Importance of CPR Robert S. Cole

Credit where Credit is Due Adapted from presentation by Ahamed Idris, MD, –Professor of Emergency Medicine University of Texas Southwestern Medical Center at Dallas

Special Thanks Dr. Peter Safar Father of Resuscitation medicine Helped develop CPR Directly responsible for the research used in therapeutic hypothermia.

Objectives Importance of maximizing CPR. Why compression:ventilation ratio 30:2 ? Complete chest wall recoil Danger of hyperventilation CPR First vs shock first 1 shock vs 3 shocks Minimize delay to shock Impedance Threshold Device (ITD): Science

A need for change… Approximately 350,000 persons die from out-of- hospital cardiac arrest each year in North America. Survival rate is poor among these patients, and most do not survive to hospital discharge. New research suggests CPR has a much greater impact on cardiac arrest survival than previously thought. Other research suggests that an impedance threshold device (ITD) may improve outcome.

CPR in Hollywood… ROSC (Getting a pulse back) 75% discharged neurologically Intact 67%

CPR in Real Life ROSC between 0.1% and 49% –3-7% typical Survival to Hospital Admission: 23% Survival to Discharge : 7.6% –THIS HAS NOT IMPROVED SIGNIFICANTLY IN 30YEARS! Good Neurological Outcome: 0.1% and 30% Predictors of Survival From Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis Comilla Sasson, Mary A.M. Rogers, Jason Dahl, and Arthur L. KellermannCirc Cardiovasc Qual Outcomes. 2010;3:63-81, published online before print November , doi: /CIRCOUTCOMES

Today: Nearly everyone dies….

But there is hope… Howard Snitzer, 59, survived 96 minutes of CPR with no neuro Deficits.

Importance Of CPR 10-20% of normal blood flow to the heart 20-30% of normal blood flow to the brain

3 Phase Model

Cardiac Output During CPR

KEY POINT: CPR, not PARAMEDICS, save lives in most Cardiac Arrests

Understanding Coronary Perfusion Pressure Note this is Aortic Pressure. CPP is “roughly” half Aortic Pressure.

Understanding Chest Compressions Compression Increased intrathoracic pressure Compression of heart and lungs Decompression (recoil) Decreased intrathoracic pressure Refilling of heart and lungs Complete chest recoil is critical

ROSC Associated with CPP

Benefit of Continuous Chest Compressions

Intra-thoracic Pressure and CPR?

New Cardiac Guidelines (2005) Rate of 100/minute. Depth of 1 1/2–2 inches –(or more in larger people). Complete chest recoil after each compression. Ventilation (less is more). –No more than 10 ventilations per minute. –Inspiration phase of no more than 1 second Minimize interruptions in chest compressions. Rotate compressors every 2–3 minutes to minimize fatigue.

2005 to 2010 changes… Component of CPR2005 ECC recommendations 2010 ECC Recommendations DEPTH OF COMPRESSION 1 ½ - 2 inchesGreater than 2 inches RATE100 /MINUTEAt least 100 /MIN VENTILATION8-10 /MINUTE CHEST RECOIL100% INTURUPTIONSMinimizedLess than 10 seconds goal

Who does good CPR?

Answer: NO ONE! Studies showed… Chest compressions were not delivered about half of the time (too much “hands off”). Most compressions were not deep enough. Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

Answer: NO ONE! Studies showed… Chest compressions were not delivered about half of the time (too much “hands off”). Most compressions were not deep enough. Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

Compression DEPTH Target = mm with complete release Reality = only 27% achieve target Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

No-Flow Ratio (Interruption of CPR) Target = less than 20% Reality = 48% Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

Compression Rate Target = ~100/min with complete release Reality = 60/min due to “No Flow Ratio” Quality of Cardiopulmonary Resuscitation During Out-of-Hospital Cardiac Arrest Wik, et al. JAMA 2005

Compression Rate… Percent segments within 10 cpm of AHA Guidelines 31 % 36.9% Abella, et al 2005 Circulation

Compression Rate…

Barriers to staying on the chest… Pausing for procedures –intubation, IV, pulse check, etc.). Pausing for rhythm analysis. Pausing after shock to await post-shock rhythm. Pausing to charge, clear, and shock. Unaware of importance of CPR in “big picture”

Importance of complete recoil

Get EVERY Compression Right Critical pressure for ROSC (Paradis et al. JAMA 1990;263:3257-8) Abella, et al 2005 Circulation

Cerebral Perfusion Pressures and CPR Abella, et al 2005 Circulation

Current Guidelines for Ventilation CPR with Advanced Airway: 8 – 10 breaths/minute Post-resuscitation: 10 – 12/min

Compression-Ventilation Ratio Ventilation rate = 12/min Compression rate = 78/min. Large amplitude waves = ventilations. Small amplitude waves = compressions. Each strip records 16 seconds of time

Reality Sucks… Compression: Ventilation Ratio 2: Breaths a minute 47 Nails in a coffin!

Prolonged Ventilations Ventilation Duration = 4.36 seconds / breath Ventilation Rate = 11 breaths / minute % time under Positive Pressure = 80%

Everyone sucks! Milwaukee –Mean Ventilation Rate: 37/minute –AFTER 2 months training: 22/minute Dallas 30/minute Tuscan34/minute Chicago>30/minute

Effect of Vent. Rate on CPP 12 RR /minute CPP 23.4 ± 1.0mmHg MIP 7.1 ± 0.7 mmHg/min 20 RR /minute CPP 19.5 ± 1.8 mmHg MIP 11.6 ± 0.7 mmHg/min 30 RR /minute CPP 16.9 ± 1.8 mmHg MIP 17.5 ± 1.0 mmHg/min

Aware of importance of CPR? s and 1990’s King County/Seattle Medic One EMS System Data, Cobb,

CPR FIRST? % ROSC

CPR FIRST BEFORE DEFIB? The rate of survival improved (24 percent to 30 percent) when CPR was initiated prior to external defibrillation, especially in patients with delayed initial response intervals (longer than 4 minutes): 27 percent with CPR versus 17 percent without CPR. The overall proportion that survived with favorable neurologic recovery also improved from 17 percent to 23 percent. Cobb LA et al. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation.JAMA 1999 Apr

CPR IMPROVING DEFIB?

CPR: Whats Next?

90% of all changes to 2010 ECC are right in the BLS segment. Builds on and further enhances the changes and research discussed in the 2005 guidelines. COMPRESSIONS are the single most emphasized segment of resuscitation.

Hands Only CPR??? Single biggest change “Hands Only CPR” AKA: Compression only CPR for lay persons and non HCP first responders.

KEY POINT: HANDS ONLY CPR MAY IMPROVE ROSC BY 7% OVER TRADITIONAL CPR

CAB??? Sequence change to chest compressions before rescue breaths (CAB rather than ABC) This is expected to reduce time from assessment of responsiveness to first compression by 30 or more seconds. This reduction in time during this critical period early in the arrest is expected to improve survival and also response to first shock.

Pulse Check? Studies have shown that both lay rescuers and healthcare providers have difficulty detecting a pulse. The lay rescuer should not check for a pulse and should assume that cardiac arrest is present if an adult suddenly collapses or an unresponsive victim is not breathing normally. Healthcare providers also may take too long to check for a pulse. The healthcare provider should take no more than 10 seconds to check for a pulse and, if the rescuer does not definitely feel a pulse within that time period, the rescuer should begin CPR.

Look, Listen, and Feel? Confusion in Agonal Respirations vs. Good Respirations “Look, Listen, and Feel” de- emphasized

CPR Prompts

Therapeutic Hypothermia?

New CPR Guidelines

Traditional Healthcare Version

IMPORTANT POINT! RATERATE DEPTHDEPTH RELEASERELEASE UNINTERRUPTEDUNINTERRUPTED DECREASED VENTILATIONDECREASED VENTILATION 5 KEY ASPECTS ASPECTS OF OF GOOD GOOD CPR! CPR!

“It is up to us to save the world.” - Peter Safar