Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation

    Key Words:
  • cardiac arrest
  • cardiopulmonary resuscitation
  • emergency
  • ventricular fibrillation
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1
Introduction

A variety of alternatives and adjuncts to conventional CPR have been developed, with the aim of enhancing perfusion during resuscitation from cardiac arrest.

Compared with conventional CPR, many of these techniques and devices require specialized equipment and training.

Some alternative techniques and devices have only been tested in highly selected subgroups of patients; this context must be considered when rescuers or healthcare systems are considering implementation.

2
CPR Techniques

2.1
Open-Chest CPR

In open-chest CPR the heart is accessed through a thoracotomy (typically created through the 5th left intercostal space) and compression is performed using the thumb and fingers, or with the palm and extended fingers against the sternum.

Open-chest CPR generates forward blood flow and coronary perfusion pressure that typically exceed those generated by closed chest compressions.

There is insufficient evidence of benefit or harm to recommend the routine use of open-chest CPR. (2010 Part 7)

Open-chest CPR can be useful if cardiac arrest develops during surgery when the chest or abdomen is already open, or in the early postoperative period after cardiothoracic surgery. (Class IIa, LOE C) (2010 Part 7)

A resuscitative thoracotomy to facilitate open-chest CPR may be considered in very select circumstances of adults and children with out-of-hospital cardiac arrest from penetrating trauma with short transport times to a trauma facility. (Class IIb, LOE C) (2010 Part 7)

2.2
Interposed Abdominal Compression-CPR

Interposed abdominal compression (IAC)-CPR is a 3-rescuer technique (an abdominal compressor plus the chest compressor plus the rescuer providing ventilation) that includes conventional chest compressions combined with alternating abdominal compressions.

Hand position, depth, rhythm, and rate of abdominal compressions are similar to those for chest compressions and the force required is similar to that used to palpate the abdominal aorta.

IAC-CPR increases diastolic aortic pressure and venous return, resulting in improved coronary perfusion pressure and blood flow to other vital organs.

Interposed abdominal compression-CPR may be considered during [adult] in-hospital resuscitation when sufficient personnel trained in its use are available. (Class IIb, LOE B) (2010 Part 7)

There is insufficient evidence to recommend for or against the use of interposed abdominal compression-CPR in the out-of-hospital setting or in children. (2010 Part 7)

2.3
“Cough” CPR

“Cough” CPR describes the use of forceful voluntary coughs every 1 to 3 seconds in conscious patients shortly after the onset of a witnessed non-perfusing cardiac rhythm in a controlled environment such as the cardiac catheterization laboratory.

“Cough” CPR is not useful for unresponsive victims and should not be taught to lay rescuers. “Cough” CPR may be considered in settings such as the cardiac catheterization laboratory for conscious, supine, and monitored patients if the patients can be instructed and coached to cough forcefully every 1 to 3 seconds during the initial seconds of arrhythmic cardiac arrest. It should not delay definitive treatment. (Class IIb, LOE C) (2010 Part 7)

2.4
Prone CPR

When the patient cannot be placed in the supine position, it may be reasonable for rescuers to provide CPR with the patient in the prone position, particularly in hospitalized patients with an advanced airway in place. (Class IIb, LOE C) (2010 Part 7)

2.5
Precordial Thump

The precordial thump is a sharp blow to the mid-sternum delivered with the ulnar side of the fist. The goal of the “thump” is to depolarize the heart. In the limited evidence identified for the 2010 evidence evaluation, the precordial thump produced mixed results with some serious complications reported.

The precordial thump should not be used for unwitnessed out-of-hospital cardiac arrest. (Class III, LOE C) (2010 Part 7)

The precordial thump may be considered for patients with witnessed, monitored, unstable ventricular tachycardia (VT) including pulseless VT if a defibrillator is not immediately ready for use, but it should not delay CPR and shock delivery. (Class IIb, LOE C) (2010 Part 7)

There is insufficient evidence to recommend for or against the use of the precordial thump for witnessed onset of asystole. (2010 Part 7)

2.6
Percussion Pacing

Percussion (eg, fist) pacing refers to the rescuer using a fist to provide regular, rhythmic and forceful percussion of the chest in an attempt to pace the myocardium.

There is insufficient evidence to recommend percussion pacing during typical attempted resuscitation from cardiac arrest. (2010 Part 7)

3
Ancillary CPR Devices

3.1
Active Compression-Decompression CPR

Active compression-decompression CPR (ACD-CPR) is performed with a device that includes a suction cup to actively lift the anterior chest during decompression.

There is insufficient evidence to recommend for or against the routine use of active compression-decompression-CPR. (2010 Part 7)

Active compression-decompression-CPR may be considered for use when providers are adequately trained and monitored. (Class IIb, LOE B) (2010 Part 7)

3.2
Phased Thoracic-Abdominal Compression-Decompression CPR With a Handheld Device

Phased thoracic-abdominal compression-decompression CPR combines the concepts of intra-abdominal compression-CPR and active compression-decompression-CPR. A handheld device alternates chest compression and abdominal decompression with chest decompression and abdominal compression.

There is insufficient evidence to support or refute the use of phased thoracic-abdominal compression-decompression for the treatment of cardiac arrest. (2010 Part 7)

3.3
Impedance Threshold Device

The impedance threshold device (ITD) is a pressure-sensitive valve that is attached to an endotracheal tube, supraglottic airway, or face mask. In three randomized controlled clinical trials, including a large, international trial involving nearly 9,000 patients, the addition of the ITD to standard resuscitation practice did not improve resuscitation outcomes.

The routine use of the impedance threshold device as an adjunct during conventional CPR is not recommended. (Class III: No Benefit, LOE A) (2015 Part 6)

3.4
Active Compression-Decompression CPR With the Impedance Threshold Device

Active Compression-Decompression-CPR is performed by applying a handheld device with a suction cup over the mid-sternum of the chest. After chest compression (ie, during decompression) the device is used to actively lift the anterior chest.

ACD-CPR is believed to act synergistically with the ITD to enhance venous return during chest decompression.

The existing evidence, primarily from 1 large randomized controlled trial of low quality, does not support the routine use of Active Compression-Decompression-CPR+ the Impedance Threshold Device as an alternative to conventional CPR. The combination may be a reasonable alternative in settings with available equipment and properly trained personnel. (Class IIb, LOE C-LD) (2015 Part 6)

3.5
Mechanical Chest Compression Devices: Piston Device

A mechanical piston device consists of an automated compressed gas- or electric-powered plunger positioned over the sternum. The piston compresses the chest at a set rate.

The evidence does not demonstrate a benefit with the use of mechanical piston devices for chest compressions versus manual chest compressions in patients with cardiac arrest. Manual chest compressions remain the standard of care for the treatment of cardiac arrest, but mechanical piston devices may be a reasonable alternative for use by properly trained personnel. (Class IIb, LOE B-R) (2015 Part 6)

The use of mechanical piston devices may be considered in specific settings where the delivery of high- quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for extracorporeal CPR [ECPR]), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices. (Class IIb, LOE C-EO) (2015 Part 6)

3.6
Load-Distributing Band Devices

The load-distributing band is a circumferential chest compression device composed of a pneumatically or electrically actuated constricting band and backboard.

The evidence does not demonstrate a benefit with the use of Load Distributing Band-CPR for chest compressions versus manual chest compressions in patients with cardiac arrest. Manual chest compressions remain the standard of care for the treatment of cardiac arrest, but Load Distributing Band-CPR may be a reasonable alternative for use by properly trained personnel. (Class IIb, LOE B-R) (2015 Part 6)

The use of Load Distributing Band-CPR may be considered in specific settings where the delivery of high-quality manual compressions may be challenging or dangerous for the provider (eg, limited rescuers available, prolonged CPR, during hypothermic cardiac arrest, in a moving ambulance, in the angiography suite, during preparation for Extracorporeal CPR), provided that rescuers strictly limit interruptions in CPR during deployment and removal of the devices. (Class IIb, LOE C-EO) (2015 Part 6)

4
Extracorporeal CPR

The term ECPR is used here to describe the initiation of cardiopulmonary bypass (extracorporeal membrane oxygenator therapy or ECMO) during the resuscitation of a patient in cardiac arrest.

ECPR is a complex process that requires a highly trained team, specialized equipment, and multidisciplinary support within the local healthcare system.

Published series have used rigorous inclusion and exclusion criteria to select patients for ECPR. Although these inclusion criteria are highly variable, most included only patients aged 18 to 75 years, with arrest of cardiac origin, after conventional CPR for more than 10 minutes without ROSC. Such inclusion criteria should be considered in a provider’s selection of potential candidates for ECPR.

There is insufficient evidence to recommend the routine use of Extracorporeal CPR for patients with cardiac arrest. (2019 ACLS)

Extracorporeal CPR may be considered for selected [adult] patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers.
(Class IIb, LOE C-LD) (2019 ACLS)

See Part 14 and the 2019 Pediatric Advanced Life Support Guidelines Update for the most recent recommendations regarding use of ECPR in infants and children.

5
Devices to Assist Ventilation

5.1
Automatic Transport Ventilators

There are few studies evaluating the use of automatic transport ventilators during attempted resuscitation.

During prolonged resuscitation efforts, the use of an automatic transport ventilator (pneumatically powered and time- or pressure- cycled) may provide ventilation and oxygenation similar to that possible with the use of a manual resuscitation bag, while allowing the Emergency Medical Services (EMS) team to perform other tasks. (Class IIb, LOE C) (2010 Part 7)

Automatic transport ventilators require both a power source and an oxygen source. Providers should always have a bag-mask device available for manual backup.

5.2
Manually Triggered, Oxygen-Powered, Flow-Limited Resuscitators

The available data regarding the effectiveness of manually triggered, oxygen-powered, flow-limited resuscitators includes a report of successful ventilation of patients with masks (ie, without advanced airways) who were not in cardiac arrest.

Manually triggered, oxygen-powered, flow-limited resuscitators may be considered for the management of patients who do not have an advanced airway in place and for whom a mask is being used for ventilation during CPR. (Class IIb, LOE C) (2010 Part 7)

Rescuers should avoid using the automatic mode of the oxygen-powered, flow-limited resuscitator during CPR because it may generate high positive end-expiratory pressure (PEEP) that may impede venous return during [and between] chest compressions and compromise forward blood flow. (Class III, LOE C) (2010 Part 7)

6
Authorship and Disclosures

6.1
2015 Writing Team

Steven C. Brooks, Chair; Monique L. Anderson; Eric Bruder; Mohamud R. Daya; Alan Gaffney; Charles W. Otto; Adam J. Singer; Ravi R. Thiagarajan; Andrew H. Travers

Table 1: Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation: 2015 Guidelines Update Writing Group Disclosures

6.2
2010 Writing Team

Diana M. Cave, Chair; Raul J. Gazmuri; Charles W. Otto; Vinay M. Nadkarni; Adam Cheng; Steven C. Brooks; Mohamud Daya; Robert M. Sutton; Richard Branson; Mary Fran Hazinski

Table 2: 2010 - Guidelines Part 7: CPR Techniques and Devices: Writing Group Disclosures

7
Footnotes

The American Heart Association requests that this document be cited as follows:

American Heart Association. Web-based Integrated Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation. ECCguidelines.heart.org

© Copyright 2015 American Heart Association, Inc.

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References