1. CPR in the ED: R U Ok? Mike McEvoy, PhD, RN, CCRN, NRP Resuscitation Committee Chair and Sr. Staff Nurse CTICU – Albany Medical Center EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine www.mikemcevoy.com

2. Outline CPR 2010: that was then, this is now… Show me the money: is there proof? What matters? Why measure? How to assess quality CPR Unique hospital issues Future solutions

3. Adult Chain of Survival: 2010 1.Immediate recognition and activation of emergency response system 2.Early CPR with emphasis on chest compressions 3.Rapid defibrillation 4.Effective ALS 5.Integrated post-cardiac arrest care

4. CPR Sequence Change  A-B-C to C-A-B  Initiate chest compressions before ventilations Why?  Reduce delay to compressions  Can be started immediately  Emphasizes importance of chest compressions

5. So, What Matters in CPR? And how should we assess effectiveness?

6. Let’s Get One Thing Straight: Where do most cardiac arrests occur? ~ 175,000 per year out of hospital –ROC data (Nichol et al, JAMA 2008) ~ 200,000 per year in hospital –2003-2007 GWTG-R data Merchant, Yang, Becker, Berg, Nadkarni, Nichol, Carr, Mitra, Bradley, Abella, Groeneveld, CCM 2011 Attention American Heart Association: You need to focus more effort on IHCA

7. Chest Compressions 2010 > 50 mm ( > 2”) At least 100 per minute 2005 38 – 51 mm (1.5 – 2”) 100 per minute Most Common Errors: 1.Too slow 2.Not deep enough 3.Prolonged interruptions 4.Leaning

8. Chest Compressions ROC: survival associated with  depth Abella et al: 100-120/min =  survival Recommendations are LOE 4 & 5 (just do it, because we like it) In truth: –Ideal actual depth of CPR unknown Probably lies near 50 mm –Best rate for CPR unknown Is likely about 100/min

9. CPR Rate vs. ROSC p < 0.0083 Abella et al. Circulation. 2005;111:428-434

10. Probability of ROSC Stiell et al. Crit Care Med 2012; 40:1192-1198

11. One Day Survival Stiell et al. Crit Care Med 2012; 40:1192-1198

12. Survival to Discharge Stiell et al. Crit Care Med 2012; 40:1192-1198

13. Effective CPR? How do you measure the effectiveness of CPR? –End tidal carbon dioxide –Feedback devices Measurement of CPR effectiveness is a proposed U.S. TJC future standard

14. Waveform Capnography Attaches to ET tube, measures CO 2

15. Oxygen  Lungs  alveoli  blood Muscles + Organs Oxygen Cells Oxygen + Glucos e ENERGY CO 2 Blood Lungs CO 2 Breath CO 2 Physiology of Metabolism

16. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

17. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

18. Measuring Exhaled CO 2 Colorimetric Capnometry Capnography

19. Carbon Dioxide (CO 2 ) Production

20. What If…

21. But, with High-Quality CPR…

22. Meet Howard Snitzer 54-years old, collapsed Jan 5, 2011 outside Don’s Foods in Goodhue, MN (pop. 900) 2 dozen rescuers took turns providing CPR for 96 minutes 6 shocks with first responder AED, 6 more shocks by Mayo Clinic Air Flight Medics Transported to Mayo Clinic Cardiac Cath Lab

23. Why Not Quit? Thrombectomy, stent to LAD 10 days inpatient “The capnography told us not to give up” EtCO 2 averaged 35 (range 32 – 37)

24. So What’s the Goal During CPR? Try to maintain a minimum EtCO 2 of 10 mmHg (1.4 kPa) Push HARD (> 2” or 5 cm) FAST (at least 100) Change rescuer Every 2 minutes

25. 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 EtCO 2 values

26. Guidelines 2005 EtCO 2 recommended to confirm ET tube placement

27. Wayne MA, Levine RL, Miller CC. “Use of End-tidal Carbon Dioxide to Predict Outcome in Prehospital Cardiac Arrest”. Annals of Emergency Medicine. 1995; 25(6):762-767. Levine RL., Wayne MA., Miller CC. “End-tidal carbon dioxide and outcome of out-of-hospital cardiac arrest.” New England Journal of Medicine. 1997;337(5):301-306. EtCO 2 detects ROSC 90 pre-hospital intubated arrest patients 16 survivors 13 survivors: rapid rise in exhaled CO 2 was the earliest indicator of ROSC Before pulse or blood pressure were palpable

28. Capnography = Results, not process

29. CPR is Complicated!

30. Hospital Issues: 1.Bed Height –Optimal = bed at knee level of person administering chest compressions Cho et al, Emerg Med J. 2009;26:807-810 2.Air Mattresses –No need to deflate mattress for CPR Perkins et al, Inten Care Med. 2003;29:2330-2335 3.Backboards –No evidence of benefit with backboard Perkins et al, Inten Care Med. 2003;29:2330-2335

31. AHA Guidelines - 2013 Pre, Intra, Post arrest recommendations: 1.Real time feedback at the point of care 2.Shock early, don’t interrupt CPR, avoid hyperventilation, optimize depth 3.BENCHMARK

32. What About Quality? In-Hospital Arrests, Dec 2004 – Dec 2005

33. Audiovisual CPR Feedback Incorporated into monitor/defibrillator Real time Accelerometer-based

34. Handheld Feedback Device Handheld accelerometer-based audiovisual device

35. Generation of Feedback

36. Post Code Reviews (Code Stat ™)

37. EMS Feedback = ROSC FDNY uses audio-visual feedback Deactivated audio feedback for 1 week ROSC  20% NY State EMS Council Report Jan 2012

38. But Hospitals ≠ EMS How effective are feedback systems?

39. We have a problem:

40. Accelerometer CPR Depth Perkins et al. Resuscitation 2009;80:79-82

41. The Mattress Issue: Mattress compression = 35 – 40% of total compression depth Accelerometer feedback devices fail to account for mattress compression Use of a backboard fails to compensate for mattress compression Perkins et al. Resuscitation 2009;80:79-82

42. CPR on Mattress

43. CPR with a Backboard

44. The Solution: Directly measure the true compression depth.

45. Two end points Direct measurement of distance (magnetic) Discrimination of X, Y, Z Triaxial Field Induction 1 2

46. TFI versus ACC Banville et al. Circulation 2011; 124:A217

47. Where Is TFI?

48. On the Code Cart!

49. Back Pad Under Patient

50. Compress Chest Pad

51. Summary Compressions are key to outcomes –Most common errors: depth and speed Need to assess effectiveness of CPR –It improves survival –Future hospital requirement Current tools: EtCO 2, ACC, TFI –CO 2 delayed –ACC inaccurate –TFI - Very promising!