The evidence behind ACLS: the importance of good BLS

Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director

Center for Resuscitation Science Vice Chair of Research

Department of Emergency Medicine University of Pennsylvania

Laerdal Workshop – December 2014

CRS Center for

Resuscitation Science

Time

% S

urvi

ving

arrest

CPR defibrillation

ROSC

hospital discharge

Cardiac arrest is the ultimate EMS disease!

1961

50 years of modern CPR

A. Peter Safar, 1950s

B. Early symposium on CPR

A B

“Chain of Survival”

Prompt Access

Early CPR

ACLS Care

Early Defib

ACLS Provider Manual (American Heart Association)

Cardiac arrest: fundamentals of therapy

Bystander contacted 9-1-1

standard CPR (n=960) chest compression alone (n=981)

Chest compression alone CPR

2010

Survival to DC

11.5% 14.4% (OR 2.9)

Berg et al, 2001

Blo

od

pre

ssur

e

Time

= chest compression

Standard CPR vs CC alone

Berg et al, 2001

Blo

od

pre

ssur

e

Time

= chest compression

Standard CPR vs CC alone

“No flow” / compression fraction

0-20 21-40 41-60 61-80 81-100 comp fraction, %

Surv

iva

l to

dis

cha

rge

, %

0

10

2

0

3

0

Christenson J et al, Circ 2009 poor survival with lowest compression fraction in OHCA

40

32

24

16

8

0 1 2 3 CPR duration, min

CPP

, mm

Hg

ICCM, 2005

2 inches vs 1.5 inches Survival: 100% 15%

Chest compression depth

Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation

Defib first - AHA CPR (90 sec) first, then defib 42 months 36 months

24% (155/639) 30% (142/478) p=0.04

Cobb et al, 1999

CPR first may improve survival

0 2 4 6 8 10 12 14

0.5

0.4

0.3

0.2

0.1

0

Wik et al, 2003

CPR first Standard care

pro

ba

bili

ty o

f sur

viva

l

time from collapse, min

CPR first may improve survival: RCT

p=0.006

CPR sensing and recording defibrillator

Similar defibrillators now made by both Philips and Zoll

Using CPR feedback to improve quality

Kramer Johansen, 2006

Abella, 2007

ventilations

ECG

compressions

rhythm check ECG: v fib

shock given

Arrest transcript

ECG: v tach

Actual arrest transcript: U of C, 2004

10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120

Chest compression rate (min-1)

Num

be

r of 3

0 se

c s

eg

me

nts

300

250

200

150

100

50

0

n=1626 segments

Chest compression rates

Abella et al, 2005

No ROSC ROSC

10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 >120

Chest compression rate (min-1)

Mean rate, ROSC group 90 ± 17 *

Mean rate, no ROSC group 79 ± 18 *

210 180 150 120 90 60 30 0

Num

be

r of 3

0 se

c s

eg

me

nts

Chest compression rates by survival

Abella et al, 2005

p=0.003

CPR renaissance: measuring CPR

Valenzuela et al, Circ 2005 Wik et al, JAMA 2005 Abella et al, JAMA 2005 Aufderheide et al,Circ 2004

Aufderheide et al, 2004

mean ventilation rate: 30 ± 3.2

first group: 37 ± 4 after retraining: 22 ± 3

16 seconds

v v v v v v v v v v

Hyperventilation during EMS resuscitation

Pause before shock

4:55 5:00 5:05 5:10

Com

pres

sion

s

ECG

Chest compression pauses before shocks

0

20

40

60

80

100

≤10.3 (n=10)

10.5-13.9 (n=11)

14.4-30.4 (n=11)

≥33.2 (n=10)

Pre-shock pause, seconds

VF re

mov

ed, p

erce

nt

90%

10%

55% 64%

p=0.003

Dose-effect of pre-shock pauses

Edelson et al, 2006

50%62%

93%100%

0%

20%

40%

60%

80%

100%

120%

<1 1-1.5 1.5-2 >2

Shoc

k su

cces

s, p

erce

nt

Compression depth, inches

ACLS Range

n=10 n=5 n=14 n=13

p=0.02

Shock success by compression depth

Edelson et al, 2006

Improving EMS care with “CC only”

Bobrow et al, 2008

Interventions: 1. Significantly delay intubation 2. 200 compressions before first shock 3. Minimize pre and post shock pauses

Tripled survival to hospital discharge (3.8% à 9.1%)

Improving EMS care with “CC only”

2009

Confirmation of this finding:

How to train for quality

l  Code review investigation:

–  All residents and students rotating through resuscitation team roles

–  Debrief teams on their events

–  Weekly 30-45 min resuscitation debriefing/teaching sessions

Debriefing intervention

Impact of CPR feedback and debriefing

Edelson et al, 2008

Impact of CPR feedback and debriefing

Edelson et al, 2008

Impact of CPR feedback and debriefing

EMS version of the Edelson 2008 study Performed using Zoll feedback defibrillators in Arizona

Impact of CPR feedback and debriefing

The key importance of CPR

2009

Reflected in the poor impact of ACLS meds:

Randomized trial of epinephrine versus no epinephrine For EMS treated cardiac arrest à NO SURVIVAL BENEFIT!

Key “take home” points

1. Cardiac arrest is not hopeless!

2. CPR quality has big impact

3. Minimize ventilations

4. Maximize chest compression rate and depth

5. Consider CPR feedback tools and code debriefing

6. Use hypothermia after cardiac arrest

Questions?

?