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In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College.

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Presentation on theme: "In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College."— Presentation transcript:

1 In-hospital Cardiac Arrest: First and foremost, Chest Compressions Charles L Campbell MS MD Associate Professor of Medicine University of Kentucky College of Medicine

2 No Disclosures

3 Outline IHCA Hospitals Vary in Outcome Why What is recommended How should it be done Does it really matter

4 IHCA is pretty common… ˜200,000 in the US Survival is 18-20% There is tremendous variability among hospitals Get with the Guidelines 135,896 – 20% with Ventricular fibrillation or Ventricular tachycardia – 64% occur in an ICU Median Survival Varies – 8.3% at the lowest Decile – 31.4 at the highest JAHA. 2014;3:e000400

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6 Clinical FeatureOdds RatioP VT/VF3.14< PEA Etiology Toxicologic 2.36 ICU1.60< Monitored1.72< Comorbid Hepatic insufficiency 0.54< Comorbid Cancer0.50< Arrest time at night 0.74< Arrest time Weekend 0.86< JAHA. 2014;3:e000400

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8 What seems to work? Performing ACLS correctly is associated with an improvement in outcome MUSC study Compared guideline adherence for survivors vs. non-survivors – 75 survivors – 75 non-survivors Survivors older and with more cormorbidities Resuscitation. 2013;85:82-87

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13 Each 10% improvement in adherance results in a ˜30% increase in ROSC. Resuscitation. 2013;85:82-87

14 What is Happening Weisfeldt and Becker 1.Electrical Phase 1.4 min 2.Defibrillation alone may be effective 2.Circulator Phase 1.Chest compressions are necessary 3.Metabolic Phase 4.Stone Heart JAMA.2002;288:

15 Time course of VF

16 Circulation. 2005;111: and e294

17 J Cardiovascular Magnetic Resonance. 2011;13:17 Hypothermia during VT/VF

18 What is Recommended Defibrillation Chest Compressions Oxygenation Medications Procedures

19 NEJM 2008;358:9-17

20 Chest Compressions Place patient on a firm surface – Backboard – Deflation of air mattress Had in the middle of the chest – 5 cm of depression – Allow complete recoil Lifting the hand completely of the chest can improve recoil Circulation. 2010;122:S

21 How Fast Rate cpm Deliver >80 per minute – That means minimal interruption Duty Cycle – Time between the start of one compression and the start of the next – Target is 50% – As much time relaxing as compressing Circulation. 2010;122:S

22 Circulation. 2005;

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25 Circulation. 2012;125: ROC consortium (9 sites) OHCA in which monitors/defib measured chest compression rates 3098 cases analyzed

26 Circulation. 2012;125:

27 Compression rate vs Compressions Delivered

28 Circulation Qual Outcomes.2013;6:

29 Compression Depth

30 Resuscitation. 2005;64:

31 Circulation Qual Outcomes.2013;6:

32 Recoil Matters…

33 Resuscitation. 2006;71:

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35 Resuscitation. 2006;64:

36 Circulation Qual Outcomes.2013;6:

37 Resuscitation, 2007;73:54-61

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40 Resuscitation. 2009;80:

41 Non-Shockable Rhythms

42 Circulation. 2012;125:

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44 Chest Compressions and Defibrillation

45 Resuscitation. 2006;71:

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47 Survival from OHCA improved after the implementation of a protocol that required 90 seconds of CPR prior to the delivery of a shock via an AED – 24% to 30% – Particularly in those in whom the intial response interval was > 4 min. JAMA. 1999;281:

48 Resuscitation. 2008;77:10-15

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51 Mechanical CPR?

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54 Conclusions Chest Compressions are the cornerstone of resuscitation – Rate – Depth – Recoil – Minimizing Interruptions – Feedback is probably helpful In some cases chest compressions aid defibrillation Mechanical chest compressors have not been demonstrated to be helpful


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