Realistic explanation of CPR

[Kteichow]

Hello everyone, this is my first time posting.

I do admissions at a subacute rehab facility, and one aspect of my position is getting a code status signed. I see mainly older adult patients and their families; some who want everything done to their 80-90 year old family member who is frail and probably wouldn't survive. Often people will ask 'Will chest compressions break the ribs/do you have to break the ribs?' or I will also get asked 'Can you just use the paddles instead of doing compressions?' I tell them that more than likely the ribs will break, and there is no such thing as CPR without doing compressions. I feel like it does not always get the realistic picture across of what really happens during a code.

My question is how do you realistically explain CPR to patients and their families about ribs being broken and the logistics of what happens during a code? Thank you!

[akulahawkRN, ADN, RN, EMT-P]

CPR is necessarily a bit violent. If the patient is an adult or even an older adult, chances are very good that some rib fractures will occur. My first CPR experience pretty much separated the sternum from the ribs and started free floating after the 2nd compression. The majority of the time the efforts are not successful and often if it is, there's neurological problems afterward. I've had only one or two "saves" where the patient was able to walk out of the hospital basically neurologically intact. That's the reality. Injuries sustained during CPR is, relatively speaking, a bit of a more minor thing than death. Significant injury can, however, occur during CPR.

As far as using "the paddles" you can say that they're only useful when the heart is in one of two rhythms and they don't actually restart the heart so doing paddles-only doesn't work. The family pretty much has two realistic options: all, or nothing.

[Meriwhen, ASN, BSN, MSN, RN]

In addition to all of what the PP posted, mention the fact that only about 25% of CPR patients survive resuscitation efforts (that stat was from my ACLS instructor in class, so I can't provide a reference).

And "survive" doesn't necessarily mean "unscathed"--PP nailed that perfectly.

Not saying you should lead all your patients' families down the DNR path...just that they all should be aware that the odds are not ever in their favor.

[CalArmy]

I go the route of talking about how it is not like on TV. I don't necessarily talk about ribs breaking but go into the fact that at 80-90 most people will not survive a code. That it is very traumatic for the family and you most likely will end up with the same end result. It's sad because their loved one in their 90s doesn't want to live with aggressive measures but their family will not let go.

[Double-Helix, BSN, RN]

As far as using "the paddles" you can say that they're only useful when the heart is in one of two rhythms and they don't actually restart the heart so doing paddles-only doesn't work. The family pretty much has two realistic options: all, or nothing.

Care to clarify what you mean by this? Defibrillation, (used when the myocardiocytes are firing electrical impulses in an unsynchronized or disorganized manner) uses a jolt of electricity to interrupt this abnormal firing. This creates a collective myocardiocyte pause, with the hope that the spontaneous electrical impulses of the cardiac muscle will resume in an organized rhythm, allowing for ROS” or return of spontaneous circulation. CPR (compressions) manually circulate blood to perfuse the brain tissue while the heart is unable to do so on its own. Defibrillation has been shown to be the single most effective intervention to achieve ROS- more effective than CPR without defibrillation or vasoactive medications. I'm curious what your rationale is when you say defibrillation doesn't actually restart the heart” and doing paddles-only doesn't work."

Did you mean that defibrillation isn't useful for asystole? There was a recent post where someone thought that defibrillation stopped the heart, and compressions restarted it. I ask for clarification to make sure that no one reads this part of your post and thinks the same.

[akulahawkRN, ADN, RN, EMT-P]

Care to clarify what you mean by this? Defibrillation, (used when the myocardiocytes are firing electrical impulses in an unsynchronized or disorganized manner) uses a jolt of electricity to interrupt this abnormal firing. This creates a collective myocardiocyte pause, with the hope that the spontaneous electrical impulses of the cardiac muscle will resume in an organized rhythm, allowing for ROS” or return of spontaneous circulation. CPR (compressions) manually circulate blood to perfuse the brain tissue while the heart is unable to do so on its own. Defibrillation has been shown to be the single most effective intervention to achieve ROS- more effective than CPR without defibrillation or vasoactive medications. I'm curious what your rationale is when you say defibrillation doesn't actually restart the heart” and doing paddles-only doesn't work."

Did you mean that defibrillation isn't useful for asystole? There was a recent post where someone thought that defibrillation stopped the heart, and compressions restarted it. I ask for clarification to make sure that no one reads this part of your post and thinks the same.

What defibrillation and synchronized cardioversion do is electrically stimulate all of the cardiomyocytes into depolarization. In effect, you cause them all to contract and go into pause. In effect, defibrillation stuns the heart, causing it to stop doing whatever it was doing. Hopefully the SA node then begins to depolarize in an organized manner and the rest of the cardiomyocytes follow along instead of contracting in a more disorganized manner. In effect, hopefully you achieve ROSC with this. This intervention has been shown to be very effective (up to 90% or so) when delivered very early on.

However this is only effective for Ventricular Fibrillation and Pulseless Ventricular Tachycardia. With VT, synch cardioversion is preferred because the shock will be delivered at a very specific point in the cycle which both increases the chance of the cardiomyocytes depolarizing without much risk of triggering VF via "R on T" during repolarization. The other rhythms the heart does are all basically organized rhythms and our interventions are designed to slow the heart down, speed it up, make it contract harder, change preload or afterload, all with the goal of improving circulation. If you have defibrillation pads and not paddles, your defibrillator will also often have a pacemaker function. The electrical waveform is optimized for stimulating cardiomyocytes but skeletal muscle will also be stimulated when you use the pacer. The pacer function is used in an overdrive manner to take over for the SA node. Done correctly you can slow a heart down or, far more commonly, speed it up. The energy needed to do this is far lower than what's used for defibrillation/cardioversion and in asystole, will only be even potentially effective if employed very early on. Yes, I do know to use a TENS unit or an electrical stim machine used in physical therapy as a pacer, it can be done and I hope I never have to resort to using one of those machines in this manner.

Lay people often do NOT understand that "the paddles" are really of limited use and can only really be used with VF and pulseless VT and those rhythms will degenerate to asystole fairly quickly. On TV and in the movies, "we" shock the patient and miraculously the patient's heart restarts and all is good in the world.

What does CPR do? Well, quite simply put, it's an attempt to provide artificial circulation to keep certain body parts perfused and viable. In particular, we want to perfuse the myocardium so that those wonderful cardiomyocytes have oxygen and glucose provided to them so they can return to aerobic metabolism and begin to do their job again. CPR only provides about 30% of normal flow... so that's one reason why it's not very effective and why we have to do compressions hard, fast, and as continuously as possible. Now if we were to do internal cardiac massage, we can get up to about 80-85% of normal flow... but not many of us are trained in doing thoracotomies in order to perform ICM. So CPR is all about attempting to maintain some minimal perfusion in order to allow the myocardium to be able to function again and begin perfusing the rest of the body as it normally should.

What's the OHCA save rate? Maybe around 10%. If high quality CPR is quickly instituted, that can bounce to between 30 and 50%. Often the down-time is unknown or is a bit extended before someone can start CPR. In-hospital "save" rates tend to be higher because CPR and ACLS can be started very, very quickly as nearly everyone is trained in CPR and ACLS trained personnel are very close by, usually.

Is that perhaps enough info? I hope so... I pretty much dumbed-down my earlier explanation so the OP has something to use as a possible script to describe what happens. If you tell someone that has minimal to no medical training and you give them the info above, their eyes will just glaze over and they won't really understand because "we" are being too technical. We know the technical stuff, why it works and doesn't. Most people just don't.

[AnnieOaklyRN, BSN, RN, EMT-P]

It isn't about what happens during CPR it's what happens after, which can include permanent disability and brain damage (permeant vegetative state), huge medical bills with a person that is still dead. I would focus more on the big picture versus the right now. CPR isn't gonna effect the dead body, but when we bring them back with only their brain stem surviving or worse a small part of their cerebral cortex, that's where people may get that its not something they want to endure!

Unfortunately society sees what is on tv and that is usually a code, CPR, a shock and like a miracle they all wake up and are fine! You need to emphasize that most patents who go into cardiac arrest stay that way and another percentage will have permanent brain damage that can leave them bed ridden etc. Advise them that only 8% of out of hospital cardiac arrests survive to discharge, that is a very small number and it's up to the patient and family if they want to roll the dice!

Encourage patients to speak up and voice what THEY want if they are cognitively able and advise the family to make sure there are no advance directives if the patient can no longer make that decision. I think families have a false idea that everyone gets a shock and wakes up and life goes on.

p.s. let them know not everyone is in a shockable rhythm either!

Annie

[Horseshoe, BSN, RN]

In addition to all of what the PP posted, mention the fact that only about 25% of CPR patients survive resuscitation efforts (that stat was from my ACLS instructor in class, so I can't provide a reference).

It's probably only a tiny fraction of that in the population the OP references (80-90 y/o already medically compromised).

[Alex Egan, LPN, EMT-B]

I always tell people that CPR is a medical procedure of last resort that has a very high risk of injury, a very low rate of success, and even if it goes perfectly can leave the patent with a severe loss of physical and mental abilities. It is the only procedure available at that point in time, some people want to have CPR and have a small 10%-30% chance of survival, others choose to let nature take its course and avoid the risk of survival with worse quality of life. The key is to choose for yourself ahead of time, because if your wishes are not known you will receive CPR.

in the situation of "just use the paddles" I would point out that CPR ACLS is a package deal not at pick and choose, if they want the best chance of success they will get the full treatment, anything else isn't acceptable. I generally also point out that shows like ER are Hollywood fiction and have a cardiac arrest survival rate of about 75%!

[KatieMI, BSN, MSN, RN]

I pull them aside, sit down, may be even get some coffee and tell, with all honesty:

- CPR in life and CPR in "Grey's Anatomy" have nothing to do with each other.

- CPR helps to start the heart back in about 20% of the patients (1 out of 5) when we speak about ALL people. Those who are already old and/or very sick, have chance about 1 out of 20 or less (official data from American Heart Association - it is somewhere on their site. I once found it by an accident).

- "start the heart" doesn't automatically mean that everything else will restart too. I work in LTACH, and like 3/4 of out clientelle come from successful codes after which at least one of their body systems just stops working. Brain, lungs, kidneys, livers, you name them. There is no guarantee things will EVER come back for any of these poor souls. That is what named "success" in this type of business.

- I was "CPRed" several times (for some reason, people tend to start compression if they see anaphylaxis). All these times, I was still there, at least when some strong a sa bull dude began to push with all his might. It was good, ol'fashioned, real 10/10 pain which lasted for weeks, because ribs WILL be broken (well, they are mostly not broken but just "disconnected" from the sternum, but it is just a technicality) and lungs WILL be bruised. There is no way to escape it. If you happen to make it, the next thing you will know is that you just want to die back, right then and there, just to stop hurting like h*** upon every breath or vent puff. This pain is also VERY difficult to manage.

After that honest talk, some of them say that they don't want such expereince for their loved ones - quot erat demonstrandum.

[Kteichow]

Thank you everyone for your input! I greatly appreciate it. Sometimes I feel like I'm too blunt when I talk about the effects of CPR and patients and their families will look at me like I have two heads í ½í¹ƒ I blame the media and fancy tv shows for portraying CPR as a miracle that works every time.

[annabanana2]

Thank you everyone for your input! I greatly appreciate it. Sometimes I feel like I'm too blunt when I talk about the effects of CPR and patients and their families will look at me like I have two heads ������ I blame the media and fancy tv shows for portraying CPR as a miracle that works every time.

I have the "should we consider a DNR" conversation with families and patients all the time. I am nearly always very blunt when describing CPR, but I'm not mean about it, if that makes sense. I don't sugarcoat anything. I explain very clearly what CPR looks like, how long it might last, what else might come along with it (ie. intubation, defibrillation, whatever is relevant) and the likely outcome. I say very clearly that the odds of the patient leaving the hospital and going home after CPR are essentially zero (my patients are terminal with a prognosis of definitely