Basic Life Support is Critical to Successful Cardiopulmonary Resuscitation

By James C. Phero, DMD

Over the past 50 years, modern cardiopulmonary resuscitation (CPR) has evolved to incorporate the fundamentals of prompt recognition and management to include early chest compressions, ventilation, defibrillation, and access to emergency medical services (EMS). This issue of Inside Dentistry is well timed with the 2010 American Heart Association (AHA) update on CPR Guidelines which provides our profession with a practical and effective approach to initiating basic life support (BLS) in the dental office.¹ The AHA continues to place an emphasis on our providing effective BLS CPR that includes: chest compressions of adequate rate and depth, allowing complete chest recoil, minimizing interruptions in chest compressions, and maintaining ventilation at one breath every 6 seconds.

These updated 2010 Guidelines changed the BLS sequence of steps from A–B–C–D (Airway, Breathing, Chest compressions, Defibrillation) to C–D–A–B (Chest compressions, Defibrillation, Airway, Breathing) for adults and pediatric patients (children and infants). The highest survival rates from cardiac arrest are reported with witnessed arrest and a rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).² The critical initial elements of BLS CPR for these patients are immediate chest compressions and early defibrillation.³ By changing the sequence to C–D–A–B, chest compressions and Automated External Defibrillator (AED) evaluation of the patient’s need for defibrillation will be initiated sooner and ventilation only minimally delayed until completion of the first cycle of chest compressions, as 30 compressions will be accomplished in approximately 18 seconds while the AED is being attached.

The updated Guidelines emphasize immediate activation of EMS and starting chest compressions for any unresponsive adult victim with no breathing or no normal breathing (ie, only gasps). “Look, Listen, and Feel” has been eliminated from the algorithm due to rescuer performance being inconsistent and time-consuming. Adult chest compressions have been increased to a depth of at least 2 inches with the chest permitted to completely recoil to permit maximal filling of the heart before the next compression is started.

Many tasks performed by the dental team during resuscitation—including chest compressions, AED placement/rhythm evaluation/shock delivery, airway management, breathing, and drug administration (if appropriate)—can be performed concurrently if the office team is trained and integrated. We should remember that improvement of competence and retention of skills in emergency management should include repeated team participation in life-support courses that have been standardization and designed to meet the team’s needs.^4,5 Ongoing AHA BLS and ACLS dental healthcare provider training and medical emergency crisis resource management (CRM) team training programs are being developed by the American Dental Association, the American Dental Society of Anesthesiology, the American Association of Oral and Maxillofacial Surgeons, and the American Academy of Pediatric Dentistry to optimize the dental team’s efforts as discussed in the team management section of this issue.

While the AHA has worked to simplify BLS and Advanced Cardiac Life Support (ACLS) Guidelines, the importance of office team training and preparedness can be seen in the CPR scenario presented here. Given that most dental offices can access EMS services within 10 minutes, the following timing for incorporation of BLS in the dental office represents appropriate care of a patient requiring office CPR. A summary of this BLS scenario can be found at www.dentalaegis.com/id.

Note: The dentist serves as the CPR team leader. The most experienced member of the office staff may need to cover in this role if the dentist is absent or incapacitated. Also as supported by the AHA 2010 Guidelines, the CPR leader may need to adapt the application of this resuscitation approach to unique circumstances. This scenario presumes a team of four members for providing CPR. With less staff available, the team leader will adjust CPR assignments. Additionally, the office team should be prepared and trained to provide CPR to the patient, a patient’s family member/escort, or an actual staff member in all office settings, not just the operatory.

Minute 0

The patient is witnessed to collapse and is verified by the dentist as unresponsive. The dentist announces that the situation is an emergency requiring outside EMS and directs Auxiliary 2 to call for EMS and to get the AED, respiratory equipment, back board, oxygen, and emergency drugs (if appropriate) if these are not already present.

Auxiliary 2 calls EMS and announces that EMS has been contacted. The “10-Minute Clock” for arrival of EMS at the office begins.

The dentist may take up to 10 seconds to verify that there is no carotid pulse. The dentist places the patient in a position to begin chest compressions and starts compressions at a depth of at least 2 inches and a rate of 100/minute with good chest recoil. An emergency in the dental operatory requiring chest compressions presents the concern of placing the patient on the floor or providing the compressions in the dental chair. If the patient can be moved onto the floor for chest compressions easily and without delay, this would be optimal. If due to patient size and/or operatory design, the patient cannot be readily and safely placed on the floor, the dentist may consider the placement of a stool under the upper portion of the dental chair to help stabilize the chair for chest compressions.^6,7 If the patient remains in the dental chair, a back board may also help to optimize chest compressions. Again, the goal of chest compressions is to compress the chest at least 2 inches at a rate of 100/minute with complete chest recoil occurring after each compression.

Minute 1 to 3

As soon as the AED is present, Auxiliary 2 turns on the AED and follows the unit’s verbal prompts. Per AED verbal instructions, chest compressions are stopped as the AED analyzes if the patient has a shockable rhythm.

Shock advised: If the rhythm is shockable (ventricular fibrillation or pulseless ventricular tachycardia), the AED will automatically charge and instruct the dentist when to press the AED button to defibrillate patient.

No Shock advised: If the rhythm is not shockable (pulseless electrical activity [PEA] or asystole), no shock is indicated.

Per the AED’s verbal instructions, Auxiliary 2 immediately resumes chest compressions. Due to the physically taxing nature of providing proper chest compressions, office team training should include alternating the staff member delivering chest compressions with each 2-minute CPR cycle.

Once the resuscitation bag, mask, oral airway, and oxygen are available, the dentist opens the patient’s airway with a head tilt and jaw lift maneuver, places an oral airway, and proceeds with two-person bag mask ventilation, where either Auxiliary 1 or Auxiliary 2 holds the mask for a good seal and the dentist provides the ventilation. Initially, two rescue breaths with the bag, mask, and oral airway are given and checked that the breaths are going into the lungs. Ventilation is performed using a resuscitation bag attached to an oxygen flow of 15 liters/minute where possible. As the patient is unconscious, an oral airway helps open the airway for ventilation. An acceptable adult breath is ~ one-half the 1-liter adult resuscitation bag. When using the face mask, the inspiratory pressure from squeezing the bag should not exceed 20 mm Hg or the epiglottis will be forced down, close the glottis, and the volume of the bag squeeze will enter and pressurize the gastric contents of the stomach potentially leading to pressurized vomiting and lung aspiration. Resuscitation bags with built in pressure gauges to monitor pressure are useful to prevent this situation. When pressures over 20 mm Hg are needed (ie, obesity, emphysema, bronchospasm) and/or CPR chest compressions are required, the dentist should consider use of an advanced airway such as an Laryngeal Mask Airway (LMA) or endotracheal intubation. While endotracheal intubation is an advanced airway option for the anesthesia provider, the LMA is an advanced airway option that all dentists can easily and rapidly insert.

Initially the 2-minute cycle of chest compressions and ventilations are coordinated at a ratio of 30 chest compressions to two bag-mask breaths for five cycles. This becomes continuous chest compressions and ventilations with one breath every 6 seconds if using an LMA or endotracheal tube. Thus, an advanced airway provides 50 additional chest compressions per 2-minute cycle over mask ventilation with no restrictions on limiting ventilation pressure (see Table 1).

Once the AED has been turned on, the AED timer will verbally announce when each 2-minute cycle has passed.

If office training includes intravenous (IV)/intraosseous (IO) therapy and drug administration, IV/IO access is initiated and the ACLS algorithm of drug therapy is started. ACLS drug therapy will be initiated with arrival of EMS if not already started. Drug therapy is not discussed as part of this BLS discussion.

Note: pulse and rhythm are not checked after defibrillation. With an AED or electrocardiogram (ECG) monitoring, the pulse is checked at the end of each 2-minute cycle while ECG rhythm is being analyzed.

Auxiliary 4 (if there is a fourth auxiliary available) is dispatched to the main entry of the office to look for and direct EMS to the emergency scene.

Minute 3 to 5

Per the AED’s verbal instructions, chest compressions are stopped while the AED analyzes whether the patient has a shockable rhythm. The dentist checks if the carotid pulse is present while the AED analyzes the patient’s cardiac rhythm.

No Shock advised: If the rhythm is not shockable (pulseless electrical activity [PEA] or asystole), no shock is indicated.

Per the AED’s verbal instructions, chest compressions and ventilations are restarted using different staff member(s).

Minute 5 to 7

Per the AED’s verbal instructions, chest compressions are stopped while the AED analyzes if the patient has a shockable rhythm. The dentist checks to see if the carotid pulse is present while the AED analyzes the patient’s cardiac rhythm.

No Shock advised: If the rhythm is not shockable (pulseless electrical activity [PEA] or asystole), no shock is indicated.

Per the AED’s verbal instructions, chest compressions and ventilations are restarted using different staff member(s).

Minute 7 to 9

Per the AED’s verbal instructions, chest compressions are stopped while the AED analyzes whether the patient has a shockable rhythm. The dentist checks to see if the carotid pulse is present while the AED analyzes the patient’s cardiac rhythm.

No Shock advised: If the rhythm is not shockable (pulseless electrical activity [PEA] or asystole), no shock is indicated.

Per the AED’s verbal instructions, chest compressions and ventilations are restarted using different staff member(s).

Minute 9 to 11

No Shock advised: If the rhythm is not shockable (pulseless electrical activity [PEA] or asystole), no shock is indicated.

Per the AED’s verbal instructions, chest compressions and ventilations are restarted using different staff member(s).

Minute 10

EMS arrives and assists in the evaluation and management of the patient. The dentist will update EMS on the CPR efforts taken and any background patient information available. Once the patient is handed off to EMS, they will direct patient care and transport to the hospital. Note that EMS will initiate ACLS if not already started to include an advanced airway, intravenous/intraosseous access for fluid and drug administration, and administration of drugs.

References

1. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science. Circulation. 2010;122:S640-S656.

2. Hazinski MF, et al. Part 1: Executive Summary: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2010;122 (Suppl 2):S250-S275.

3. Rea TD, et al. Predicting survival after out-of-hospital cardiac arrest: role of the Utstein data elements. Ann Emerg Med. 2010;55:249-257.

4. Müller MP, Hänsel M, Stehr SN, et al. A state-wide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emerg Med J. 2008; 25:296-300.

5. Kardong-Edgren SE, Oermann MH, Odom-Maryon T, Ha Y. Comparison of two instructional modalities for nursing student CPR skill acquisition. Resuscitatio. 2010;81:1019-1024.

6. Laurent F, Segal N, Augustin P. Chest compression: Not as effective on dental chair as on the floor. Resuscitation. 2010;81(12):1729.

7. Fujino H, Yokoyama T, Yoshida K, and Suwa K. Using a stool for stabilization of a dental chair when CPR is required. Resuscitation. 2010;81 (12):1729.

About the Author

James C. Phero, DMD
Professor of Clinical Anesthesiology, Pediatrics, and Surgery
College of Medicine
University of Cincinnati Academic Medical Center
Cincinnati, Ohio