Adult CPR Update 2005

Dr Adrian Burger

Emergency Medicine Registrar

UCT/Stellenbosch

Background

• ILCOR vs AHA

• 36 Months before 2005 Consensus Conference

• Awareness - limitations of evidence

- benefits of CPR

• Tipping point - major changes

- re-affirmed others

Background

• USA - 250 000 to 330000 estimated annual SCA deaths per year

• Survival < 6% worldwide average• Trials - short term outcomes - underpowered, small - not randomized - design limitations• Informed consent

Method

• Critical review of sequence and priorities

• Identify factors with greatest impact on survival

• Recommendations for interventions that should be performed frequently and well

• Emphasis on HIGH QUALITY CPR

So Why Change Then?

• Poor survival not inevitable

• Lay Rescuer CPR + AED Programs

Witnessed VF SCA 49%-74% Survival

• Make it all easier

Common Elements of Success

• Trained Rescuers

• Rapid Recognition

• Prompt CPR

• Defibrillation < 5 min

The Brief

• Simple

• Appropriate

• All Ages

Simple

• “Lay rescuers not be expected to learn, select or perform different sequences of CPR”

Appropriate

• Asphyxial and VF SCA

• ?Compression alone VF

• ?Ventilation + Compression

Asphyxial and Prolonged arrest

Age Effective

• Infant and Children

- Asphyxial Arrests more likely

• Adults

- VF SCA more likely

Age Groups

• Lay Rescuers

Infant under 1 year

Child 1-8 years

Adult 8 and older

• HCP

Infant under 1 year

Child 1 year to puberty

Adult puberty & older

Airway

• For Lay rescuers - Head Tilt Chin Lift

• For HCP - Jaw Thrust

- Head Tilt Chin Lift

- Manual C-spine control in CPR

• Head Tilt Chin Lift EVEN IN TRAUMA

Breathing

• Match Pulmonary Blood Flow & Ventilation

• Not excessive ventilations

-Initial O2 content adequate in VF SCA -Reduced perfusion 25%-30% of normal

-Reduced venous return -Gastric Insufflation

CPR For Lay Rescuers

• Check normal breathing • 2 rescue breaths of 1s each• Visible chest rise• Immediate chest compressions (no pulse check) • 2 hands, centre of chest, nipple line,

100/min• AED when arrives

CPR For HCP

• “Phone First” for all sudden collapse and if lone rescuer• “CPR First” for unresponsive infants and children, all

victims of likely hypoxic arrest and if lone rescuer• Check for adequate breathing• 2 rescue breaths of 1s each• Visible chest rise• Check response• Pulse check• Rescue breathing without compressions 10-12/min• Technique of compressions same as lay rescuers

The Ratios

• Universal 30:2 -All Lone Rescuers of Infants (not newborns),

Children & Adults -All Lay Rescuer situations -2 Rescuer Adult CPR without advanced airway

• 15:2 -2 Rescuer CPR for Infants and Children

Put Simply

• 30:2 - All Lone Rescuers (Lay & HCP)

for All victims

- 2 Rescuers Adults (no advanced

airway)

• 15:2 - 2 Rescuers for Infants and Children

And if there’s an ETT or LMA?

• Breathing rate: 8-10/min

• Compression rate: 100/min

• Swap roles regularly

-objectively <1-2 minutes

-subjectively >5 minutes

HIGH QUALITY CPR

• RATE - push hard, push fast 100/min

• DEPTH - 1.5 TO 2 inches

• COMPLETE CHEST RECOIL

• MINIMISE INTERRUPTIONS

• CHANGE REGULARLY

Restore Coronary & Cerebral Blood Flow

Technique of CPR

• Push Hard and Push Fast

• Complete Chest Recoil

• Minimal Interruptions <10s

• Change Regularly

The Shocking Facts

Changes

• Challenged Defib first to all VF victims,

especially > 4 to 5 min

• Improved survival for CPR first?

• Insufficient data for CPR first to all VF SCA

Consensus

Lay Rescuers

• AED as soon as available

EMS

• Witnessed SCA VF: Defib

• Not witnessed or > 4 to 5 min: CPR first

Non Consensus

• In hospital cardiac arrest

• Ideal duration of CPR before defib

• Ideal duration of VF to switch to CPR first

Only One Shocker

• No specific studies

• 1st shock efficacy - termination of VF at least 5s after the shock

• Monophasic defib - low 1st shock efficacy

• Biphasic defib - average 90% 1st shock efficacy

• If 1st shock fails - low amplitude VF, CPR greater value

So the VF is terminated…

• Most have a nonperfusing rhythm• PEA/Asystole = CPR• AED rhythm analysis 29-37 seconds

Therefore 1 shock immediately followed by CPR for

5 cycles or 2 minutes (+ physicians discretion)

How much?

Adults• Biphasic Truncated Exponential Waveform use

150J to 200J• Biphasic Rectilinear Waveform use 120J• Monophasic Waveform use 360J

Children• Initial 2J/kg biphasic or monophasic• Subsequent 2-4J/kg• AEDS okay for > 1 year old

Drugs - To Use or not use?

• “No Placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases rate of survival to hospital discharge”

• Vasopressin vs Epinephrine

• No evidence for routine use of any antiarrythmic during cardiac arrest

Drug administration

• “LEAN” Lignocaine, epinephrine, atropine, naloxone, and vasopressin

• IV or IO preferable to ET

• If no IV or IO: 2.5XIV dose in 5-10ml H2O

IV/IO vs ET

• Predictable drug delivery• Predictable drug effect

• low dose of adrenaline systemically leads to a B -adrenergic effect

• Vasodilatation• Lower coronary artery

perfusion pressure & flow• Reduced potential of

ROSC• Pulmonary

vasoconstriction

Other drugs in short• NaBic: No evidence for routine use Adverse effects of vasodilatation, alkalosis, CO2 production, catecholamine Specific instances, eg TCA, hyperkalaemia

• Calcium: No benefit from routine use Indicated for hypocalcaemia, hyperkalaemia, CCB toxicity

• Fluids: Indicated with hypovolaemic arrest Class indeterminate as routine Avoid glucose unless hypoglycaemic

Implications

• Deemphasizes drug administration

• Reemphasizes BLS

• Drug administration during CPR

• Co-ordinate - reduced interval increases shock success

• AEDS - quicker, during CPR, re-program

Post Resus

• Little evidence to support specific Rx• No standardized Rx• Supportive - myocardial, organ function - glucose - avoid hyperventilation - temperature• Therapeutic hypothermia - improved

outcome of out-of-hospital adult VF arrest

FBAO

• Simplified - mild or severe

• Mild - victim coughing: do not interfere

• Severe - silent cough

- respiratory distress

- stridor

- unresponsive

Severe FBAO

• Activate EMS• Anecdotal evidence• Adults & >1yo : abdominal thrusts first

: chest thrusts• Combinations of above most effective• Chest thrusts: obese, pregnant• CPR for unresponsive patients• Look into mouth, but no blind finger sweeps

18 March 2006

www.resuscitationcouncil.co.za

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References

• Circulation, 2005; 112

• Currents, winter2005-2006

• JAMA, Feb 9, 2000-Vol 283, No6 p783-790