Aiming for high quality CPR: why it matters and how we can get there
Benjamin S. Abella, MD, MPhil, FACEP Clinical Research Director
Center for Resuscitation Science Department of Emergency Medicine University of Pennsylvania
Laerdal SUN workshop Philadelphia, December 2014
Speaker disclosures
Research Funding: NIH - NHLBI
American Heart Association
Medtronic Foundation
Speaking Honoraria: Philips Healthcare
Advisory Board: HeartSine Technologies
CardioReady
Volunteer: American Heart Association
Sudden Cardiac Arrest Association
Electrical recording of the heart rhythm:
Normal rhythm: heart is moving blood (functional “cardiac output”)
Cardiac arrest rhythm: chaotic rhythm means no blood flow (no functional cardiac output)
In cardiac arrest, abrupt and total loss of cardiac output Uniformly fatal unless immediate treatment given (e.g. CPR)
Cardiac arrest
400,000 arrests / year
2 / 3 Out-of-hospital
1 / 3 In-hospital
survival to hospital
discharge 1-5% 10-20%
Seattle: 10-20%!
Cardiac arrest epidemiology in the US
Time
% S
urvi
ving
arrest
CPR defibrillation
ROSC
hospital discharge
Mortality from cardiac arrest
Drs. Knickerbocker, Kouwenhoven, and Jude – Johns Hopkins, 1950s – studied defibrillation and chest compressions in the laboratory
Development of chest compressions
1961
Approaching 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
Chest compression alone CPR
Recent publication from the American Heart Association, endorsing the use of dispatch 911 CPR instructions:
Is patient conscious?
Is patient breathing normally?
START CPR; INSTRUCTIONS
Sample algorithm for dispatch recognition of cardiac arrest
“no”
“no”
Lerner et al, Circulation 2012
Dispatch-assisted CPR and AED use If someone calls 911 and doesn’t know CPR or how to use an AED, the dispatcher can coach them on the spot Growing concept across the US
Hallstrom et al, 2000
Bystander contacted 9-1-1
standard CPR (n=279) chest compression alone (n=241)
29/279 (10.4%) 35/241 (14.6%)
Improvement due to: ? less time to train ? better CPR strategy
Chest compression alone CPR
p=0.18
Bystander contacted 9-1-1
standard CPR (n=960) chest compression alone (n=981)
Chest compression alone CPR: revisited
2010
Survival to DC
11.5% 14.4% (OR 2.9)
1996
Ventilation was the biggest technical challenge for lay rescuers Mouth-to-mouth is HARD
Unrealistic to ventilate well?
2012
Lay public feels more Confident with CC only More willing to share Information with others
Compression-only: training is easier
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
Chest compression depth
CCM 2012
CPR quality and survival
2013
Rate of 90-100 may be best; too slow or too fast may yield worse outcomes
CPR quality and survival
2013
Deeper compressions Favors survival; no max Depth identified
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
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
Possible model underlying these data
1. Slow compression rates 2. Frequent and lengthy pauses 3. Shallow compressions 4. Hyperventilation
Current CPR quality: summary
The problem with cardiac arrest
The military solution
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
AHA statement on CPR quality
2013
Concept of “report cards” for resuscitation
CPR in the workplace
Friday, June 13, 2008 Tim Russert, TV correspondent Known asymptomatic coronary dz Suffered AMI à cardiac arrest
Attempted resuscitation (CPR and defibrillation) failed Unknown CPR quality or pre-shock pause time
CPR in the home
Friday, June 25, 2009 Michael Jackson died at home Respiratory arrest from drug OD
Attempted resuscitation (CPR and defibrillation) failed CPR performed in the bed – questionable quality, pauses in performance?
March 17, 2012 Fabrice Muamba had cardiac arrest while on UK football field Arrest duration was over 78 minutes
Prolonged CPR and shocks – Full neurologic recovery
Demonstration of CPR saving lives
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%)
New directions in CPR: Hands-only CPR – evidence suggests mouth-to-mouth may not be required, especially for bystander response New for 2010 guidelines: Airway-Breathing-Circulation is now Circulation-Airway-Breathing
C A B
Guidelines update 2010
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!
Assessment during CPR is poor
In 2010, few options available to obtain “output” from patients during resuscitation
Patient receiving care
Treatment (input)
Effects (output)
In 2010, few options available to obtain “output” from patients during resuscitation
Patient receiving care
Treatment (input)
Effects (output)
Patient with pneumonia antibiotics
Temp curve wbc count
Assessment during CPR is poor
Progress in resuscitation inputs/outputs
Time (years)
Qu
alit
y
CPR introduced
30:2 CPR
CPR quality emphasis
Pulse check
Rhythm strip
Pulse check
Rhythm strip
Pulse check
Rhythm strip
Problem with CPR quality recording
CPR recording gives “incorrect” output: measures provider, not patient
Patient with pneumonia antibiotics
Temp curve wbc count
medication log sheet
Candidate patient-based outputs
Need methods to measure physiology
Physiologic measurement Example Coronary perfusion pressure Paradis NA, 1990
Arterial pressure Rivers EP, 1993
Cerebral oximetry Newman DH, 2004
Blood markers Adrie C, 2002
End-tidal CO2 Ornato, 1989
End-tidal carbon dioxide (ET-CO2)
expiration inspiration
ET-CO2
CO2
Advantages: non-invasive clinically available extensively studied
Does ET-CO2 correlate with CPR quality?
Sheak et al, AHA abstract presentation 2013
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
Acknowledgements
Lance Becker Marion Leary Bob Neumar Dave Gaieski Roger Band Brendan Carr Barry Fuchs Dan Kolansky Vinay Nadkarni Raina Merchant Kelsey Sheak Marisa Cinousis Emily Esposito Raghu Seethela
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