First Things First (assess & treat for the following)

Definition

• Cardiopulmonary Resuscitation (CPR) has the mnemonic “ABC” for airway/breathing/circulation. There is a new paradigm emphasizing circulation as the most important component of ABC, at least in primary cardiac arrest. Cardiocerebral Resuscitation (CCR) or Continuous Chest Compression-CPR (CCC-CPR) is developed from this paradigm. Aim of CCR is to put maintenance of coronary and cerebral circulation as a priority, minimizing interruptions for intubation, ventilation, defibrillation, etc. of the patient.
• At present, CCR should be seen as a refinement of the broad resuscitation efforts of the arrest victim, but not as an alternative to traditional CPR algorithms. The ultimate goal of CPR is a good neurological outcome. This is possible by maintaining adequate cerebral and coronary perfusion in a timely fashion, the main emphasis of the CCR concept.

Pathophysiology

• CPR is the common approach to two different pathophysiologic conditions: primary cardiac arrest (i.e., due to arrhythmias) and cardiac arrest secondary to respiratory failure. Most of the cases of sudden, unexpected collapse are likely to be due to primary cardiac arrest. Cardiac arrest secondary to ventricular fibrillation has three phases:
  • Electrical phase: The first 5 minutes of cardiac arrest, where defibrillation is the most important intervention. This is the rationale behind the availability of AEDs in public places (e.g., airports, casinos).
  • Circulatory phase: Roughly between 5 and 15 minutes after cardiac arrest. For a good neurological recovery, effective chest compressions are needed before and after defibrillation efforts. If coronary perfusion is inadequate, even a successful defibrillation is likely to result in pulseless electrical activity.
  • Metabolic phase: Starting 15 or so minutes after cardiac arrest, metabolic effects due to lack of perfusion becomes pronounced. New concepts, such as hypothermia, are needed to improve survival of the victim during this phase.