**2.1 Bystander CPR**

During an event of cardiac arrest, sooner the temporary circulation is reestablished via chest compression, better are the chances of survival with good neurological function [2]. Clinical studies have shown an increase in survival if the victim receives early resuscitation including defibrillation. The analysis showed a four times increase in chance of survival in victims who received an early bystander CPR [3], which can be achieved if the bystander starts CPR by the time the professional rescuer team arrives at the site. Hence, it is encouraged to promote this critical aspect in our basic cardiopulmonary life support management to cardiac arrest victims through public awareness campaigns. Surveys among medical and public groups have shown the declining rates of bystander CPR. The primary reason was the apprehension of contracting the contagious disease and causing harm during the process [4, 5].

Since 1990, a simpler version of "chest compression-only" CPR is being explored for bystanders. A new concept came into the picture: cardiocerebral resuscitation. It emphasizes that circulation is more important than ventilation during the early efforts of resuscitation. One survey showed that it is more acceptable among the common public [6]. It has been reported that "chest compression-only" CPR or compression-only life support (COLS) is a viable option for providing immediate resuscitation by bystanders with an improved overall outcome as compared to no CPR [7].

## **2.2 CPR (dispatcher-assisted)**

Emergency medical dispatcher services are crucial links in emergency health services [8, 9]. They are the first responders of an emergency call. Their role involves identifying the emergency, guiding the bystander and simultaneously dispatching an emergency medical service (EMS). Internationally, various strategies have been explored to increase the rate of bystander CPR. One of such strategies is to enhance the role of the emergency medical dispatchers and comprises services like giving CPR instructions to assist bystanders: dispatcher-assisted CPR (DA-CPR). For this system to work effectively, there is a need for optimal training of the dispatchers for providing instructions to bystanders to deliver CPR. EMS system needs to be configured to support DA-CPR. This strategy can have a positive impact on point of care instructions. It increases the feasibility of bystander CPR and improves the outcome of cardiac arrest outside the hospital.

If we combine the above-mentioned strategies of early bystander CPR and DA-CPR, the results can be promising. This will result is the early restoration of circulation and better neurological outcomes. It will be more acceptable by the bystanders to provide only chest compression as mouth to mouth breathing is either not acceptable or not performed appropriately delaying chest compression. A recent meta-analysis has demonstrated the beneficial survival outcome DA-CPR [10]. The recent international consensus strongly recommends that emergency medical dispatch service centers have a proper system to support DA-CPR services [11].

**3**

*Cardiopulmonary Resuscitation: Recent Advances DOI: http://dx.doi.org/10.5772/intechopen.91866*

**2.3 Cardiocerebral resuscitation (CCR)**

is done before chest compression in such cases [17].

worsening the perfusion of vital organs [21].

quality chest compressions before defibrillation.

**3.2 Analysis during compressions with fast reconfirmation**

**(pVT): debrillation**

**3.1 Early vs. late rhythm analysis**

The concept was cardiocerebral resuscitation was first developed by the University of Arizona Saver Heart Center Resuscitation Group [3, 12–15]. The original idea had three components which include continuous chest compression by bystanders, EMS advanced cardiac life support, and aggressive post-resuscitation care. The notion of CCR involves chest compressions only and avoiding mouth to mouth ventilation in cases of witnessed cardiac arrest. The basis of this model was a three-phase time-sensitive model of cardiac arrest for ventricular fibrillation by Weisfeldt and Becker [16]. The first phase is the electric phase that lasts less than 4 min and the appropriate intervention is defibrillation followed by ventilation. The second phase is the circulatory phase (4–15 min) when the fibrillating heart has consumed all of the energy stores. During this phase, it is preferable to start with chest compression followed by defibrillation to perfuse the myocardium and reduce metabolic acidosis which in turn increases the success of defibrillation. There is a high possibility of developing asystole or pulseless electrical activity if defibrillation

Considering the above discussion, the main question arises if the rescue breaths are a misnomer? Recent data has shown a decrease in survival among patients with bystander initiated rescue effort with assisted-ventilation, especially in a subset of patients who are at a greater chance of survival like witnessed cardiac arrest and shockable rhythm [18, 19]. There are many drawbacks of mouth to mouth resuscitation like the decreased willingness of bystander, inability to deliver optimal rescue breaths by lay-person along with long interruptions to chest compressions during cardiac arrest [20]. Even if interruptions are minimal, positive pressure ventilation increases the intrathoracic pressure, decreasing the venous return, eventually

There are two subsets of cardiac arrest: primary cardiac arrest with arterial blood-rich in oxygen and other being secondary to respiratory arrest with deoxygenated arterial blood [3]. Above approach may not be very useful in the later.

**3. Ventricular fibrillation (VF) and pulseless ventricular tachycardia** 

Rhythm analysis is an important component of the CPR algorithm. It helps us to determine further course of action based upon the type of rhythm: shockable or non-shockable. No specific time frame is given to check the rhythm by the currently available literature. A randomized control trial was conducted to compare the impact of brief interval 30–60 s versus long interval of 120 s of chest compression before rhythm analysis in OHCA [22]. It was concluded that the duration for rhythm analysis is to be decided by the EMS team based on local circumstances. It is usually preferable to have an early rhythm analysis in cases where bystander CPR was given before EMS arrival. The authors also emphasized on delivering high-

There is a need for rhythm analysis intermittently while performing CPR. Chest

compressions can create artifacts that make it difficult to analyze the rhythm. [23]. Thus, interruptions of chest compressions (CCs) are mandatory during

*Sudden Cardiac Death*

**2. Basic life support**

**2.1 Bystander CPR**

the process [4, 5].

CPR [7].

**2.2 CPR (dispatcher-assisted)**

tried and tested ideas together, applying them for treatment for cardiac arrest. This chapter focuses on ideas and the innovative techniques, analyze their efficacy, and

During an event of cardiac arrest, sooner the temporary circulation is reestablished via chest compression, better are the chances of survival with good neurological function [2]. Clinical studies have shown an increase in survival if the victim receives early resuscitation including defibrillation. The analysis showed a four times increase in chance of survival in victims who received an early bystander CPR [3], which can be achieved if the bystander starts CPR by the time the professional rescuer team arrives at the site. Hence, it is encouraged to promote this critical aspect in our basic cardiopulmonary life support management to cardiac arrest victims through public awareness campaigns. Surveys among medical and public groups have shown the declining rates of bystander CPR. The primary reason was the apprehension of contracting the contagious disease and causing harm during

Since 1990, a simpler version of "chest compression-only" CPR is being explored for bystanders. A new concept came into the picture: cardiocerebral resuscitation. It emphasizes that circulation is more important than ventilation during the early efforts of resuscitation. One survey showed that it is more acceptable among the common public [6]. It has been reported that "chest compression-only" CPR or compression-only life support (COLS) is a viable option for providing immediate resuscitation by bystanders with an improved overall outcome as compared to no

Emergency medical dispatcher services are crucial links in emergency health services [8, 9]. They are the first responders of an emergency call. Their role involves identifying the emergency, guiding the bystander and simultaneously dispatching an emergency medical service (EMS). Internationally, various strategies have been explored to increase the rate of bystander CPR. One of such strategies is to enhance the role of the emergency medical dispatchers and comprises services like giving CPR instructions to assist bystanders: dispatcher-assisted CPR (DA-CPR). For this system to work effectively, there is a need for optimal training of the dispatchers for providing instructions to bystanders to deliver CPR. EMS system needs to be configured to support DA-CPR. This strategy can have a positive impact on point of care instructions. It increases the feasibility of bystander CPR

If we combine the above-mentioned strategies of early bystander CPR and DA-CPR, the results can be promising. This will result is the early restoration of circulation and better neurological outcomes. It will be more acceptable by the bystanders to provide only chest compression as mouth to mouth breathing is either not acceptable or not performed appropriately delaying chest compression. A recent meta-analysis has demonstrated the beneficial survival outcome DA-CPR [10]. The recent international consensus strongly recommends that emergency medical dispatch service centers have a proper system to support

and improves the outcome of cardiac arrest outside the hospital.

bring forward the latest updates to improve the CPR outcome.

**2**

DA-CPR services [11].

### **2.3 Cardiocerebral resuscitation (CCR)**

The concept was cardiocerebral resuscitation was first developed by the University of Arizona Saver Heart Center Resuscitation Group [3, 12–15]. The original idea had three components which include continuous chest compression by bystanders, EMS advanced cardiac life support, and aggressive post-resuscitation care. The notion of CCR involves chest compressions only and avoiding mouth to mouth ventilation in cases of witnessed cardiac arrest. The basis of this model was a three-phase time-sensitive model of cardiac arrest for ventricular fibrillation by Weisfeldt and Becker [16]. The first phase is the electric phase that lasts less than 4 min and the appropriate intervention is defibrillation followed by ventilation. The second phase is the circulatory phase (4–15 min) when the fibrillating heart has consumed all of the energy stores. During this phase, it is preferable to start with chest compression followed by defibrillation to perfuse the myocardium and reduce metabolic acidosis which in turn increases the success of defibrillation. There is a high possibility of developing asystole or pulseless electrical activity if defibrillation is done before chest compression in such cases [17].

Considering the above discussion, the main question arises if the rescue breaths are a misnomer? Recent data has shown a decrease in survival among patients with bystander initiated rescue effort with assisted-ventilation, especially in a subset of patients who are at a greater chance of survival like witnessed cardiac arrest and shockable rhythm [18, 19]. There are many drawbacks of mouth to mouth resuscitation like the decreased willingness of bystander, inability to deliver optimal rescue breaths by lay-person along with long interruptions to chest compressions during cardiac arrest [20]. Even if interruptions are minimal, positive pressure ventilation increases the intrathoracic pressure, decreasing the venous return, eventually worsening the perfusion of vital organs [21].

There are two subsets of cardiac arrest: primary cardiac arrest with arterial blood-rich in oxygen and other being secondary to respiratory arrest with deoxygenated arterial blood [3]. Above approach may not be very useful in the later.
