1. Adult CPR Update 2005 Dr Adrian Burger Emergency Medicine Registrar UCT/Stellenbosch

2. Background ILCOR vs AHA 36 Months before 2005 Consensus Conference Awareness - limitations of evidence - benefits of CPR Tipping point - major changes - re-affirmed others

3. Background USA - 250 000 to 330000 estimated annual SCA deaths per year Survival < 6% worldwide average Trials - short term outcomes - underpowered, small - not randomized - design limitations Informed consent

4. Method Critical review of sequence and priorities Identify factors with greatest impact on survival Recommendations for interventions that should be performed frequently and well Emphasis on HIGH QUALITY CPR

5. So Why Change Then? Poor survival not inevitable Lay Rescuer CPR + AED Programs Witnessed VF SCA 49%-74% Survival Make it all easier

6. Common Elements of Success Trained Rescuers Rapid Recognition Prompt CPR Defibrillation < 5 min

7. The Brief Simple Appropriate All Ages

8. Simple “Lay rescuers not be expected to learn, select or perform different sequences of CPR”

9. Appropriate Asphyxial and VF SCA ?Compression alone VF ?Ventilation + Compression Asphyxial and Prolonged arrest

10. Age Effective Infant and Children - Asphyxial Arrests more likely Adults - VF SCA more likely

11. Age Groups Lay Rescuers Infant under 1 year Child 1-8 years Adult 8 and older HCP Infant under 1 year Child 1 year to puberty Adult puberty & older

12. Airway For Lay rescuers - Head Tilt Chin Lift For HCP - Jaw Thrust - Head Tilt Chin Lift - Manual C-spine control in CPR Head Tilt Chin Lift EVEN IN TRAUMA

13. Breathing Match Pulmonary Blood Flow & Ventilation Not excessive ventilations -Initial O2 content adequate in VF SCA -Reduced perfusion 25%-30% of normal -Reduced venous return -Gastric Insufflation

14. CPR For Lay Rescuers Check normal breathing 2 rescue breaths of 1s each Visible chest rise Immediate chest compressions (no pulse check) 2 hands, centre of chest, nipple line, 100/min AED when arrives

15. CPR For HCP “Phone First” for all sudden collapse and if lone rescuer “CPR First” for unresponsive infants and children, all victims of likely hypoxic arrest and if lone rescuer Check for adequate breathing 2 rescue breaths of 1s each Visible chest rise Check response Pulse check Rescue breathing without compressions 10-12/min Technique of compressions same as lay rescuers

16. The Ratios Universal 30:2 -All Lone Rescuers of Infants (not newborns), Children & Adults -All Lay Rescuer situations -2 Rescuer Adult CPR without advanced airway 15:2 -2 Rescuer CPR for Infants and Children

17. Put Simply 30:2 - All Lone Rescuers (Lay & HCP) for All victims - 2 Rescuers Adults (no advanced airway) 15:2 - 2 Rescuers for Infants and Children

18. And if there’s an ETT or LMA? Breathing rate: 8-10/min Compression rate: 100/min Swap roles regularly -objectively <1-2 minutes -subjectively >5 minutes

19. HIGH QUALITY CPR RATE - push hard, push fast 100/min DEPTH - 1.5 TO 2 inches COMPLETE CHEST RECOIL MINIMISE INTERRUPTIONS CHANGE REGULARLY Restore Coronary & Cerebral Blood Flow

20. Technique of CPR Push Hard and Push Fast Complete Chest Recoil Minimal Interruptions <10s Change Regularly

21. The Shocking Facts

22. Changes Challenged Defib first to all VF victims, especially > 4 to 5 min Improved survival for CPR first? Insufficient data for CPR first to all VF SCA

23. Consensus Lay Rescuers AED as soon as available EMS Witnessed SCA VF: Defib Not witnessed or > 4 to 5 min: CPR first

24. Non Consensus In hospital cardiac arrest Ideal duration of CPR before defib Ideal duration of VF to switch to CPR first

25. Only One Shocker No specific studies 1 st shock efficacy - termination of VF at least 5s after the shock Monophasic defib - low 1 st shock efficacy Biphasic defib - average 90% 1 st shock efficacy If 1 st shock fails - low amplitude VF, CPR greater value

26. So the VF is terminated… Most have a nonperfusing rhythm PEA/Asystole = CPR AED rhythm analysis 29-37 seconds Therefore 1 shock immediately followed by CPR for 5 cycles or 2 minutes (+ physicians discretion)

27. How much? Adults Biphasic Truncated Exponential Waveform use 150J to 200J Biphasic Rectilinear Waveform use 120J Monophasic Waveform use 360J Children Initial 2J/kg biphasic or monophasic Subsequent 2-4J/kg AEDS okay for > 1 year old

28. Drugs - To Use or not use? “No Placebo-controlled study has shown that any medication or vasopressor given routinely at any stage during human cardiac arrest increases rate of survival to hospital discharge” Vasopressin vs Epinephrine No evidence for routine use of any antiarrythmic during cardiac arrest

29. Drug administration “LEAN” Lignocaine, epinephrine, atropine, naloxone, and vasopressin IV or IO preferable to ET If no IV or IO: 2.5XIV dose in 5-10ml H2O

30. IV/IO vs ET Predictable drug delivery Predictable drug effect low dose of adrenaline systemically leads to a B -adrenergic effect Vasodilatation Lower coronary artery perfusion pressure & flow Reduced potential of ROSC Pulmonary vasoconstriction

31. Other drugs in short NaBic: No evidence for routine use Adverse effects of vasodilatation, alkalosis, CO2 production, catecholamine Specific instances, eg TCA, hyperkalaemia Calcium: No benefit from routine use Indicated for hypocalcaemia, hyperkalaemia, CCB toxicity Fluids: Indicated with hypovolaemic arrest Class indeterminate as routine Avoid glucose unless hypoglycaemic

32. Implications Deemphasizes drug administration Reemphasizes BLS Drug administration during CPR Co-ordinate - reduced interval increases shock success AEDS - quicker, during CPR, re-program

33. Post Resus Little evidence to support specific Rx No standardized Rx Supportive - myocardial, organ function - glucose - avoid hyperventilation - temperature Therapeutic hypothermia - improved outcome of out-of-hospital adult VF arrest

34. FBAO Simplified - mild or severe Mild - victim coughing: do not interfere Severe - silent cough - respiratory distress - stridor - unresponsive

35. Severe FBAO Activate EMS Anecdotal evidence Adults & >1yo : abdominal thrusts first : chest thrusts Combinations of above most effective Chest thrusts: obese, pregnant CPR for unresponsive patients Look into mouth, but no blind finger sweeps

36. 18 March 2006 www.resuscitationcouncil.co.za

37. ?

38. References Circulation, 2005; 112 Currents, winter2005-2006 JAMA, Feb 9, 2000-Vol 283, No6 p783- 790