|url=http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.189380v1|title=Hands-Only (Compression-Only) Cardiopulmonary Resuscitation: A Call to Action for Bystander Response to Adults Who Experience Out-of-Hospital Sudden Cardiac Arrest.|accessdate=2008-04-02}}</ref><ref>{{cite web|url=http://www.erc.edu/index.php/docLibrary/en/viewDoc/775/3/|title=Advisory statement of the European Resuscitation Council: Advisory statement of the European Resuscitation Council on Basic Life Suppport.|accessdate=2008-06-13}}</ref> CPR is generally continued, usually in the presence of [[advanced life support]], until the patient regains a heart beat (called "return of spontaneous circulation" or "ROSC") or is declared [[death|dead]]. CPR is unlikely to restart the heart, but rather its purpose is to maintain a flow of oxygenated blood to the [[brain]] and the [[heart]], thereby delaying [[necrosis|tissue death]] and extending the brief window of opportunity for a successful resuscitation without permanent [[brain damage]]. [[Defibrillation]] and [[advanced life support]] are usually needed to restart the heart. ==History== {{main|History of CPR}} [[Image:Picture of old resus methods.jpg|Sign showing old Silvester and Holger-Nielson methods of resuscitation|thumb|right]] CPR has been known in theory, if not practice, for many hundreds or even thousands of years; some claim it is described in the [[Bible]], discerning a superficial similarity to CPR in a passage from the [[Books of Kings]] (II 4:34), wherein the Hebrew prophet [[Elisha]] warms a dead boy's body and "places his mouth over his". In the 19th century, doctor H. R. Silvester described a method (The Silvester Method) of artificial respiration in which the patient is laid on their back, and their arms are raised above their head to aid inhalation and then pressed against their chest to aid exhalation.<ref>{{cite web|url=http://www.ucl.ac.uk/slade/slide/ShortStory/7b.html|publisher=University College London|title=Silvester's method|accessdate=2007-06-12}}</ref> The procedure is repeated sixteen times per minute. This type of artificial respiration is occasionally seen in films made in the early part of the 20th century. A second technique, called the Holger Neilson technique, described in the first edition of the [[Boy Scout Handbook]] in the United States in 1911, described a form of artificial respiration where the person was laid on their front, with their head to the side, and a process of lifting their arms and pressing on their back was utilized, essentially the Silvester Method with the patient flipped over. This form is seen well into the 1950s (it is used in an episode of ''[[Lassie (1954 TV series)|Lassie]]'' during the Jeff Miller era), and was often used, sometimes for comedic effect, in theatrical cartoons of the time (see ''[[Tom and Jerry (MGM)|Tom and Jerry]]'s'' "[[The Cat and the Mermouse]]"). This method would continue to be shown, for historical purposes, side-by-side with modern CPR in the Boy Scout Handbook until its ninth edition in 1979. However it was not until the middle of the 20th century that the wider medical community started to recognize and promote artificial respiration combined with chest compressions as a key part of resuscitation following [[cardiac arrest]]. The combination was first seen in a 1962 training video called "The Pulse of Life" created by [[James Jude]], [[Guy Knickerbocker]] and [[Peter Safar]]. Jude and Knickerbocker, along with [[William Kouwenhouen]] had recently discovered the method of external chest compressions, whereas Safar had worked with [[James Elam]] to prove the effectiveness of artificial respiration. Their combined findings were presented at annual Maryland Medical Society meeting on [[September 16]], [[1960]] in Ocean City, and gained rapid and widespread acceptance over the following decade, helped by the video and speaking tour they undertook. [[Peter Safar]] wrote the book ''ABC of resuscitation'' in 1957. In the U.S., it was first promoted as a technique for the public to learn in the 1970s. <ref> See, e.g., "Award of the Heart", ''TIME'' magazine, November 28, 1973, retrieved on 05-28-2008 from time.com </ref> Mouth-to-mouth ventilation was combined with chest compressions based on the assumption that active ventilation is necessary to keep circulating blood oxygenated, and the combination was accepted without comparing its effectiveness with chest compressions alone. However, research over the past decade has shown that assumption to be in error, resulting in the AHA's acknowledgment of the effectiveness of chest compressions alone (see Cardiocerebral resuscitation below).<ref name=Circstatement/> ==Use in cardiac arrest== [[Image:CPR training-03.jpg|thumb|CPR training: CPR is being administrated while a second rescuer prepares for [[defibrillation]].]] The medical term for the condition in which a person's heart has stopped is [[cardiac arrest]]<ref>{{cite web|url=http://www.americanheart.org/presenter.jhtml?identifier=4481|title=Definition of Cardiac Arrest|accessdate=2007-06-13|publisher=American Heart Association}}</ref> (also referred to as ''cardiorespiratory arrest''). CPR is used on patients in cardiac arrest in order to [[oxygenation|oxygenate]] the blood and maintain a [[cardiac output]] to keep vital organs alive. Blood circulation and oxygenation are absolute requirements in transporting [[oxygen]] to the tissues. The [[brain]] may sustain [[brain damage|damage]] after blood flow has been stopped for about four minutes and irreversible damage after about seven minutes. If blood flow ceases for 1 or 2 hours, the cells of the body [[necrosis|die]] unless they get an adequately gradual bloodflow, (provided by cooling and gradual warming, rarely, in nature [such as in a cold stream of water] or by an advanced medical team). Because of that CPR is generally only effective if performed within 7 minutes of the stoppage of blood flow.<ref>Newsweek 2007-05-07</ref> The heart also rapidly loses the ability to maintain a normal rhythm. Low body temperatures as sometimes seen in drowning prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen to reach the brain to delay [[brain death]], and allows the heart to remain responsive to [[defibrillation]] attempts. If the patient still has a [[pulse]], but is not breathing, this is called [[respiratory arrest]] and [[artificial respiration]] is more appropriate. However, since people often have difficulty detecting a pulse, CPR may be used in both cases, especially when taught as first aid (see below). ==Guidelines== In 2005, new CPR guidelines<ref name=AHA2>{{cite web|url=http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-19|title=Adult Basic Life Support|accessdate=2007-06-13|publisher=American Heart Association}}</ref><ref>{{cite web|url=http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-156|title=Pediatric Basic Life Support|accessdate=2007-06-13|publisher=American Heart Association}}</ref> were published by the [[International Liaison Committee on Resuscitation]], agreed at the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science.<ref>{{cite web|url=http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-5|title=Adult Basic Life Support|accessdate=2007-06-13|publisher=American Heart Association}}</ref><ref>{{cite web|url=http://circ.ahajournals.org/cgi/content/full/112/22_suppl/III-73|title=Pediatric Basic and Advanced Life Support|accessdate=2007-06-13|publisher=American Heart Association}}</ref> The primary goal of these changes was to simplify CPR for lay rescuers and healthcare providers alike, to maximise the potential for early resuscitation. The important changes for 2005 were:<ref name=AHA1>{{cite web|url=http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-12|title=Overview of CPR|accessdate=2007-06-13|publisher=American Heart Association}}</ref> * A universal compression-ventilation ratio (30:2) recommended for all single rescuers of [[infant]] (less than one year old), [[child]] (1 year old to puberty), and [[adult]] ([[puberty]] and above) victims (excluding newborns).<ref>{{cite web|url=http://www.resus.org.au/faqs_guidelines_march06.pdf|title=Australian Resuscitation Council Guidelines as of March 6|accessdate=2007-06-13}}</ref> The primary difference between the age groups is that with adults the rescuer uses two hands for the chest compressions, while with children it is only one, and with infants only two fingers (index and middle fingers). While this simplification has been introduced, it has not been universally accepted, and especially amongst healthcare professionals, protocols may still vary.<ref>{{cite web|url=http://www.resus.org.uk/pages/pals.pdf|title=Resuscitation Council UK Paediatric Advanced Life Support Guidelines|accessdate=2007-06-13}}</ref> * The removal of the emphasis on lay rescuers assessing for pulse or signs of circulation for an unresponsive adult victim, instead taking the absence of ''normal'' breathing as the key indicator for commencing CPR. * The removal of the protocol in which lay rescuers provide rescue breathing without chest compressions for an adult victim, with all cases such as these being subject to CPR. Research<ref name=AHA2/> has shown that lay personnel cannot accurately detect a pulse in about 40% of cases and cannot accurately discern the absence of pulse in about 10%. The pulse check step has been removed from the CPR procedure completely for lay persons and de-emphasized for healthcare professionals. ==Alternative methods== ===Compression only (cardiocerebral) resuscitation=== The traditional [[International Liaison Committee on Resuscitation]] (ILCOR) approach described above has been challenged in recent years by advocates for compression only CPR, also known as cardiocerebral resuscitation (CCR). This technique is simply chest compressions without [[artificial respiration]]. The respiration component of CPR has been a topic of major controversy over the past decade. The CCR method has been championed by the [[University of Arizona]]'s [[Sarver Heart Center]], and a study by the university,<ref>{{cite web|url=http://www.scienceblog.com/cms/a-better-sort-of-cpr-11985.html|title=A better sort of CPR|accessdate=2007-06-16}}</ref> claimed a 300% greater success rate over standard CPR.<ref>{{cite journal|url=http://circ.ahajournals.org/cgi/content/full/111/16/2134?etoc|last=Ewy|first=Gordon A|date=24th November 2004|title=A new Cardiopulmonary resuscitation|accessdate=2007-06-15|journal=Circulation|publisher=American Heart Association|volume=111|issue=2134-2142|pmid=15851620|doi=10.1161/01.CIR.0000162503.57657.FA|pages=2134}}</ref> The exceptions were in the case of [[drowning]] or [[drug overdose]]. In March 2007, a Japanese study in the medical journal ''[[The Lancet]]'' presented strong evidence that compressing the chest, not mouth-to-mouth (MTM) ventilation, is the key to helping someone recover from cardiac arrest.<ref>{{cite journal|title=Cardiopulmonary resuscitation by bystanders with chest compression only (SOS-KANTO): an observational study|journal=Lancet|date=March 17, 2007|volume=69(9565)|pages=920–6)|unused_data=SOS-KANTO study group}}</ref> An editorial by Gordon Ewy MD (a proponent of CCR) in the same issue of The Lancet called for an interim revision of the ILCOR Guidelines based on the results of the Japanese study, but the next scheduled revision of the Guidelines was not until 2010. However, on March 30, 2008, the American Heart Association broke away from the ILCOR position and stated that compression-only CPR works as well as, and sometimes better than, traditional CPR.<ref>[http://www.cnn.com/2008/HEALTH/03/31/hands.only.cpr.ap/index.html Heart Association: Hands-only CPR works]</ref> The method of delivering chest compressions remains the same, as does the rate (100 per minute), but the rescuer delivers only the compression element which, the University of Arizona claims, keeps the bloodflow moving without the interruption caused by MTM respiration. ===Rhythmic abdominal compressions=== Rhythmic abdominal compression-CPR works by forcing blood from the blood vessels around the abdominal organs, an area known to contain about 25 percent of the body's total blood volume. This blood is then redirected to other sites, including the circulation around the heart. Findings published in the September 2007 issue of the American Journal of Emergency Medicine using pigs found that 60 percent more blood was pumped to the heart using rhythmic abdominal compression-CPR than with standard chest compression-CPR, using the same amount of effort. There was no evidence that rhythmic abdominal compressions damaged the abdominal organs and the risk of rib fracture was avoided. Avoiding mouth-to-mouth breathing and chest compressions eliminates the risk of rib fractures and transfer of infection.<ref>[http://www.emsvillage.com/articles/article.cfm?id=2214 Research: Abdomen pushing key to new CPR technique?<!-- Bot generated title -->]</ref> ===Self-CPR=== A form of "self-CPR" termed "[[Cough CPR]]" was the subject of a [[hoax]] [[chain e-mail]] entitled "How to Survive a [[myocardial infarction|Heart Attack]] When Alone" which wrongly cited "[[ViaHealth]] [[Rochester, New York|Rochester]] General Hospital" as the source of the technique. Rochester General Hospital has denied any connection with the technique.<ref>{{cite web|url=http://www.viahealth.org/body_rochester.cfm?id=329|title=ViaHealth Rochester General Hospital statement on 'Cough CPR' email|accessdate=2007-06-13}}</ref><ref>{{cite web|url=http://www.snopes.com/medical/homecure/coughcpr.asp|title=Snopes Urban Legends Reference - Cough CPR|accessdate=2007-06-13}}</ref> Rapid coughing has been used in hospitals for brief periods of [[cardiac arrhythmia]] on [[electrocardiogram|monitored]] patients. One researcher has recommended that it be taught broadly to the public.<ref>{{cite journal | author = Rieser M | title = The use of cough-CPR in patients with acute myocardial infarction. | journal = J Emerg Med | volume = 10 | issue = 3 | pages = 291–3 | year =1992 | month=May-Jun | pmid = 1624741 | doi = 10.1016/0736-4679(92)90335-Q}}</ref><ref>{{cite news | author=Associated Press | title=Cough may help during heart attack -- Technique may allow patients to stay conscious, study finds | date=October 31, 2003 | url=http://msnbc.msn.com/id/3077018/}}</ref> However, “cough CPR” cannot be used outside the hospital because the first symptom of cardiac arrest is unconsciousness<ref>Australian Resuscitation Council Newsletter (2003) Vol. 27 No. 3 p. 2; available at http://www.resus.org.au/newsletters/newsletter_nov_2003.pdf</ref> in which case coughing is impossible. Further, the vast majority of people suffering chest pain from a [[myocardial infarction|heart attack]] will not be in cardiac arrest and CPR is not needed. In these cases attempting “cough CPR” will increase the workload on the heart and may be harmful. When coughing is used on trained and monitored patients in hospitals, it has only been shown to be effective for 90 seconds.<ref>Australian Resuscitation Council Newsletter (2005) Vol. 29 No. 3 p. 2; available at http://www.resus.org.au/newsletters/newsletter_dec2005.pdf</ref> The [[American Heart Association]] (AHA) and other resuscitation bodies,<ref>Australian Resuscitation Council Newsletter (2005) Vol. 29 No. 3 p. 2; available at http://www.resus.org.au/newsletters/newsletter_dec2005.pdf</ref> do not endorse "Cough CPR", which it terms a misnomer as it is not a form of ''resuscitation''. The AHA does recognize a limited legitimate use of the coughing technique:<blockquote>"This coughing technique to maintain blood flow during brief [[Cardiac arrhythmia|arrhythmias]] has been useful in the hospital, particularly during [[cardiac catheterization]]. In such cases the patients [[electrocardiogram|ECG]] is monitored continuously, and a physician is present."<ref>{{cite web|url=http://www.americanheart.org/presenter.jhtml?identifier=4535|title=Cough CPR|accessdate=2007-06-13|publisher=American Heart Association}}</ref></blockquote> ==Prevalence and effectiveness== ===Chance of receiving CPR=== Various studies suggest that in out of home cardiac arrest, bystanders, lay persons or family members attempt CPR in between 14%<ref name=swor>{{cite journal|last=Swor|first=RA|couauthors=Jackson RE; Cynar M; Sadler E; Basse W; Boji B; Rivera-Rivera EJ; Maher A; Grubb W; Jacobson R et al.|title=Bystander CPR, ventricular fibrillation and survival in witnessed, unmonitored out-of-hospital cardiac arrest|journal=Annals of Emergency Medicine|date=June 1995|volume=25|issue=6|pmid=:7755200|pages=780–4|doi=10.1016/S0196-0644(95)70207-5}}</ref> and 45%<ref name=wik>{{cite journal|last=Wik|first=L|coauthors=Steen PA; Bircher NH|title=Quality of bystander cardiopulmonary resuscitation influence outcome after prehospital cardiac arrest|journal=Resuscitation|date=December 1994|volume=28|issue=4|pages=195–203|pmid=: 7740189|doi=10.1016/0300-9572(94)90064-7}}</ref> of the time, with a median of 32%. This indicates that around 1/3 of out-of-home arrests have a CPR attempt made on them. However, the effectiveness of this CPR is variable, and the studies suggest only around half of bystander CPR is performed correctly.<ref>{{cite journal|last=Van Hoeyweghen|first=RJ|coauthors=Bossaert LL; Mullie|title=Quality and efficiency of bystander CPR. Belgian Cerebral Resuscitation Study Group|journal=Resuscitation|date=August 1993|volume=26|issue=1|pages=47–52|unused_data=|; Calle P; Martens P; Buylaert WA; Delooz H}}</ref><ref>{{cite journal|last=Gallagher|first=EJ|coauthors=Lombardi G; Gennis P|title=Effectiveness of bystander cardiopulmonary resuscitation and survival following out-of-hospital cardiac arrest|journal=JAMA|date=December 1995|volume=274|issue=24|pmid=: 8568985}}</ref> There is a clear correlation between age and the chance of CPR being commenced, with younger people being far more likely to have CPR attempted on them prior to the arrival of emergency medical services.<ref name=swor/><ref>{{cite journal|last=jackson|first=RE|coauthors=Swor RA|title=Who gets bystander cardiopulmonary resuscitation in a witnessed arrest?|journal=Academy of Emergency Medicine|date=June 1997|volume=4|issue=6|pages=560–4|pmid=: 9189184}}</ref> It was also found that CPR was more commonly given by a bystander in public, than when an arrest occurred in the patient's home, although health care professionals are responsible for more than half of out-of-hospital resuscitation attempts.<ref name=wik/> This is supported by further research, which suggests that people with no connection to the victim are more likely to perform CPR than a member of their family.<ref name=bossaert>{{Cite journal|last=Bossaert|first=L|coauthors=Van Hoeyweghen R|title=Bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest. The Cerebral Resuscitation study group|journal=Resuscitation|date=1989|volume=17|issue=Suppl S55-69|pmid=: 2551021}}</ref> There is also a correlation between the cause of arrest and the likelihood of bystander CPR being initiated. Lay persons are most likely to give CPR to younger cardiac arrest victims in a public place when it has a medical cause; victims in arrest from trauma, exsanguination or intoxication are less likely to receive CPR.<ref name=bossaert/> ===Chance of receiving CPR in time=== CPR is only likely to be effective if commenced within 6 minutes after the blood flow stops,<ref name=cummins>{{cite journal|last=Cummins|first=RO|coauthors=Eisenberg MS; Hallstrom AP; Litwin PE|title=Survival of out-of-hospital cardiac arrest with early initiation of cardiopulmonary resuscitation|journal=American Journal of Emergency Medicine|date=March 1985|volume=3|issue=2|pages=114–9|pmid=: 3970766}}</ref> because permanent brain cell damage occurs when fresh blood infuses the cells after that time, since the cells of the brain become dormant in as little as 4-6 minutes in an oxygen deprived environment and the cells are unable to survive the reintroduction of oxygen in a traditional resuscitation. Research using cardioplegic blood infusion resulted in a 79.4% survival rate with cardiac arrest intervals of 72±43 minutes, traditional methods achieve a 15% survival rate in this scenario, by comparison. New research is currently needed to determine what role CPR, electroshock, and new advanced gradual resuscitation techniques will have with this new knowledge<ref>{{cite journal | last = Athanasuleas | first = Constantine | coauthors = Buckberg, Gerald D.;Allen, Bradley S.; Beyersdorf, Friedhelm; Kirsh, Marvin M. | title = Sudden cardiac death: directing the scope of resuscitation towards the heart and brain. | journal = Resuscitation | volume = 70 | issue = 1 | pages = 44–51 | date = 2006 | pmid = 16759784 {{ISSN|0300-9572}} | url = http://repositories.cdlib.org/cgi/viewcontent.cgi?article=5092&context=postprints | format = [[PDF]] | accessdate = 2007-05-02 | doi = 10.1016/j.resuscitation.2005.11.017 }}</ref> A notable exception is cardiac arrest occurring in conjunction with exposure to very cold temperatures. [[Hypothermia]] seems to protect the victim by slowing down [[metabolism|metabolic]] and [[human physiology|physiologic]] processes, greatly decreasing the tissues' need for oxygen.<ref>{{cite journal|last=Guilfoy|first=Christine|journal=American Journal of Physiology - Heart and Circulatory Physiology|title=Heart has enough oxygen to survive hypothermia|accessdate=2007-06-14|date=18th July 2006|url=http://www.eurekalert.org/pub_releases/2006-07/aps-hhe071206.php}}</ref> There are cases where CPR, defibrillation, and advanced warming techniques have revived victims after substantial periods of hypothermia.<ref>{{cite journal | last = Eich | first = Christoph | coauthors = Brauer, Anselm; Kettler, Dietrich | title = Recovery of a hypothermic drowned child after resuscitation with cardiopulmonary bypass followed by prolonged extracorporeal membrane oxygenation | journal = Resuscitation | volume = 67 | issue = 1 | pages = 145–8 | date = 2005 | pmid = 16129537 {{ISSN|0300-9572|doi=10.1016/j.resuscitation.2005.05.002}} | url = http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6T19-4H0BT55-6-2&_cdi=4885&_user=10&_orig=browse&_coverDate=10%2F31%2F2005&_sk=999329998&view=c&wchp=dGLbVtz-zSkWW&md5=77efe410bf27606a0386b5d6ab8d387d&ie=/sdarticle.pdf | format = [[PDF]] | accessdate = 2007-01-29 | doi = 10.1016/j.resuscitation.2005.05.002 }}</ref> ===Chance of surviving=== Used alone, CPR will result in few complete recoveries, and those that do survive often develop serious complications. Estimates vary, but many organizations stress that CPR does not "bring anyone back," it simply preserves the body for [[defibrillation]] and [[advanced life support]].<ref name=AHA6/> However, in the case of "non-shockable" rhythms such as [[Pulseless electrical activity|Pulseless Electrical Activity]] (PEA), defibrillation is not indicated, and the importance of CPR rises. On average, only 5%-10% of people who receive CPR survive.<ref>{{cite web|last=WebMD Medical News|url=http://www.webmd.com/content/article/32/1728_79637.htm|title=Real CPR isn't everything it seems to be|accessdate=2007-06-13}}</ref> The purpose of CPR is not to "start" the heart, but rather to circulate oxygenated blood, and keep the brain alive until advanced care (especially defibrillation) can be initiated. As many of these patients may have a pulse that is impalpable by the layperson rescuer, the current consensus is to perform CPR on a patient that is not breathing. A pulse check is not required in basic CPR since it is so often missed when present, or even felt when absent, even by health care professionals.{{Fact|date=February 2007}} Studies have shown the importance of immediate CPR followed by defibrillation within 3–5 minutes of sudden VF cardiac arrest improve survival. In cities such as Seattle where CPR training is widespread and defibrillation by EMS personnel follows quickly, the survival rate is about 30 percent. In cities such as New York City, without those advantages, the survival rate is only 1-2 percent.<ref name=AHA7>[http://www.americanheart.org/presenter.jhtml?identifier=4483 Cardiopulmonary Resuscitation (CPR) Statistics<!-- Bot generated title -->]</ref> :{| class="wikitable" |- ! Type of Arrest ! ROSC ! Survival ! Source |- | Witnessed In-Hospital Cardiac Arrest | 48% | 22% |<ref name=CMAJ>{{cite journal|last=Brindley|first=Peter G|coauthors=Markland, Darren M. Kutsogiannis, Demetrios J|title=Predictors of survival following in-hospital adult cardiopulmonary rescuitation|journal=Canadian Medical Association Journal|volume=174|issue=4|date=2002-08-20|url=http://www.cmaj.ca/cgi/content/full/167/4/343|accessdate=2007-06-14|pmid=12197686}}</ref> |- | Unwitnessed In-Hospital Cardiac Arrest | 21% | 1% |<ref name=CMAJ/> |- | Bystander Cardiocerebral Resuscitation | 40% | 6% |<ref name=RSCUK>{{cite web|url=http://www.resus.org.uk/pages/compCPRs.htm|title=Resuscitation Council Comment on CPR study|publisher=Resuscitation Council UK|date=April 2007|accessdate=2007-06-14}}</ref> |- | Bystander Cardiopulmonary Resuscitation | 40% | 4% |<ref name=RSCUK/> |- | No Bystander CPR (Ambulance CPR) | 15% | 2% |<ref name=RSCUK/> |- | Defibrillation within 3-5 minutes | 74% | 30% |<ref name=AHA6>{{cite web|url=http://www.americanheart.org/presenter.jhtml?identifier=4483|title=CPR statistics|publisher=American Heart Association|accessdate=2007-06-14}}</ref><ref name=AHA7/> |} ROSC - Return of spontaneous circulation ===Therapeutic Hypothermia=== {{main|Therapeutic hypothermia}} In some cases, doctors may choose to induce hypothermia after return of spontaneous circulation (ROSC). This procedure is called [[therapeutic hypothermia]]. The first study conducted in Europe focused on people who were resuscitated 5-15 minutes after collapse. Patients participating in this study experienced spontaneous return of circulation (ROSC) after an average of 105 minutes. Subjects were then cooled over a 24 hour period, with a target temperature of 32-34°C (89.6-93.2°F). 55% of the 137 patients in the hypothermia group experienced favorable outcomes, compared with only 39% in the group that received standard care following [[resuscitation]].<ref name="NEJ1">Holzer, Michael. “Mild Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest.” New England Journal of Medicine. (2002) Vol. 346, No. 8.</ref> Death rates in the hypothermia group were 14% lower, meaning that for every 7 patients treated one life was saved.<ref name="NEJ1"/> Notably, complications between the two groups did not differ substantially. This data was supported by another similarly run study that took place simultaneously in Australia. In this study 49% of the patients treated with hypothermia following cardiac arrest experienced good outcomes, compared to only 26% of those who received standard care.<ref>Bernard, Stephen et al. "Treatment of Comatose Survivors of Out-of-Hospital Cardiac Arrest with Induced Hypothermia." N England Journal of Medicine. (2002) Vol. 346, No. 8.</ref> ===Chest compression adjuncts=== Several different devices have become available in order to help facilitate rescuers in getting the chest compressions completed correctly. These devices can be split in to three broad groups - timing devices, those that assist the rescuer to achieve the correct technique, especially depth and speed of compressions, and those which take over the process completely. ====Timing devices==== They can feature a [[metronome]] (an item carried by many ambulance crews) in order to assist the rescuer in getting the correct rate. The CPR trainer [http://www.siliconchip.com.au/cms/A_108147/article.html cited here] has timed indicators for pressing on the chest, breathing and changing operators. ====Manual assist devices==== These items can be devices to placed on top of the chest, with the rescuers hands going over the device, and a display giving information on depth or force.<ref>{{cite web|url=http://www.cprezy.co.uk|title=CPREzy|accessdate=2007-08-18}}</ref> Several published evaluations of one particular product, known as CPREzy, with these features show that the device can improve the performance of chest compressions.<ref>{{cite journal|journal=Resuscitation|volume=64|issue=2005|title=CPREzy: an evaluation during simulated cardiac arrest on a hospital bed|first=Gavin D|last=Perkins|coauthors=Augre, Colette; Rogers, Helen;Allan, Michael; Thickett, David R|date=23rd August 2004|url=http://www.cprezy.com/PDF/CPREzy%20on%20Hosp%20Bed%20(GDP).pdf|doi=10.1016/j.resuscitation.2004.08.011)|doi_brokendate=2008-06-26}}</ref><ref>{{cite journal|journal=Resuscitation|volume=54|issue=2002|last=Boyle|first=Andrew J|coauthors=Wilson, Andrew M; Connelly, Kim; McGuigan, Louisa; Wilson, Jenny; Whitbourn, Robert|date=March 2002|title=CPREzy:an evaluation during simulated cardiac arrest on a hospital bed}}</ref> More recently, these features have also been combined in to a wearable format, as a glove.<ref>{{cite web|url=http://www.cprglove.com/|title=CPR Glove Website|accessdate=2007-08-18}}</ref> This glove also has additional features such as a basic electro-cardiogram device. This device was developed by students as part of their thesis, and has been named as one of the top ten inventions of 2007 in Popular Science magazine.<ref>{{cite web|url=http://www.popsci.com/popsci/technology/9d37485a9f492110vgnvcm1000004eecbccdrcrd.html|publisher=Popular Science Magazine|title=The glove that saves lives|last=Rosenwald|first=Mike|accessdate=2007-08-20}}</ref> Certain ZOLL defibrillation pads are capable of performing similar function, in that they may display rate and depth of compressions. Additionally, a certain algorithm allows them to monitor electrical activity even during CPR ("[http://www.zoll.com/page.aspx?id=2980 see-thruCPR]"). ====Automatic devices==== There are also some devices available which take over the chest compressions for the rescuer. These devices use techniques such as pneumatics to drive a compressing pad on to the chest of the patient. One such device, known as the LUCAS, was developed at the University Hospital of Lund, is powered by the compressed air cylinders or lines available in ambulances or in hospitals, and has undergone numerous clinical trials, showing a marked improvement in coronary perfusion pressure<ref>{{cite journal|journal=Resuscitation|last=Steen et al|title=Evaluation of LUCAS, a new device for automated mechanical compression and active decompression|date=2002|volume=55}}</ref> and return of spontaneous circulation.<ref>{{cite journal|journal=Resuscitation|volume=69|last=Rubertsson et al.|title=Increased restoration of spontaneous circulation after cardiac arrest with the LUCAS device compared to manual chest compressions|date=2006}}</ref> Another system called the [[AutoPulse]] is electrically powered and uses a large band around the patients chest which contracts in rhythm in order to deliver chest compressions. This is also backed by clinical studies showing increased successful return of spontaneous circulation.<ref>{{cite journal|last=Casner|first=M|coauthors=Anderson, D; Isaacs, SM|title=The impact of a new CPR assist device on the rate of return of spontaneous circulation in out-of-hospital cardiac arrest|journal=Prehospital Emergency Care|volume=9|issue=1|date=Jan-Mar 2005|url=http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=pubmed&dopt=AbstractPlus&list_uids=16036830&query_hl=11&itool=pubmed_docsum}}</ref><ref>{{cite journal|journal=Journal of the American Medical Association|volume=295|issue=22|last=Hallstrom|first=Al|coauthors=Rea, Thomas; Sayre, Michael; Christenson, James; Anton, Andy; Mosesso, Vince; Ottingham, Lois; Olsufka, Michele; Pennington, Sarah; White, Lynn; Yahn, Stephen; Husar, James; Morris, Mary; Cob, Leonard|title=Manual chest compression vs use of an automated chest compression device during resuscitation following out-of-hospital cardiac arrest|url=http://jama.ama-assn.org/cgi/reprint/jama;295/22/2620.pdf?ijkey=V96Oxk0wfyGibgF&keytype=finite}}</ref> ==Place in film and television== CPR is often severely misrepresented in movies and television as being highly effective in resuscitating a person who is not breathing and has no circulation. A 1996 study published in the New England Journal of Medicine showed that CPR success rates in television shows was 75%.<ref>{{cite web|url=http://content.nejm.org/cgi/content/abstract/334/24/1578|title=CPR statistics|accessdate=2007-06-13|publisher=American Heart Association}}</ref> It is important to note that CPR techniques portrayed on television and in film are purposely incorrect. Actors performing simulated CPR will keep their elbows bent, to prevent force from reaching the fictional victim's heart. As well as causing significant local [[blunt trauma|trauma]], in theory performing CPR on healthy persons may disrupt heart rhythms.<ref>{{cite web|url=http://www.cprlongisland.com|title=CPR course descriptions|accessdate=2008-02-25|publisher=CPR Long Island}}</ref> ==Application on animals== It is entirely feasible to perform CPR on animals like cats and dogs. The principles and practices are virtually identical to CPR for humans. One is cautioned to only perform CPR on unconscious animals to avoid the risk of being bitten<ref>{{cite web | title=CPR for Cats & Dogs | url=http://depts.washington.edu/learncpr/cat_dog.html | publisher=University of Washington School of Medicine}}</ref> and that animals, depending on species, have a smaller bone density than humans causing bones to become weakened after performed. ==References== {{reflist|2}} ==See also== * [[Basic Life Support]] (BLS) * [[Cardiocerebral Resuscitation]] (CCR), a similar technique. * [[CPR mask]] * [[Resusci Anne]] * [[Face shield]] * [[Advanced life support]] ==External links== *[http://www.erc.edu/ ERC European Resuscitation Council] *[http://depts.washington.edu/learncpr/ Learn CPR - University of Washington] *[http://www.akuttjournalen.com/ Akuttjournalen.com - The Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine] *[http://health.howstuffworks.com/cpr.htm How Stuff Works - CPR] {{First aid topics|state=expand}} {{Emergency medicine}} {{Lifesaving and Lifeguarding}} [[Category:Emergency medicine]] [[Category:First aid]] {{Link FA|de}} [[ar:إنعاش قلبي رئوي]] [[bs:Kardiopulmonalna reanimacija]] [[ca:Reanimació cardiopulmonar]] [[cs:Kardiopulmonální resuscitace]] [[de:Herz-Lungen-Wiederbelebung]] [[es:Reanimación cardiopulmonar]] [[fr:Réanimation cardio-pulmonaire]] [[ko:심폐소생술]] [[hr:Kardiopulmonalna reanimacija]] [[he:החייאה]] [[lt:Reanimacija]] [[nl:Reanimatie]] [[ja:心肺蘇生法]] [[no:Hjerte-lunge-redning]] [[pl:Resuscytacja krążeniowo-oddechowa]] [[pt:Reanimação cardiorrespiratória]] [[ru:Сердечно-лёгочная реанимация]] [[simple:Cardiopulmonary resuscitation]] [[sr:Кардиопулмонална реанимација]] [[fi:Painelu-puhalluselvytys]] [[sv:Hjärt- och lungräddning]] [[tr:Kalp masajı]] [[ur:قلبی رئوی احیاء]] [[yi:סי-פי-אר]] [[zh:心肺复苏术]]