2. Presenter Disclosure Information Colby Rowe FINANCIAL DISCLOSURE: No relevant financial relationship exists No Unlabeled/Unapproved Uses in Presentation

4. “Hard and Fast” At least 100 compressions per minute Two Inch Compression with Complete Release

5. Good Release = Good Venous Return to the Heart

6. Optimal Blood flow During CPR 100% 25% 0% 50% 75% Normal Blood Flow Blood Flow During CPR

7. Blood flow During CPR with Under-compression 0 Normal Blood Flow Blood Flow During CPR 100% 25% 0% 50% 75%

8. Blood flow During CPR with Under-compression and Hyperventilation 0 Normal Blood Flow Blood Flow During CPR 100% 25% 0% 50% 75%

9. Blood flow During CPR with Under-compression, Hyperventilation and Long Pre-shock Pauses. 100 25 0 50 75 Normal Blood Flow Blood Flow During CPR Ventilation, defibrillation, intubation, IV, drugs, etc. 100% 25% 0% 50% 75%

10. Coronary Perfusion pressure (Ao diastolic - RA diastolic) Chest Compressions and CPP Berg, Circ 2001

11. Shock Success by Compression Depth Shock Success, Percent Compression Depth, Inches n=10 n=5n=17n=15 P=0.008 Dana P. Edelson, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation, Volume 71, Issue 2, 2006, 137 - 145

12. Effect of Compression Depth on Survival 1.6 inch

14. Diagram of preshock, postshock, and perishock pause. Cheskes S et al. Circulation. 2011;124:58-66 Copyright © American Heart Association, Inc. All rights reserved.

15. Association between pre- shock pause and shock success. Cases are grouped by pre- shock pause in 10 s intervals. Note that longer pre-shock pauses are significantly associated with a smaller probability of shock success. The quality of CPR prior to defibrillation directly affects clinical outcomes. Specifically, longer pre- shock pauses and shallow chest compressions are associated with defibrillation failure. Pre-Shock Pause Duration and Defibrillation Success 15 Dana P. Edelson, et al. Effects of compression depth and pre-shock pauses predict defibrillation failure during cardiac arrest. Resuscitation, Volume 71, Issue 2, 2006, 137 - 145

16. Peri-Shock Pause and Survival Pre-shock pause, secs. <10 secs.10–19 secs.≥20 secs. Survival, % 35.135.525.1 P=0.02 Post-shock pause, secs. <10 secs.10–19 secs.≥20 secs. Survival, % 31.830.822.7 P=0.06 Peri-shock pause, secs. <20 secs.20–39 secs.≥40 secs. Survival, % 32.631.920.3 P=0.01 Cheskes S, et al; Resuscitation Outcomes Consortium (ROC) Investigators. Perishock pause: an independent predictor of survival from out-of-hospital shockable cardiac arrest. Circulation. 2011 Jul 5;124(1):58-66.

17. Consecutive Case Ventilation Rate (breaths/min) Ventilation Duration (secs./breath) % Positive Pressure Group 1 Mean ± SEM 37 ± 4* 0.85 ±.07* 50 ± 4% Group 2 Mean ± SEM 22 ± 3* 1.18 ±.06* 44. 8.2%5 ± * p < 0.05 Aufderheide T, et al. Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation. Circulation. 2004; 109: 1960-1965.

18. Porcine Survival Study Breaths/MinuteO2/CO2 Survival Rate 7 Pigs =12 BPM 100% O2 6/7 (86%) 7 Pigs = 30 BPM 100% O2 1/7 (14%)* 7 Pigs = 30 BPM *P < 0.05 95% O2/5% CO2 1/7 (14%)* Aufderheide T, et al. Hyperventilation-Induced Hypotension During Cardiopulmonary Resuscitation. Circulation. 2004; 109: 1960-1965

19. Time (mins) % rSO2 Illustration of the Impact of Manual & Automated Chest Compression on Cerebral Perfusion in Two Patients Automated CPR (patient 1) Manual CPR (patient 2)

20. Impact of automated CPR on rSO 2 * * p= <0.0001 Mann-Whitney Test, (Manual CPR n=22, Automated CPR n=12)

21. Quality of Compressions AHA Standards Stapleton E. Quality of CPR During Transport. JEMS 1991Sep;16(9):63-4, 66, 68

23. Manual CPRAutomated CPR * ROSC = Return of Spontaneous Circulation lasting > 20 mins. *p < 0.05 using Fischer's Exact test. (Manual CPR n=44, Automated CPR n=20) % ROSC Automatic CPR leads to higher Return Spontaneous Circulation Following Cardiac Arrest

24. Saving the PEA’s and Asystole Patients! by Fine Tuning Appreciation of H’s and T’s

26. H's T's HypoxiaToxins HypovolemiaTamponade (cardiac) Hydrogen ion (acidosis)Tension pneumothorax Hypo-/hyperkalemiaThrombosis, pulmonary HypothermiaThrombosis, coronary

27. What can Prehospital Providers do for H’s and T’s anyway? Decompress Tension Pneumothorax Pericardiocentesis Volume Toxicology Antidotes Treatment of Hyper/Hypokalemia Early notification “Trauma system strategy” “12 Lead ECG strategy”

28. H’s and T’s Process 1.Systematically consider - based on the presenting problem – Trauma = hypovolemia, tension pneumothorax, tamponade – History is a good first step! 2.How to recognize? – Tamponade = Ultrasound identification 3.How to treat? – Tamponade = Pericardiocentesis

29. Potential Usefulness of Ultrasound Pneumothorax, Tension Pneumothorax Pericardial Tamponade Hypovolemia Cardiogenic Shock Pulmonary Embolus … and more

32. Thank you!