CPR Algorithm : from present to future

Dimosthenis AvramidisPediatric Cardiology Dpt.Mitera Children's Hospital

Worldwide there are > 135 million cardiovascular death annually

The incidence of out of hospital cardiac arrest ranges from 20-140/100000 in the US

Survival ranges from 2-11% in the US

These statistics establish cardiac arrest as one of the most lethal public health problems in the US taking more lives than colorectal cancer, breast cancer, prostate cancer, influenza, pneumonia auto accidents HIV firearms and house fires combined

Causes of Death (U.S.)

Lloyd-Jones D, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009 Jan 27;119(3):e21-

181.

Sudden Cardiac

Arrest

• Heart disease kills more people each year than cancer− 1 in every 2.9 of all deaths

• Every year 230,000 - 325,000 people have a cardiac arrest outside of a hospital.− Only 7.6% will survive

Heart

Disease

26%

Cancer23%

All other causes

19%

Stroke6%

Historical Perspective

• 1960s – Peter Safar

– Prone position inadequate

– Expired air did provide sufficient O2.

– Head tilt, chin lift kept patent airway

1961

A. Peter Safar, 1950s

B. Early symposium on CPR

A B

CPR is over 50 years old, but recent changes have shown increases in survival

Coronary Perfusion Pressure

How Does CPR Cause Blood Flow?Thoracic Pump

+

Ensure Total Chest Recoil with:1) Lifting palm during compressions

or2) Using feedback device

+

CouldNotResuscitate

ResuscitatedButExpired

24-hourSurvivors

35302520151050

Co

ron

ary

Perf

usi

on

Pre

ssu

re (

mm

Hg)

Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation 1988; 16: 241-250

Not the pH

Not the oxygen content

Survival is related to arterial pressures

generated by chest compressions

It’s all about Coronary

Perfusion Pressure !

Paradis et al. JAMA 1990; 263:1106

5 sec

80

160

mm

Hg

Time (sec)

40

120

0

Coronary Perfusion Pressures

Cerebral Perfusion

Pressures

No Cerebral

Perfusion

Single rescuer performing 30:2 with realistic 16 sec.

interruption of chest compressions for MTM ventilations

Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

0

5 sec

80

160

mm

Hg

Time (sec)

40

120

Coronary Perfusion Pressures

Continuous Cerebral Perfusion Pressures

Single rescuer performing

continuous chest compressions

Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

Perfusion with continuous compressions

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)

Nu

mb

er

of

30

se

c s

eg

me

nts

300

250

200

150

100

50

0

n=1626 segments

Chest compression rates

Abella et al, 2005

No ROSCROSC

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 group90 ± 17 *

Mean rate,

no ROSC group79 ± 18 *

210

180

150

120

90

60

30

0

Nu

mb

er

of

30

se

c s

eg

me

nts

Survival better with compression rate of

100 – 120 compressions/minute

Abella et al, 2005

p=0.003

40

32

24

16

8

0

1 2 3

CPR duration, min

CPP,

mm

Hg

ICCM, 2005

2 inches vs 1.5 inchesSurvival:

100%

15%

Survival better with compressions >2 inches deep

Probability of ROSC

Stiell et al. Crit Care Med 2012; 40:1192-1198

One Day Survival

Stiell et al. Crit Care Med 2012; 40:1192-1198

Survival to Discharge

Stiell et al. Crit Care Med 2012; 40:1192-1198

Sho

ck s

ucc

ess

, pe

rce

nt

Compression depth, inches

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

p=0.02

Shock success by compression depth

Edelson et al, 2006

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

Patients can be hyperventilated to DEATH!

Pause before shock

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

Co

mp

ress

ion

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

Sho

ck s

ucc

ess

, pe

rce

nt

90%

10%

55%64%

p=0.003

Shock success by pre-shock pauses

Edelson et al, 2006

2005 AHA Guidelines

2010 AHA Guidelines

EVENEVENEVEN

Medications proven to improve outcome in cardiac arrest?

•

•

•

The priority is quality compressions

2009

Reflected in the poor impact of ACLS meds:

Randomized trial of EPINEPHrine versus no EPINEPHrineFor EMS treated cardiac arrest NO BENEFIT IN

SURVIVAL TO DISCHARGE FROM HOSPITAL!

The Metabolic Phase (~>10 minutes)Survival decreasedScience searching for more successful treatments

3-Phase Time-Sensitive Model of Cardiac Arrest Due to VF

The Electrical Phase (0 to ~5 minutes)Early defibrillation life-saving

The Circulatory Phase (~5 to ~10 minutes)Intubation and immediate AED can be detrimentalCompressions first may be life saving

Weisfeldt ML, Becker LB. JAMA 2002;288:3035

“Tucson” version (2003) Cardiocerebral Resuscitation(Intubation delayed; Bag Valve Mask ventilation)

200 chestcompressions

200 chestcompressions

No intubation:Bag Valve Maskventilation

An

alys

is

200 chestcompressions

An

alys

is

Follow ACLS Guidelines?

200 chestcompressions

EMSarrival

Begin IV 1 mg EPINEPHrine every3 to 5 minutes

•If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis and shock if indicated

An

alys

is

CPR (2010) emphasizes:

Circulation

Airway

Breathing

CCR (Cardiocerebral Resuscitation) emphasizes:

Circulation (uninterrupted compressions)

Deemphasizes ventilation

Monitoring the effects of CPR:“if you don’t measure it you can not improve it”

Cardiac perfusion pressure (CPP)of>20 mmHg-defined by arterial end diastolic pressure minus central venous pressure (CVP). Requires and arterial line and a

central line during CPR

Capnography-ET CO2 of > 20 mmHg

Waveform CapnographyAttaches to ET tube, measures CO2

Oxygen Lungs alveoli blood

Muscles + Organs

Oxygen

Cells

Oxygen

Oxygen+

Glucose

ENERGY

CO2

Blood

Lungs

CO2

Breath

CO2

Physiology of Metabolism

SpO2 versus EtCO2

Oxygenation and VentilationOxygenation (Pulse Ox)

– O2 for metabolism

– SpO2 measures % of O2 in RBCs

– Reflects changes in oxygenation within 5 minutes

Ventilation (Capnography)

– CO2 from metabolism

– EtCO2 measures exhaled CO2

at point of exit

– Reflects changes in ventilation within 10 seconds

Capnography Waveforms

45

0

45

0

Hypoventilation

Normal

Hyperventilation

45

0

Capnography1) Qualitative waveform capnography

(PETC02) provides a quality measure for CPR

2) Optimal goal for CPR is PETC02 of 35-40 mmHg equates to same as when ROSC

3) If PET Co2 is < 10 mmHg attempt to improve CPR-a PetC02 is 10 or less after initiation of ACLS is associated with poor outcomes.

Guidelines 2005EtCO2 recommended to confirm ET tube

placement

Guidelines 2010• Continuous quantitative waveform

capnography recommended for intubated patients throughout peri-arrest period. In adults:

1. Confirm ETT placement

2. Monitor CPR quality

3. Detect ROSC with EtCO2 values

Handheld Feedback Device

Handheld accelerometer-based audiovisual device

Generation of Feedback

Post Code Reviews

(Code Stat ™)

Anesthesia and Analgesia 1959;38 (6): 423

Anesthesia and Analgesia 1959;38 (6): 423

Hypothermia

The new guidelines recommend cooling comatose adult patients with ROSC after out of hospital VF, PEA and Asystole cardiac arrest to 32-34 degrees C (89-93 degrees F) for up to 12-24 hours

P=0.51

No difference in survival

Survival

Outcomes

Outcome TTM33 TTM36 HR or RR (95% CI) P Value

PRIMARY OUTCOME

Mortality at the end of trial

Dead no./total no. (%) 235/473 (50) 225/466 (48) HR=1.06 (0.89-1.28) 0.51

SECONDARY OUTCOMES

Neurological function at

follow-up

CPC 3-5–no./total no. (%)

mRS 4-6–no./total no. (%)

Serious adverse events

Any event–no./total no. (%)

252/469 (54)

245/469 (52)

439/472 (93)

242/464 (52)

239/464 (52)

417/464 (90)

RR=1.02 (0.88-1.16)

RR=1.01 (0.89-1.14)

RR=1.03 (1.00-1.08)

0.78

0.87

0.09

100% follow-up

99% follow-up

ConclusionIn unconscious survivors of out-of-hospital cardiac arrest of presumed cardiac cause

targeting a temperature of 33°C did not confer any benefit compared to

targeting a temperature of 36°C

Equipment organized to be efficient

Team member roles pre-assigned

Frequent practice/ simulation

Pit Crew ApproachCompressions are Priority

• Continuous chest compressions with minimal interruption are key

• USE any available feedback device/ metronome

• Alternate compressions between providers across patient’s chest (e.g. 100 each)

• Chest compressions should continue when charging an AED or manual defibrillator

• Chest compressions should resume immediately after any shock

Goal = keep interruptions for rhythm check/defibrillation < 10 seconds

Goal = NO interruption for airway device insertion

Pit Crew ApproachAirway Options During CPR

• Airway insertion must not interrupt compressions !

Pit Crew ApproachMechanical CPR Devices

• Mechanical CPR devices do not lead to more survivors than manual CPR

• Minimizing interruption in chest compressions during first 10 minutes of cardiac arrest is critical, so mechanical CPR device by BLS providers must be delayed until after the first 4 cycles of uninterrupted compressions/defibrillation attempts

Post-resuscitation Care Checklist

Before moving patient:

Augment marginal BP with IV fluid bolus and pressor drip

Obtain 12-lead ECG if possible

Titrate O2 to SpO2 between 95 – 99%

Monitor continous ETCO2 and ventilation rate if advanced airway

Mask travels with bag-valve no matter what airway is in place

Package on backboard/firm surface

Is transport to center capable of PCI / hypothermia possible?