1. Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams
The goal of this presentation is to provide up-to-date and evidence-based information regarding EMS care of patients with cardiac arrest. The Pennsylvania Department of Health encourages all EMS providers to complete this course as the first step to becoming part of a High-Functioning EMS CPR Team. Pennsylvania is one of six states – others are Arizona, Illinois, Minnesota, North Carolina, and Washington – participating in the HeartRescue Project. The goal of this project is to increase the survival from sudden cardiac arrest by 50% in each of the participating states.
This lecture session should last 1.5 hours and has been accredited for 1.5 hours of EMS Continuing Education credits by the PA Department of Health.
To complete the High-Functioning CPR Team education, an EMS provider must complement this didactic lecture with a hands-on simulation-based pit crew style training in cardiac arrest care. To have the full effect, the hands-on pit crew training should be held within a single EMS agency so that providers complete this component with the partners that they are likely to work with when treating patients.

2. Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams
To develop an EMS crew into a High-Functioning EMS CPR Team, we must deliver patient care that includes treatments that have been proven to lead to the best outcomes – “evidence-based care”. It all starts with understanding the science.
“The Science”

3. Cardiac arrest is the ultimate EMS disease!
CPR
defibrillation
% Surviving
ROSC
Death is inevitable, and not every cardiac arrest patient will be successfully resuscitated, but excellent CPR, defibrillation, post-resuscitation care, and hospital care will provide for the highest survival rate possible for sudden cardiac arrest.
ROSC = return of spontaneous circulation, or the return of a sustained pulse after a period of cardiac arrest.
hospital
discharge
Time

4. CPR is over 50 years old, but recent changes have shown increases in survival
CPR has a long history. Mouth-to-mouth resuscitation was described by Dr. Peter Safar from the University of Pittsburgh in the 1950’s, and chest compressions were described at Johns Hopkins. These were combined into the description of Cardiopulmonary Resuscitation in 1960 – more than 50 years ago. Unfortunately, the survival rate from out-of-hospital (OOH) cardiac arrest was stagnant and poor through most of the history of CPR. After the 2005 guidelines when more attention was placed on quality compressions many EMS agencies saw the survival rate begin to improve.
With continued advances, EMS agencies may be able to attain successful resuscitation (survival to hospital discharge with normal neurologic function) of nearly 50% of witnessed cardiac arrest patients who have a shockable cardiac rhythm.
A. Peter Safar, 1950s
B. Early symposium on CPR
1961 4

5. Survival is related to arterial pressures generated by chest compressions35 30 25 20 15 10 5
Not the pH
Not the oxygen content
It’s all about Coronary Perfusion Pressure !
Coronary Perfusion
Pressure (mm Hg)
Studies have shown that the most important factor in attaining survival from sudden cardiac arrest (SCA) is CPR that generates good blood pressure through the coronary arteries – or coronary perfusion pressure (CPP). In this 1988 study by Kern, Ewy, and others, pigs that had good CPP during CPR had high rates of survival, and those that had poor CPP could not be resuscitated. Further, survival was not related to pH or oxygen content. These studies speak to focusing cardiac arrest care on excellent compressions and not on correcting pH with sodium bicarbonate or hyperoxygenation. The best way to improve an acidotic pH is to better perfuse the tissues with adequate chest compressions.
24-hour
Survivors
Resuscitated
But
Expired
Could
Not
Resuscitate
Kern, Ewy, Voorhees, Babbs, Tacker Resuscitation 1988; 16:
Paradis et al. JAMA 1990; 263:1106

6. Chest compression rates
300
250
200
150
100 50
n=1626 segments
Number of 30 sec segments
The 2010 CPR guidelines from the American Heart Association suggest that compressions should be delivered at a rate of OVER 100 compressions / minute. [Historical note: in 2005, the guidelines called for an increase in compressions to around 100 compressions / minute.] This 2005 study by Abella from the University of Pennsylvania showed that, when measured, many chest compressors did not deliver rates over 100/minute. In fact, some were even as slow as compressions/ minute.
R>120
Chest compression rate (min-1)
Abella et al, 2005

7. Survival better with compression rate of 100 – 120 compressions/minute
Mean rate, ROSC group
90 ± 17 *
210
180
150
120 90 60 30
p=0.003
Mean rate,
no ROSC group
79 ± 18 *
No ROSC
Number of 30 sec segments
ROSC
When the rates of chest compression are plotted for the patients in whom ROSC was attained (green) and for those patients that did not attain ROSC (black), it is clear that most survivors received the faster chest compressions. The mean rate of chest compressions in all patients that attained ROSC was 90, compared with a mean rate of 79 compressions/ minute in the patients that did not attain ROSC. So we need to PUSH FASTER, but it is probably possible to push too fast. A target of compressions/minute is probably ideal.
>120
Chest compression rate (min-1)
Abella et al, 2005

8. Survival better with compressions >2 inches deep40 32 24 16 8
2 inches vs 1.5 inches
Survival:
100%
15%
CPP, mm Hg
Additionally, the depth of compressions is important. The 2010 AHA guidelines call for compression depth of AT LEAST 2 inches in adults. [Historical note: the 2005 guidelines suggested a compression depth of 1.5 to 2 inches in an adult.] In this study from the ICCM, the coronary perfusion pressure and survival were both significantly better with 2 inch compressions versus 1.5 inch compressions. So we need to PUSH DEEPER.
CPR duration, min
ICCM, 2005

9. Shock success by compression depth
Shock success, percent
In addition to better CPP with deep compressions, Edelson showed that the success of a defibrillation shock is much higher if the compressions are deeper.
n=10
n=13
n=14
n=5
Compression depth, inches
Edelson et al, 2006

10. 2005 AHA Guidelines
The 2005 AHA Guidelines called for pushing HARDER, FASTER, and DEEPER.

11. 2010 AHA Guidelines
EVEN
Then the 2010 guidelines should be characterized by emphasizing pushing EVEN harder, EVEN faster, and EVEN deeper.

12. How Does CPR Cause Blood Flow? Thoracic Pump
It is a common misconception that chest compressions circulate blood by squeezing the heart between the sternum and the underlying spine. This is not correct. Blood flow during chest compressions primarily occurs because of changes in intrathoracic pressure – or the thoracic pump model. In this model, the down stroke of a chest compression decreases the diameter of the chest wall, thereby increasing the intrathoracic pressure. Fluid under pressure flows out by the path of least resistance. During the upstroke of a compression, the chest recoils and creates negative intrathoracic pressure. This negative pressure “sucks” fluid (blood) into the thorax.
It should be noted that if the airway is patent, the changes in intrathoracic pressure that move blood in and out of the chest also move some air in and out of the lungs. Therefore, with excellent compressions, there is some passive ventilation. +

13. Ensure Total Chest Recoil with: 1) Lifting palm during compressions or 2) Using feedback device
There are two techniques to ensure that total chest wall recoil occurs. The first is to modify the method of chest compression so that the palm of the hand lifts off of the chest with each compression. In Arizona, Dr. Gordon Ewy teaches that the entire hand lifts off of the chest with each compression. Another technique that may be more controlled is to keep light contact between the fingers and the chest wall, but to allow the palms to lift off of the chest slightly – “as if to allow a credit card to be swiped under the hands after each compression”. This technique is different from what many providers have been taught, but it can become commonplace with regular practice. The second method to ensure total chest wall recoil is to use a real-time feedback device. Advances in technology have led to some feedback devices that are applied under the hands to inform the compressor about adequate depth, rate, and recoil. These devices sense if the compressor is continuing to lean on the chest and apply pressure after each compression. A compressor who is tired may lean on the chest between compressions and reduce the effectiveness of the chest compressions. +

14. Allow Complete Recoil
This video shows excellent CPR technique – shoulders over patient’s sternum, elbows locked, compressing up and down using the low back as a fulcrum, and a slight lift of the palms off of the chest between each compression.

15. Allow Complete Recoil Lift Palms During Compressions
This video shows a different angle and a close up view of the palm lifting from the chest between compressions.

16. CPR sensing and recording defibrillator
The Pennsylvania Department of Health does not recommend or favor any specific brand of FDA-approved AED, cardiac monitor, or defibrillator. These are two examples of CPR sensing monitor/defibrillators. With increasing technology, we will undoubtedly see improvements in the real-time feedback that AEDs, monitors, and defibrillators give to EMS providers during CPR. This feedback will allow providers to alter the quality of their CPR during a resuscitation and will help to ensure optimal CPR.
Examples: Devices providing real-time feedback
are available from several manufacturers

17. Patients can be hyperventilated to DEATH!
16 seconds
v v v v v v v v v v
mean ventilation rate: 30 ± 3.2
Dr. Aufderhiede, from Milwaukee Wisconsin, measured the ventilation rate by seasoned EMS crews during real cardiac arrests. He found that the average rate of ventilation was 37 breaths / minute. After retraining the EMS providers, the rate continued to be 22 breaths / minute. Still over twice the AHA recommended 8-10 breaths per minute. This hyperventilation is extremely detrimental to effective chest compressions.
In addition to describing the flow of blood into and out of the chest, the thoracic pump model also is useful in understanding how hyperventilation of a patient with cardiac arrest can be deadly. Each ventilation increases the volume in the chest and therefore increases the intrathoracic pressure. Excessive ventilation can lead to a constant positive intrathoracic pressure, and without the periods of negative intrathoracic pressure, blood will not flow into the chest to be circulated with compressions.
Dr. Aufderheide did additional experiments that measured the significant increase in intrathoracic pressure with hyperventilation, and these studies also showed a decrease in survival when animals in cardiac arrest are hyperventilated.
first group: 37 ± after retraining: 22 ± 3
Aufderheide et al, 2004

18. Single rescuer performing 30:2 with realistic 16 sec.
interruption of chest compressions for MTM ventilations 80
160
mmHg
Time (sec) 40
120
Cerebral Perfusion
Pressures
No Cerebral
Perfusion
5 sec
In 2007, Dr. Ewy demonstrated the effect of a compression to ventilation ratio of 30:2 on the coronary perfusion pressure (CPP) and cerebral perfusion pressure in pigs. This graph shows two important points. First, when compressions are initiated, maximum CPP and cerebral perfusion is not attained until after about 10 compressions. [Historical note: this explains the increase in survival from sudden cardiac arrest after the 2005 AHA guidelines switched the ration from 15:2 to 30:2, providing more compressions in a row.] Second, notice the dramatic and sustained drop in CPP and cerebral perfusion during the pause to give two breaths.
Coronary Perfusion Pressures
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

19. Perfusion with continuous compressions80
160
mmHg
Time (sec) 40
120
Single rescuer performing
continuous chest compressions
5 sec
Continuous Cerebral Perfusion Pressures
Dr. Ewy further demonstrated that with continuous chest compressions – no pause for ventilations – after the initial gradual rise in CPP, the maximal CPP is sustained during the continuous chest compressions. Likewise, cerebral perfusion gradually increases to a maximal cerebral perfusion pressure over about 10 compressions, but then is sustained when compressions are not interrupted.
Coronary Perfusion Pressures
Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

20. CPR before defibrillation may increase survival (when CA not witnessed by EMS)
Influence of cardiopulmonary resuscitation prior
to defibrillation in patients with out-of-hospital
ventricular fibrillation
24% (155/639)
30% (142/478) p=0.04
We now understand the thoracic pump model; understand the importance of quality chest compressions that are fast, deep and allow total recoil; understand how detrimental hyperventilation can be; and understand the improved CPP and cerebral perfusion when continuous uninterrupted compressions occur. Now defibrillation must be added to these excellent chest compressions.
When a cardiac arrest is not witnessed by an EMS provider with a defibrillator, survival is increased if CPR is performed for a short period before defibrillation is attempted. Studies have examined doing CPR for 90 seconds to 2 minutes (approximately 2 minutes) before a defibrillation attempt, when the cardiac arrest is not witnessed by EMS providers.
Defib first CPR (90 sec) first, then defib
42 months months
Cobb et al, 1999

21. CPR first may improve survival: RCT
0.5
0.4
0.3
0.2
0.1
CPR first
Standard care
probability of survival
In 2003, Wik showed that the technique of doing CPR first (before attempting defibrillation) improves the survival for patients in whom CPR is not started for the first 4 minutes of cardiac arrest. On the other hand, a defibrillation first strategy leads to better survival if it is done when the patient is defibrillated within a couple minutes of collapse. Realistically for EMS providers, this means that if the EMS provider witnessed the cardiac arrest, defibrillation should occur immediately if that can be accomplished. But if the EMS provider does not witness the collapse, then 2 minutes (or 200 compressions) of chest compressions before a defibrillation attempt may lead to more survivors.
p=0.006
time from collapse, min
Wik et al, 2003

22. Chest compression pauses before shocks
4: : : :10
Compressions ECG
In the past, it has been common practice to have long pauses before and after a defibrillation attempt. In some cases, this is driven by technology – like the time that it takes to analyze a heart rhythm and charge an AED. In other cases, old habits like watching the monitor after a defibrillation or pausing to check a pulse have led to these delays. High-Functioning EMS CPR Teams that train to eliminate these pauses in compressions can reduce all pauses to less than 7 seconds.
Pause before shock

23. Shock success by pre-shock pauses
100
p=0.003
90% 80 60
64%
Shock success, percent
55% 40 20
If you recall the graph of the effect of ventilatory pauses during 30:2 CPR, you understand the concern for pauses as they relate to perfusion, but pre-shock pauses are also detrimental to the success of a defibrillation attempt. This study by Edelson shows that defibrillation attempts are highly successful if the pre-shock pause is less than 10 seconds, but they are also of diminished success when the preshock pause increases.
10%
≤10.3
(n=10)
(n=11)
(n=11)
≥33.2
(n=10)
Pre-shock pause, seconds
Edelson et al, 2006

24. CPR renaissance: measuring CPR matters
The recent emphasis in measuring the quality of CPR has led to a renaissance in resuscitation. In the past, many EMS providers that had done CPR many times did not experience the satisfaction of having a large number of survivors. Today, the new emphasis on providing effective CPR has led to a surge in survival – CPR really is life-saving, but we must measure our results in order to improve.
Valenzuela et al, Circ 2005
Wik et al, JAMA 2005
Abella et al, JAMA 2005
Aufderheide et al,Circ 2004 24

25. Key “take home” points Cardiac arrest is not hopeless!
CPR quality has biggest impact
Adequate chest compression rate ( /min)
Maximize chest compression depth (>2 in.)
Allow for complete chest recoil
Minimize pauses !!
Minimize ventilations (8-10 bpm)
Use capnography & debriefing, consider CPR feedback tools
Ensure access to hypothermia and cardiac catheterization
The instructor should spend time reading each of these key take home points with emphasis. This is a good place to pause for any questions regarding the preceding information regarding effective chest compressions and other principles of basic care for sudden cardiac arrest.

26. 3-Phase Time-Sensitive Model of Cardiac Arrest Due to VF
The Electrical Phase (0 to ~5 minutes)
Early defibrillation life-saving
The Circulatory Phase (~5 to ~10 minutes)
Intubation and immediate AED can be detrimental
Compressions first may be life saving
The Metabolic Phase (~>10 minutes)
Survival decreased
Science searching for more successful treatments
There are three phases of cardiac arrest. It is important to understand the difference between the electrical and circulatory phases, because the most appropriate treatment is slightly different. Sudden cardiac arrest or primary cardiac arrest is seen in individuals who are in their normal state of health before they collapse with a shockable rhythm. The mechanism in this case is of presumed cardiac etiology and is associated with sudden dysrhythmia (almost always VF).
The first few minutes of a VF cardiac arrest are known as the electrical phase. This phase starts the moment that the patient’s rhythm goes into VF, and lasts approximately 4 minutes. During this phase, the VF is usually course and the patient may not have suffered sequelae from the time without cerebral / coronary perfusion. The priority treatment for these patients is immediate defibrillation. If the cardiac arrest is witnessed by EMS and the defibrillator is at the patient’s side, immediate defibrillation is the treatment of choice, without any chest compressions. Of course, if there is any delay in defibrillation, chest compressions should be initiated immediately while the defibrillator is obtained. [Historical note: In the past, AHA guidelines stressed early defibrillation for all patients in VF. This was a good approach for those patients whose VF was witnessed in a hospital setting or by EMS, but it is not the best approach for patients in the circulatory phase.]
The second phase is the circulatory phase. In this case, the patient’s VF is not as course as it originally was, and the patient’s heart and brain have had about 5 minutes or more without perfusion. This is the most common VF cardiac arrest presentation for EMS providers, because the time needed for bystander recognition of the patient’s collapse, the call to 911, the processing and dispatching of the call, and the response time by EMS can seldom be done in a period of time that is less than 5 minutes from patient collapse to EMS providers at the patient’s side. In the circulatory phase, initiating chest compressions and restoring perfusion to the heart and brain are the priority. The defibrillation is likely to be more successful if the heart is perfused for a short period prior to defibrillation. Additionally, early focus on intubation or airway management may be detrimental in this phase, and chest compressions should not be delayed.
The final phase, or metabolic phase, occurs after an extended period without circulation. Survival is rare in this phase, and unfortunately there is no evidence that treatments like adjusting the patient’s pH with bicarbonate, giving antidotes, or other medications/ treatments have any effect on improving outcome for these patients.
Bystander CPR can alter these phases and approximate times, giving EMS more opportunity to save more patients with excellent neurologic outcome.
Weisfeldt ML, Becker LB. JAMA 2002;288:3035

27. Dispatcher-assisted hands-only CPR
2010
Bystander contacted 9-1-1
There is growing evidence that concentrating on chest compressions alone, without ventilation, may improve survival in some patient groups. This study shows improved survival in patients who received CPR instructions from a 911 dispatcher when the dispatcher instructed the bystander in hands-only CPR or compressions only, rather than traditional CPR with interposed ventilations. In addition to being easier to instruct over-the-phone, the compression-only instructions from a dispatcher may lead to better compliance in bystanders who now do not have to give mouth-to-mouth ventilation as part of the procedure.
standard CPR (n=960) chest compression alone (n=981)
11.5% % (OR 2.9)
Survival to DC 27

28. CCR (Cardiocerebral Resuscitation) emphasizes:
CPR (2010) emphasizes:
Circulation
Airway
Breathing
CCR (Cardiocerebral Resuscitation) emphasizes:
Circulation (uninterrupted compressions)
Deemphasizes ventilation
In the 2010 AHA guidelines, this increased emphasis on the importance of compressions was recognized by the change from the A-B-Cs to C-A-B, placing compressions as the priority after recognizing a cardiac arrest. In some systems, they have further deemphasized the respiratory component of CPR by referring to CCR (Cardiocerebral Resuscitiation) which emphasizes the fact that perfusing the heart and brain are the priorities.

29. “Tucson” version (2003) Cardiocerebral Resuscitation (Intubation delayed; Bag Valve Mask ventilation)
EMS
arrival
200 chest
compressions
200 chest
compressions
200 chest
compressions
200 chest
compressions
Analysis
Analysis
Analysis
No intubation:
Bag Valve Mask
ventilation
Begin IV
1 mg EPINEPHrine every
3 to 5 minutes
Follow ACLS
Guidelines?
Since 2003, a CCR protocol in Arizona has repeatedly been shown to lead to excellent rates of discharge from the hospital with good neurologic function. This protocol concentrates on aggressive attention to minimally interrupted chest compressions, with pauses for defibrillation approximately every 2 minutes (or 200 compressions). The concentration is on compressions, rapid defibrillation attempt, then compressions, alternating over the first approximately 8 minutes of the resuscitation attempt. In this protocol, epinephrine is administered every 3-5 minutes, but intubation is purposefully delayed. In AZ, EMS agencies were given the option to either do no ventilation or to provide BVM ventilation as long as they avoided hyperventilation. Tucson, AZ was one of the first communities to use this CCR approach, but it is now encouraged statewide. Pennsylvania’s Primary Cardiac Arrest Protocol #3050 was designed around this successful protocol.
If adequate bystander chest compressions are provided, EMS providers perform immediate rhythm analysis and shock if indicated

30. Survival after Bystander CPR for OHCA in Arizona (2005 to 2010)
Compression Only CPR Advocated and Taught A. B.
All OHCA
Witnessed/Shockable
35%
30%
25%
20%
15%
10% 5% 0%
33.7%
AOR 1.6 (95% CI, )
P < 0.001
Survival to Hospital Discharge
17.7%
13.3%
In 2010, Bobrow described the results of the Arizona compression-only CPR technique in the Journal of the American Medical Association. In this study, the survival to discharge from the hospital rose from about 8% to about 13% with this technique for all out-of-hospital cardiac arrests, and for the most salvageable group of cardiac arrests who were witnessed and in a shockable rhythm, the rate of survival to hospital discharge almost doubled from about 18% to almost 34%.
7.8%
Std-CPR
COCPR
Std-CPR
COCPR
Bobrow, et al. JAMA 2010:304:

31. Neurological Intact Survival from CCR Witnessed collapse and shockable rhythm
50%
40%
30%
20%
10% 0%
39/102
75/192
35/89
34/136
Survival to Hospital Discharge
Neurologically Normal
39%
38%
38%
This results were not isolated to Arizona. Several locations across the U.S. have now shown surprisingly similar results. These include studies from Wisconsin, Arizona, and Missouri.
Rock and Walworth
Arizona
K.C. MO
Annals Emergency
Med 2008
Annals Emergency
Med 2009
Circulation 2009

32. Gasping Should Not Distract from Recognizing Patient in Cardiac Arrest
EMD recordings of 445 witnessed cardiac arrests
Non-witnessed arrest: 16% gasping
Witnessed arrest: 55% gasping (p <0.001)
Example of Gasping (Bondi Beach, YouTube)
In the past, particularly with the A-B-C model, when a patient was breathing, providers believed that they were not in cardiac arrest, and chest compressions were delayed. The AHA now suggests that bystanders should start compressions on patients that are unresponsive and not breathing normally. Healthcare providers are still encouraged to check a pulse, but they too should not be distracted from starting chest compressions because of a patient’s agonal respirations. This is a very important point for dispatch programs also. Dispatchers will often be told of or even hear loud gasping respirations over the phone from patients in cardiac arrest. It is important that they recognize these as agonal respirations and not normal breathing.
The study listed here shows that agonal breathing is very common in witnessed cardiac arrests – the most salvageable kind of cardiac arrest. Other studies have shown that if CPR is started during gasping respirations, the survival rate is higher than in those patients who do not have gasping respirations at the time of starting.
The video link in this slide is a hyperlink to a cardiac arrest at Bondi Beach near Sydney Australia. Although there could be improvements in the chest compression technique, the slow compressions, the interruptions in compressions, and the BVM technique, the video does highlight an excellent example of the difference between the patient’s agonal gasping respirations during the resuscitation and the regular respirations associated with good chest movement that occur after the successful resuscitation.
Clark et al. Ann Emerg Med 1992;21:1464

33. Medications proven to improve outcome in cardiac arrest?
What medications have been shown to improve outcome in cardiac arrest patients?
This is a trick question. There are no medications that have been definitively shown to improve survival from cardiac arrest. We still generally use epinephrine. We generally use high-flow oxygen, but there is no data that this improves survival, and if the patient does develop return of spontaneous circulation (ROSC) the oxygen should be titrated down to the minimum amount needed to obtain a pulse oximetry reading of at least 95%. We also still generally give an antidysrhythmic medication like amiodarone or lidocaine for persistent VF, but there is no evidence that this actually improves survival to hospital outcome either.
But the AHA has given the routine use of sodium bicarbonate, calcium and some other medications a class III recommendations (meaning that they are not shown to be helpful and may actually be harmful). Many providers that were trained in ACLS prior to the changes of may believe that medications are important. In fact, in the past, so much attention was placed on the medications that we often did not concentrate on providing effective compressions – a huge mistake for patient survival.

34. The priority is quality compressions
Reflected in the poor impact of ACLS meds:
2009
Although we still give EPINEPHrine routinely, a recent randomized trial in Europe showed no benefit to survival to hospital discharge. An Asian study also showed no benefit to EPINEPHrine. This information is provided to further steer the EMS provider taking this course to concentrate on the quality of compressions over medications, but it is still reasonable and suggested in our statewide protocols that EPINEPHrine be given every 3-5 minutes.
Randomized trial of EPINEPHrine versus no EPINEPHrine
For EMS treated cardiac arrest  NO BENEFIT IN SURVIVAL TO DISCHARGE FROM HOSPITAL! 34

35. Bringing Science to the Pit Crew: High-Functioning EMS CPR Teams
Now that we have covered the most recent science, it is clear that effective chest compressions must be the priority for the best survival results in sudden cardiac arrest. This is a good place to STOP and solicit any QUESTIONS about the science***********
Now that we understand the most recent science related to cardiac arrest care, we will focus on techniques that can be used to provide the most effective and efficient resuscitations. The NASCAR Pit Crew is an excellent example of how a team can preplan and practice techniques that make a resuscitation more efficient. We will look at various aspects of the EMS resuscitation that can be improved with a “pit crew” approach. This entire lecture is part of PA’s modular training that trains EMS provider teams to improve their approach to cardiac arrests and that recognizes EMS agencies that commit to changes in their agencies that make the agency a High-functioning CPR Agency.
“The Pit Crew Approach”

36. AHA 2010 Guidelines C-A-B Uninterupted chest compressions
Waveform capnography
Deemphasized:
Intubation
Drugs
Mechanical CPR
This diagram from the 2010 AHA guidelines is helpful in allowing providers to visualize how a resuscitation is focused within continuous 2-minute loops of CPR with attention to monitoring the CPR. It should be noted that the 2010 guidelines also:
Use a compressions first approach of C-A-B
Concentrate on quality compressions and monitoring the quality of the compressions
Use waveform capnography (Class I recommendation) to confirm airway placement
Deemphasize endotracheal intubation, medications, and mechanical CPR devices from the level of support that they were given in the past.

37. Statewide Protocols 331A/ 3031A General Cardiac Arrest - Adult
Don’t be fooled by agonal respirations
Cycles of 200 uninterrupted compressions
Early defib if good bystander CPR or EMS witnessed arrest

38. 331A 4 cycles of 200 compressions/ defib
Compressions cause passive ventilation
Medical director sets airway/ ventilation options
Effective 7/1/13, Pennsylvania has updated the adult general cardiac arrest protocols for BLS and ALS providers based upon the compression-only CPR technique used in Arizona, and this protocol is the basis for the pit crew approach to resuscitation covered by this course.
Here is an overview of the statewide BLS adult General Cardiac Arrest Protocol #331. The patient receives 200 compressions, followed by shock (if indicated) at maximum energy, then this is repeated for 4 cycles.
If dispatch assisted CPR or bystander CPR is being done when EMS arrives, as long as the CPR appears to be of good quality, the EMS providers may skip the first 200 compressions and proceed directly to the first attempted defibrillation.
The airway options must be decided upon by the EMS agency/agency medical director, but for efficient pit crew care, all practitioners in the EMS agency should use the same approach.

39. 331A After 4 cycles of 200 uninterrupted
compressions, add ventilations at 15:1
Indications for possible BLS field termination of CPR
Arrest not witnessed by EMS, AND
No ROSC/pulse prior to transport, AND
No AED shock delivered prior to transport

40. 3031A EPINEPHrine every 3-5 minutes
Antidysrhythmic if 2nd shock needed
Medical director sets airway/ventilation options for agency
Monitor capnography
Avoid intubation during initial cycles of compressions
Here is an overview of the statewide ALS adult General Cardiac Arrest Protocol #3031. The patient receives 200 compressions, followed by shock (if indicated) at maximum energy, then this is repeated for 4 cycles.
If dispatch assisted CPR or bystander CPR is being done when EMS arrives, as long as the CPR appears to be of good quality, the EMS providers may skip the first 200 compressions and proceed directly to the first attempted defibrillation.
All patients should get EPINEPHrine every 3-5 minutes, and patients should get an antidysrhythmic medication after the second shock if the patient VF is recurrent.
Using a pit crew approach, the agency medical director may decide that IO should be used as the initial route of vascular access in all cardiac arrests
The airway options must be decided upon by the EMS agency/agency medical director, but for efficient pit crew care, all practitioners in the EMS agency should use the same approach

41. 3031A
After the initial 4 cycles of 200 compressions and shocks, if necessary, then care continues using the standard approach with ventilation at 8-10 breaths/minute or one breath every 15 compressions. This Statewide adult General Cardiac Arrest Protocol :
applies to all rhythms
emphasizes quality CPR with minimal interruptions
Requires defibrillation attempts at either 360 joules or at the highest energy that the defibrillator can deliver. NOTE – programs that had used defibrillators that started at lower doses of energy found poor rates of termination of fibrillation with these lower doses.
Continues to use EPINEPHrine every 3-5 minutes
Continues to use an antidysrhythmic medication for REFRACTORY VF/VT
Deemphasizes other medications except for a few specific conditions
emphasizes the use of waveform capnography not only for confirmation of endotracheal tube placement, but also as a measure of perfusion with chest compressions.
NOTE that in cardiac arrest, the quantitative value of the capnograph is directly related to the patient’s cardiac output generated by the chest compressions. The capnograph also provides the earliest indication that ROSC may have occurred – even earlier than pulse check, therefore frequent pulse checks are discouraged, and providers should use other indicators like a sudden elevation in ETCO2 to help determine when there is a chance of ROSC and an indication for pulse check.

42. 3031A Treat reversible causes Appropriate medication
Pneumothorax
Hypovolemia
Appropriate medication
Antidysrhythmic
Mg for torsades (rare)
Calcium/bicarbonate in dialysis
Avoid inappropriate care
Naloxone
Glucose testing

43. High-Functioning CPR Agency The Pit Crew Team
Let’s further examine the pit crew concept.
This lecture is the first of a four-module tool kit that leads an EMS agency to becoming a High-functioning CPR EMS Agency. After completing this lecture, all EMS providers in an agency should complete the second module (high-fidelity pit crew team training) in cardiac arrest training. During the hands-on pit crew simulations, teams from the EMS agency will use the following techniques to function as efficient team members and leaders.
NASCAR pit crews have perfected this style of teamwork.

44. Equipment organized to be efficient
Even before the cardiac arrest call, High-functioning EMS Agencies must prepare their equipment to function as an effective team. Each agency should carefully review opportunities to improve efficiency and to shave every second off of their CPR care. Agencies should use input from all members of their team when making these preparations, and they should alter the preparations so that they are specific to the equipment that the agency uses.
Examples of these preparations could include:
If the agency wants IO to be the initial approach to vascular access, consider placing the first dose of EPINEPHrine in the IO device kit.
If the agency uses a monitor that allows for two waves to be displayed, consider setting the default so that both the ECG and the capnography wave are displayed when the monitor is turned on. This saves time and prevents confusion that may occur if the providers must change this setting during a cardiac arrest.
Consider packaging the capnography adapter with the bag-valve-mask since the capnograph should always be connected to the ventilation device so that it is in place and warmed up at the time of intubation. Furthermore, the capnograph can be used to monitor the perfusion even when BVM ventilation is being done.
Each EMS agency can develop additional preplans that focus on efficiency of care during CPR.

45. Team member roles pre-assigned
EMS team members should be preassigned to ensure efficient CPR. A common pit crew approach for CPR is that the first two providers kneel on opposite sides of the patient’s chest and alternate compressions. The PA statewide protocol calls for cycles of 200 compressions before each defibrillation attempt. Because continuous compressions can be tiring, some teams have found it more effective to alternate 100 compressions each before switching. Either way, communication is important, and the provider doing compressions may count to him/herself, but should develop a universal method of letting his/her partner know when it is time to switch. For example, when near the end of a cycle of 100 compressions, the compressor can count key compressions out loud, e.g. “80…90… 95, 96, 97, 98, 99, 100” then switch without interruption.
The PA HeartRescue program has provided some examples of pit crew templates that EMS agencies may use. Ideally, agencies should use templates that are configured to the number and types of providers that usually respond to cardiac arrests with the specific agency.

46. Frequent practice/ simulation
For a pit crew to function efficiently, it requires initial training and teamwork practice, but it also requires ongoing training and teamwork. The analogy for the EMS CPR pit crew team is that the team must regularly practice within the EMS agency so that members that regularly work provide patient care together also train together. The second module of this course is a high-fidelity simulation training with members of the same EMS agency, and the third module is low-fidelity simulation practice on a regular basis at the EMS agency’s station. This is called the “shift change pit crew simulation”, and these sessions should occur regularly at EMS agency meetings or at shift change. These low-fidelity sessions should be short, should use simple equipment like a half mannequin, but they should include objective evaluation of performance (e.g. timing pauses in CPR with a stopwatch in an attempt to continue to shave off seconds).

47. Let’s Examine a NASCAR Pit Crew
The attached link to a YouTube pit crew video can be used to get students thinking about the pit crew concept.

48. Team Leader Attributes NREMT
Creates, implements and revises an action plan
Communicates accurately and concisely while listening and encouraging feedback
Receives, processes, verifies, and prioritizes information
Reconciles incongruent information
Demonstrates confidence, compassion, maturity, (respect for team members), and command presence
Takes charge
Maintains accountability for team’s actions/outcomes
Assesses situation and resources and modifies accordingly
The National Registry of EMTs has recently developed objective metrics to evaluate future EMS providers who are taking their national registry certification exams. This slide lists the attributes of an effective team leader. These metrics for the performance of the team leader and team member should be reviewed in this course. They give a good example of the features of a good team leader or member. These metrics are also built into the objective performance evaluations that are used in the High-fidelity simulation module of this course.

49. Team Member Attributes NREMT
Demonstrates followership – is receptive to leadership
Maintains situational awareness
Utilizes appreciative inquiry
Avoids freelance activity
Uses closed-loop communication
Reports progress on tasks
Performs tasks accurately and in a timely manner
Advocates for safety and is safety conscious at all times
Leaves ego/rank at the door
This slide lists the attributes of a successful team member.

50. Pit Crew Approach Compressions are Priority
Continuous chest compressions with minimal interruption are key
USE any available feedback device/ metronome
Alternate compressions between providers across patient’s chest (e.g. 100 each)
Chest compressions should continue when charging an AED or manual defibrillator
Chest compressions should resume immediately after any shock
Goal = keep interruptions for rhythm check/defibrillation < 10 seconds
Goal = NO interruption for airway device insertion
The first 10 minutes of the resuscitation are critical to good patient outcomes. Because optimal chest compressions are essential during this time, it is vital for the pit crew team to focus two providers on doing 4 cycles of 200 compressions with optimal form. Other providers on scene, or one of the initial two providers that is not currently doing compressions, may accomplish additional airway care or vascular access, but these things should not interrupt the continuous compressions. The continuous compressions should only be interrupted by AED rhythm analysis, manual rhythm check, or delivering defibrillation shock. Chest compressions should continue when either an AED or manual defibrillator is being charged. In fact, when there is the possibility of a shockable rhythm during a primary cardiac arrest, if ALS is on scene, the defibrillator should be charged before the rhythm check – in this way, the chest compressions can be interrupted once for the rhythm check, defibrillation attempt, and switching of compressor. Ideally, this should all be done without interrupting chest compressions for more than 7 seconds.

51. Pit Crew Approach “The Triangle of Life”

53. The Pit Crew approach requires that each EMS agency preplan the roles of EMS providers at a cardiac arrest. This partial diagram shows the roles for 3 of the 4 providers in a team where two BLS providers arrive first, followed by two ALS providers. Each EMS agency should preplan using the configuration for response in their community (e.g. BLS personnel from a first responder agency, mixed ALS –BLS two-person ambulance staffing, ambulance staffing with more than two providers, supervisory personnel, etc.).
In general, all pit crew approaches have some things in common:
The triangle of CPR must be maintained, particularly during the first cycles of compressions and defibrillations (about the first 10 minutes).
Two compressors must be initially assigned to each side of the patient’s chest. These two individuals take turns providing minimally interrupted chest compressions with excellent technique. Because 2 minutes or 200 uninterrupted chest compressions can be tiring, we suggest that pit crews have these two providers alternate in cycles of 100 compressions. It is critical that the coordination and communication among the 3 individuals in this triangle is practiced and efficient. For example, systems should develop their own technique for communicating the chest compression count. One successful method is to have the compressor count to him/herself for the first 90 compressions, but then count out loud at before the switch to give adequate warning to the partner and to ensure a seamless switch without interruption in compressions.

55. Pit Crew Approach Airway Options During CPR
Airway insertion must not interrupt compressions !
Intubation deemphasized and should be delayed until after 800 compressions
Options with 3031A (set by medical director):
Naso/oropharyngeal Airway + NRB oxygen
King LT/ Combitube + oxygen
There are several airway options when using the Statewide Primary Cardiac Arrest Protocol #3050. Generally, endotracheal intubation should not be done until after the four cycles of 200 compressions, and any airway care should not interrupt compressions. Again, this is for the primary cardiac arrest patient with SCA – not for patients with secondary cardiac arrest, particularly if from hypoxic events like drowning of pediatric respiratory failure.
When using the primary cardiac arrest protocol, there are several options for airway management, and the EMS agency medical director should assist the agency in determining what option will be used. These include:
no airway management during the compression-only cycles
open airway with nasopharyngeal airway or oropharyngeal airway and provide supplemental oxygen
Insert a supraglottic airway and allow passive ventilation or apply supplemental oxygen
NOTE that these patients will still be getting some ventilation even if the EMS provider is not giving active ventilations. The positive and negative intrathoracic pressures from the chest compressions will allow for some ventilatory air flow.

56. Pit Crew Approach Ventilation Options During CPR
Avoid Hyperventilation!
Options with 3031A (set by medical director):
No ventilation during initial 800 compressions(with open airway, there is passive ventilation with compressions)
1 ventilation/ 15 compressions
Monitor ventilation by capnography
ITD optional
Like the airway options, the EMS agency medical director should assist the agency in determining the preferred method of ventilation. The most important aspect of any ventilation that is provided is that it is critical to avoid hyperventilation. Even mild hyperventilation can increase the intrathoracic pressures, thereby making chest compressions ineffective.
When treating primary cardiac arrest, EMS agencies may opt to provide no ventilation during the first 4 cycles of 200 compressions, or may opt to provide some supplemental ventilation with Bag-valve without interrupting compressions. If this is done with a bag-mask device, the EMS provider should attempt to provide a ventilation during the upstroke of the chest compression – giving a breath every 15 compressions. If a supraglottic airway, like King LT, is used, the EMS providers may ventilate without synchronizing with chest compression upstroke, but should provide about 8-10 breaths per minute.
Good aids in ensuring that hyperventilation does not occur include:
Using the respiratory rate on the capnograph and keeping the number between 8-10 breaths per minute
Or providing one breath every 15 compressions, whether or not the patient has an advanced airway.
These aids to ventilating at the correct rate also are useful for patients who later are intubated with an endotracehal tube (ETT).
An impedence threshold device, ITC, can be used by the EMS agency if approved by the EMS agency medical director.

57. Pit Crew Approach Breathing / Ventilation Summary
Ventilation not needed during initial 4 cycles of CPR for PRIMARY CARDIAC ARREST
Ventilation still has role in:
Pediatrics, <15 y/o (15:2)
Secondary Cardiac Arrest (15:1)
Drowning
Hypoxic Cardiac Arrest
Suspected Respiratory Cause
Overdose, etc.
For patients with primary cardiac arrest – those with witnessed collapse from normal state with primarily shockable rhythms, ventilation is not required during the initial 4 cycles of 200 compressions (or approximately 8 minutes).
Patients with secondary causes of cardiac arrest, like drowning, respiratory/hypoxic etiologies, sepsis, overdose, etc still require ventilation interposed with chest compressions. For adults this should be at a ratio of 30 compressions to 2 ventilations, but if continuous compressions are used, then giving one breath every 15 compressions is a reasonable approach. In pediatric patients under the age of 8, a ratio of 15:2 should still be used. For newborn patients in cardiac arrest, follow the Statewide Neonatal Resuscitation Protocol.

58. Pit Crew Approach Breathing / Ventilation Summary
If BVM used,
2-Person, 2-Thumbs-up
Technique Preferred
It is well proven that two-person BVM ventilation is more effective than the one-person technique. If a third rescuer is available, this individual should situate him/herself at the head of the patient and provide a good mask seal using the two thumbs up technique. The two providers doing compressions should share the role of squeezing the bag-mask during the off-cycle when the individual is not doing the compressions.

59. Pit Crew Approach Medications During CPR
Routes
? IO first line access
ETT ineffective
No role for checking labs
Role of medications
Epinephrine (IIb)
Ideally within first minute
Antidysrhythmic (IIb)
For refractory VF/VT
Although there is increasing controversy over the role and effectiveness of any medication during CPR. Epinephrine is still recommended in our protocols at a dose of 1 mg IV or IO for adults every 3-5 minutes. This has a IIb recommendation from the AHA. EMS agencies, with oversight from their medical directors, may choose to set a policy for the route of first vascular access. Agencies may choose to use intraosseous as the primary access in all cardiac arrests first line, or they may choose to use intraosseous secondary to limited attempts at intravenous access.
For patients who remain in refractory ventricular fibrillation after attempts to defibrillate, an antidysrhythmic medication, amiodarone or lidocaine, should be given. Again, this has a Iib recommendation from the AHA.

60. Pit Crew Approach Mechanical CPR Devices
Mechanical CPR devices do not lead to more survivors than manual CPR
Minimizing interruption in chest compressions during first 10 minutes of cardiac arrest is critical, so mechanical CPR device by BLS providers must be delayed until after the first 4 cycles of uninterrupted compressions/defibrillation attempts
During cardiac arrest treatment, all other medications have either a class III recommendation – not beneficial and potentially harmful – or they are indicated only in specific instances.
Atropine is no longer indicated in cardiac arrest.
Bicarbonate should not be used routinely in cardiac arrest and should only be given if the cardiac arrest may be associated with tricyclic antidepressant overdose or for known or suspected hyperkalemia.
Calcium should only be used in cardiac arrest when treating known or suspected (e.g. dialysis patient).
Magnesium should be used early in the treatment of true torsades, but torsades due to prolonged QT is rare and related to either congenital issues or medications.
While naloxone plays an important role in reversing severe respiratory depression in patients with narcotic overdose when a pulse is present, there is no role for naloxone during CPR, even when narcotic overdose caused the cardiac arrest.
Likewise, there is no evidence that checking glucose or administering glucose in an adult patient in cardiac arrest leads to improvement, but these tasks can take the team’s focus off of efficient compressions and other resuscitation tasks. Patients with cardiac arrest secondary to hypoglycemia would have had profound hypoglycemia and many metabolic changes over a very long period of time before cardiac arrest occurs.

61. Real-time feedback examples
Feedback devices that are built into monitors and AEDs can be very helpful in ensuring adequate chest compression rate, adequate depth, and that full recoil is achieved by fully releasing the pressure at the end of the compression. If monitors have these feedback mechanisms, EMS agencies should ensure that they are activated by default when chest compressions are done, and QI programs should review the results that are stored in the monitor. Some devices do not have real –time feedback, but do have a built in metronome to pace the rate of chest compressions. EMS agencies with these devices should encourage personnel to use them. Although real-time feedback of CPR efficiency during a cardiac arrest is ideal, if the device only permits post-code analysis of chest compression and respiratory rates, the QI program should still use this information to ensure that compression rates are adequate and interruptions in compressions are minimal.

62. Pit Crew Approach How can we monitor our success?
Real-time feedback
Feedback from monitor/AED
Continuous waveform capnography
Post-code
Debriefing
QI Review
Benchmarking (Cardiac Arrest Registry for Enhanced Survival – CARES)
Because the primary circulatory goal in treating cardiac arrest is to obtain the best coronary perfusion pressure (which is the primary determinant of successful resuscitation), it would be helpful to monitor the quality of the compressions in real-time. There are several methods of monitoring the effectiveness of our compressions. Several monitors/AEDs provide real-time feedback related to the mechanics of the CPR, and continuous wave-form capnography (end-tidal CO2 monitoring) provides a physiologic measure of cardiac output during chest compressions. Pennsylvania’s paramedics have been required to use waveform capnography to immediately and continuously monitor the correct placement of an endotracheal tube since the establishment of statewide ALS protocols in 2007, but this device is also an effective monitor of cardiac output in cardiac arrest. When a patient has a pulse, the height or quantity of expired CO2 is most affected by the rate and volume of ventilation, but in a pulseless patient, the level of expired CO2 is directly proportional to the cardiac output, which is improved by better chest compression technique. Furthermore, when ROSC occurs, there is a sudden rise in ETCO2 from the baseline before ROSC, and this is helpful in reducing pulse checks unless the ETCO2 has increased.

63. Pit Crew Approach High-functioning Team
Teamwork
Leadership
Situational Awareness (Roles)
Communication
Mutual Support
Role of Checklist
Designed for Efficiency/ Uniformity
Evidence-based
“Perfect practice makes perfect”
Initial training/ Simulation
Regular practice/ Simulation

64. High-Functioning CPR Team Continuous Quality Improvement
Each agency must adjust pit crew example diagram for local response:
Number of responders
BLS and ALS
Device preferences
Medical director oversight
Must Measure Outcomes
PDSA Cycle (Continuous Improvement)
Plan – Do – Study – Act
Small Tests of Change
Continuous quality improvement plays a critical role in improving an agencies survival rate from OOHCA. The agency should follow outcomes continuously as new techniques are added (e.g. IO as first vascular access, use of the impedence threshold device (ITD), use of a mechanical CPR device, etc.). The system must plan a pit crew approach that matches their response configuration and the types of procedures/ specific equipment that they use. And of course, it is critical that the personnel within the agency do initial pit crew training using the agency’s approach and that this is reinforced through regular drills at “shift change” or other convenient times.

65. Sequential improvement in Wake County, NC
In this example from Wake County, North Carolina, you can see the changes in outcome from cardiac arrest from baseline, to the new CPR (instituting the change from 15:2 to 30:2 after the 2005 guidelines), to the addition of ITDs, to the addition of therapeutic hypothermia at the hospitals. All EMS agencies in Pennsylvania should track their results continuously, and all should participate in the CARES (Cardiac Arrest Registry to Enhance Survival) database to compare the agencies results to the state and national averages.

66. 3080 – Post-resuscitation Care Checklist
Before moving patient:
Augment marginal BP with IV fluid bolus and pressor drip
Obtain 12-lead ECG if possible
Titrate O2 to SpO2 between 95 – 99%
Monitor continous ETCO2 and ventilation rate if advanced airway
Mask travels with bag-valve no matter what airway is in place
Package on backboard/firm surface
Is transport to center capable of PCI / hypothermia possible?
The resuscitation does not end with ROSC. Patients are often most tenuous in the minutes after obtaining ROSC, and there is a high incidence of rearrest in this period. A quick and complete approach to patients after ROSC is critical. Some agencies begin post-resuscitation care, but purposefully do not move the patient for 10 minutes after ROSC, so that they are most prepared for rearrest.
A checklist approach to patients with ROSC could include:
Note the time or ROSC and start the 10-minute scene time.
Immediately assess full set of vital signs and patient’s mental status, also breath sounds, etc.
Ensure adequate airway and ventilate at breaths per minute in adults (note this is a bit faster than the rate during CPR)
Initiated IV fluid bolus and pressor (dopamine or epinephrine infusion) for all patient’s with initial SBP < 110. The pressor can be titrated down or discontinued later, but if the BP falls, it may be too late by the time the pressor is mixed to augment the BP.
Titrate oxygen down to only maintain saturation between 95-99% (100% oxygen that supersaturates the plasma with oxygen may increase death of brain cells through free radicals.
Obtain a 12-lead ECG
Package the patient for move to ambulance
Contact medical command so that hospital can prepare for post-arrest care (e.g. prepare for therapeutic hypothermia and/or call in cath lab team for STEMI
Transport when ROSC stable for 10 minutes

67. Conclusion Improved Dispatch/Bystander CPR
High-quality uninterrupted compressions
NASCAR Pit Crew Approach to Cardiac Arrest
Transport to hypothermia/PPCI Center
QI – Measure Our Outcomes
Celebrate Our Success !!
This presentation has attempted to review the science behind cardiac arrest care, with special emphasis on the science behind efficient chest compressions that lead to the best coronary perfusion pressure and therefore the best survival rates. It is critical that excellent compressions begin with trained bystanders or with dispatch centers teaching hands-only CPR by phone to bystanders. EMS crews provide much more organized care and teamwork when using a pit crew approach to cardiac arrest care. When the cardiac arrest is a primary cardiac arrest (i.e. from a suspected cardiac dysrhythmia and not secondary to drowning, overdose, sepsis, etc), four cycles of 200 uninterrupted compressions, each followed by a defibrillation attempt, is a very effective approach. The hospital care of cardiac arrest survivors is best regionalized to hospitals that provide therapeutic hypothermia , PCI, and other advanced care. It is key that each system tracks its success by measuring outcomes, including the outcome of survival with good neurologic function. The CARES registry allows each agency to measure their outcome and to compare these against state and national benchmarks. And lastly, we must celebrate our successes and our survivors.

68. Dr. Gordon Ewy (Univ. of Arizona)
Thank You!
Dr. Gordon Ewy (Univ. of Arizona)
Dr. Benjamin Abella (Univ. of Pennsylvania)
for providing several slides to this presentation
Thanks to Drs. Gordon Ewy and Ben Abella who provided some of the slide content in this presentation.