HIGH QUALITY CPR:

IS IT TIME FOR MECHANICAL ASSISTANCE?

Nicole Kupchik MN, RN, CCNS, CCRN-K, PCCN-CMC

EMERGENCY NURSES ASSOCIATION - 2018

Objectives

Discuss issues with CPR performance in hospitals

Describe challenges to providing high quality CPR

Discuss the data behind the use of mechanical CPR

devices

Let’s start with cardiac arrest basics…

In resuscitation, what matters?

In resuscitation, what matters?

2015 Guidelines overview

Chest compression rate 100 – 120/min

Depth 2 – 2.4 inches

Minimize peri-shock pauses

Do NOT over-ventilate!!!

Utilize Capnography for ET placement, CPR quality, ROSC

Medications:

Epinephrine 1 mg every 3 – 5 min

Amiodarone 300 mg IV for ventricular fibrillation

“Poor quality CPR should be considered

a preventable harm”

Meany, Bobrow, Mancini et al (2013) Circulation 128(4):417-435

CC Rate 141

Depth with fast CPR rates

Minute by minute breakdown

CPR with a Backboard

Mattress Swing

Should we put an emphasis on

intubation in the first 15 minutes?

Andersen et al (2017) JAMA; 317:5 Favors NO intubation Favors intubation

60 minute case……Minutes 1 - 26

When is CPR challenging?

Prolonged codes

Cardiac Cath Lab

In a hospital bed

When you don’t have enough

staff/limited resources

On a morbidly obese patient

Back of a moving ambulance

Should we rethink the way we provide chest compressions?

Efficient Application

Manual CPR vs. Mechanical CPR

2589 patients

4 Swedish, 1 Dutch, 1

British EMS system

LUCAS n = 1300

Manual CPR n = 1289

4 hour survival

Follow up 6 months

Rubertsson, Lingren, Smekal et al (2013) JAMA

LINC: Survival with good outcomes (CPC 1-2)

ICU discharge(CPC 1-2)

Hospitaldischarge(CPC 1-2)

At 1 month(CPC 1-2)

At 6 months(CPC 1-2)

L-CPR(N=1300)

7.5% 8.3% 8.1% 8.5%

M-CPR(N=1289)

6.4% 7.8% 7.3% 7.6%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

L-CPR = LUCAS M-CPR = Manual Rubertsson et al, JAMA. 2014 Jan 1;311(1):53-61

Does Mechanical CPR applied early

make a difference?

Seems to!

RCT LUCAS 2

vs. manual CC

LUCAS applied

onsite vs.

ambulance

MECCA Trial – MEchanical Cardiopulmonary Resuscitation vs. Standard Manual CPR in

OHCA by Emergency Ambulance Crew

Excludes pulseless V-Tach

Anantharaman, Ng, Ang et al (2017) Singapore Med 58(7):424-31

Cath Lab Experience

Retrospective analysis

Cardiac Catheterization Lab

43 patients

12 Manual CPR, 31 Mechanical CPR

ROSC 74% in MCC vs. 42% in Manual CPR

Venturini et al 2017. Resuscitation; 115:56-60

Cardiac Cath Lab Survival with MCC

Venturini et al 2017. Resuscitation; 115:56-60

In-Hospital MCC Meta-Analysis

8 Observational & RCTs – Low quality of evidence

Couper et al 2016. Resuscitation;103:24-31

Mechanical CPR with a Shock - #1

Pre-Shock Pause w/ Mechanical CPR-#2

mCPR & Capnography without, then

with a Pulse

Pulseless – Capno 20 mm Hg with CPR

Conversion to an organized rhythm – Capno over 50 mm Hg

Can Mechanical CPR be used as a

bridge?

2013

The Paris experience

Pre-hospital E-CPR in the Louvre Museum, Paris

Mechanical CPR as a bridge?

The “Art” of E-CPR!

ECMO

Extracorporeal Membrane Oxygenation

56 year old with OHCA

Transient

ROSC

4 mg of Epi,

but continues

loss of pulse

Unclear if STEs

on ECG

What to do

next? Would anyone take this patient to the cath lab?

Mechanical CPR Devices

Case continued…OHCA, RBBB

Arrest in the Cath Lab

Stent placed to the LAD

Arrest in the Cath Lab

ECMO comes to you?

2015 Feedback & Mechanical Devices

Levels of Evidence – ILCOR/AHA

Recommendation Class LOE

Using feedback devices to guide compression quality IIb B-R

The use of mechanical compression devices may be a

reasonable for use by properly trained personnel.

The use of mechanical compression devices may be

considered in specific settings where the delivery of high

quality manual compressions may be challenging or dangerous

to the provider.

IIb C-EO

ECPR – Venous/Arterial ECMO may be considered for

refractory cardiac arrest when the cause is likely reversible

IIb C-LD

Neumar et al (2015). Circulation;132[suppl 2]:S315-S367

nkupchik@gmail.com

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@nicolekupchik

Nicole Kupchik

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In conclusion,

HIGH quality CPR & early defibrillation matter!

Manual CPR is extremely challenging in hospitals

Mechanical CPR applied efficiently, can improve

CPR quality