05 Jun Life-Sustaining Treatments – The Big Three: CPR, Mechanical Ventilation, and Feeding Tubes: Part 1
Life-Sustaining Treatments (LSTs) Part 1: Cardiopulmonary Resuscitation
CPR stands for cardiopulmonary resuscitation. CPR is a medical procedure used in an emergency when a person experiences cardiac arrest. It involves someone pushing on the chest with their hands (chest compressions), artificial breathing using mouth-to-mouth respirations or a mask attached to a small bag to push air into the lungs, medications to stimulate the heart, and a machine that delivers electrical shocks to the chest (defibrillator).
Attempts to revive a person whose heart has stopped date back to the 18th century when the Scottish surgeon William Tossach used mouth-to-mouth breaths to save a suffocated coal miner, but it was not until the early 1960’s when Dr. William Kouwenhoven and his team at John’s Hopkins developed an external defibrillator, the 200-pound Hopkins Closed Chest Defibrillator, that cardiopulmonary resuscitation became the standard for managing cardiac arrest. In 1963 the American Heart Association formally endorsed CPR.
If a person is in cardiac arrest, breathing stops as well. Blood stops flowing throughout the body, and oxygen cannot get to the brain. The brain can survive without oxygen for only about five minutes. After that point a person will have some brain damage even if their heart started again.
Cardiac arrest can be expected or unexpected. It is expected as a normal part of the natural dying process. It can also happen unexpectedly because of sudden, severe illness or injury or due to a heart problem that a person may or may not have known about. CPR can save lives, especially when given to an otherwise healthy person immediately after the heart stops.
The chances of surviving are better if CPR is started quickly after the heart stops. For in-hospital cardiac arrest, CPR works about half of the time, but only 17 out of 100 people who receive CPR in the hospital survive to be discharged. Despite wide-spread availability of CPR training, only half of by-standers state that they would be willing to attempt CPR. Only 10% of people who receive out-of-hospital CPR survive. For people with chronic heart, lung, liver, or kidney disease and metastatic cancer, about half the number of people will survive.
The word “resuscitation” has been problematic. As a general term it means any maneuvers intended to revive an unconscious person, but in CPR it is more specific: the unconscious person is clinically dead, being without a pulse and not breathing.
Healthcare staff automatically start CPR when a person goes into cardiac arrest unless there is a Do Not Resuscitate (DNR) order. In some places, this order is called DNAR (Do Not Attempt Resuscitation). With either a DNR or DNAR order healthcare staff will not do CPR in the event of cardiac arrest. It is important to understand that DNR/DNAR applies ONLY to the circumstance where a person has no pulse and is not breathing. Choosing not to have CPR should not affect options for other life-sustaining treatments such as blood transfusions, vasopressors, IV fluids, antibiotics, artificial nutrition, mechanical ventilation, and dialysis.
If a person survives CPR, they may have a sore chest or broken ribs because of the chest compressions. They may have a collapsed lung requiring placement of a chest tube. If there was not enough blood and oxygen circulating to vital organs, there may be brain, liver, and kidney problems afterward. The majority of people who survive CPR will initially need to be on a ventilator in an intensive care unit. This is why people cannot have life-sustaining treatment orders for no mechanical ventilation if they choose to have CPR.
Cardiopulmonary resuscitation is a potentially life-saving medical procedure. Chances of recovery after CPR depends on whether cardiac arrest occurs inside or outside of a hospital and also on a person’s overall condition and how many other medical problems they have.