1. High Performance CPR San Luis Obispo County EMS Agency

2. Thank you to our sponsors !!! Emergency Medical Services Fund

3. WHY? 400,000 cardiac arrests /year 88 % occur out of the hospital > 911 National survival rate <8% Survival of out-of hospital cardiac arrest has remained stagnant HPCRP programs – shockable rhythm survival rate – 30-50%

4. What is Happening in SLO? (24 month review) 540 cardiac arrest responses 424 received EMS treatment 230 transported to a hospital 71 had “shockable rhythm” on ALS arrival (16%) 22 patients survived to discharge SLO overall survival rate 5% SLO survival rate of patients transported 10%

5. High Performance CPR (“Pit Crew CPR”) HPCPR Programs o Increase in out-of-hospital survival by 30-50% o Programs in Seattle and Arizona demonstrate out-of hospital survival for witnessed “shockable rhythm” of 40-50% Goals for SLO o Increase overall survival rate through – public education, early 911, use of AED, and HPCPR o Increase the number of patients with shockable rhythm with bystander CPR and HPCPR o Increase out of hospital survival for shockable rhythms that meet the standards being seen in other HPCPR programs

6. Objectives for today History Science Elements of HPCPR CPR Rate/Depth/Recoil Minimal Interruptions Airway management Translating knowledge into practice Hands-on practice Simulation Review

7. HISTORY

8. 1961 A. Peter Safar, 1950s B. Early symposium on CPR A B CPR is over 50 years old, but recent changes have shown increases in survival

9. Figure 2: Temporal Trends in OHCA Survival Over Time (Sasson et. al. Circuation: Cardiovascular Quality and Outcomes Nov. 2009.)

10. 1960 >2010 What have we learned about CPR? History has provide a better understanding of CPR CPR makes a difference! CPR must be started as soon as a victim collapses We must rely on a trained/willing public to initiate CPR CPR performed, even by pros, it is often not done well Compressions are interrupted too frequently Excessive ventilation is provided too frequently Chest compressions are often too slow and too shallow CPR is a DYNAMIC process CPR quality has a major impact on outcome

11. The Result > HPCR or PIT Crew Model Same name…many versions CPR Minimized interruptions ( < 5-10 sec.) Effective compression (rate/depth) Maximize compression fraction Frequent rotation reducing provider fatigue Controlled ventilations Defibrillation Charge @ 200 compression

12. GOAL: MINIMIZE INTERRUPTIONS

13. Common “Tasks” > Interruptions Airway interventions and IVs Ventilations Pulse checks Rhythm analysis Defibrillation Changing compressors Patient movement

14. Interruptions - Old vs New Historical 30:2 100 compressions/min =18 sec. for compressions 5 sec. break for ventilations every 30 compressions Results in active compression 78% of the time NOT counting other breaks in CPR HPCPR/Pit Crew Continuous compressions w/asynchronous ventilation 10 sec break every 2 min = 92% compressions 5 sec. break every 2 min = 96% compression

15. 5 sec 80 160 mmHg Time (sec) 40 120 0 Coronary Perfusion Pressures Cerebral Perfusion Pressures No Cerebral Perfusion Single rescuer performing 30:2 with realistic 16 sec. interruption of chest compressions for MTM ventilations Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525

16. 0 5 sec 80 160 mmHg Time (sec) 40 120 Coronary Perfusion Pressures Continuous Cerebral Perfusion Pressures Single rescuer performing continuous chest compressions Ewy GA, Zuercher, M. Hilwig, R.W. et al Circulation 2007;116:2525 Perfusion with continuous compressions

17. 0 20 40 60 80 100 ≤10.3 (n=10) 10.5-13.9 (n=11) 14.4-30.4 (n=11) ≥33.2 (n=10) Pre-shock pause, seconds Shock success, percent 90% 10% 55% 64% p=0.003 Defibrillation success and pre-shock pauses Edelson et al, 2006

18. HPCPR Goal: Less than 5-10 second break in every 2 minute cycle of CPR

19. GOAL: QUALITY CPR RATE/DEPTH/RECOIL

20. Rate Matters

21. 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100 100-110 110-120 R>120 Chest compression rate (min-1) Number of 30 sec segments 300 250 200 150 100 50 0 n=1626 segments Chest compression rates of auto pulse devices Abella et al, 2005

22. DEPTH

23. 40 32 24 16 8 0 1 2 3 CPR duration, min CPP, mm Hg ICCM, 2005 2 inches vs 1.5 inches Survival: 100% 15% Survival better with compressions >2 inches deep

24. Shock success, percent Compression depth, inches n=10 n=5n=14n=13 p=0.02 Shock success by compression depth Edelson et al, 2006

25. RECOIL OR COMPRESSION FRACTION

26. How Does CPR Cause Blood Flow? Thoracic Pump +

27. Ensure Total Chest Recoil with: 1) Lifting palm during compressions or 2) Using feedback device +

28. VENTILATIONS: SMALL AMOUNT ON UP STROKE

29. Breathing / Ventilation Passive oxygen insufflation (POI) Ventilations may not be necessary during initial 4 cycles of CPR - consider utilization of nonrebreather at 15 L BVM - Small volume on upstroke of compression (200-400cc every 10 compressions = 10-12/min) Remember: Ventilations still have important role in: Pediatric arrests <15 y/o (15:2) Secondary Cardiac Arrest (30:2) Trauma Drowning Hypoxic Cardiac Arrest Suspected Respiratory Cause Overdose, etc.

30. Aufderheide et al. Circulation 2004; 109:1960-5 Hyperventilation during CPR = Decrease in Survival

31. Hyperventilation > Excessive ventilation increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output and survival. Breaths that are too large or too forceful may cause gastric inflation and its resultant complications.

32. ETCO2 - capnography Assess chest compression performance if ETCO2 is <10 mmHg during CPR. An abrupt sustained increase to a normal value (35 to 40 mmHg) is an indicator of ROSC. Sustained ETCO2 <10mmHG is useful in determining termination.

33. Bringing Science to Practice High-Functioning EMS CPR Teams

34. Starts with the Bystanders

35. 35% 30% 25% 20% 15% 10% 5% 0% 17.7% 33.7% Survival to Hospital Discharge Std-CPRCOCPR Survival after Bystander CPR for OHCA in Arizona (2005 to 2010) Compression Only CPR (COCPR) Advocated and Taught Bobrow, et al. JAMA 2010:304:1447-1454 P < 0.001 Witnessed/Shockable 7.8% Std-CPR 13.3% COCPR A.B. All OHCA AOR 1.6 (95% CI, 1.08-2.35)

36. Bystander contacted 9-1-1 standard CPR (n=960) chest compression alone (n=981) Dispatcher-assisted hands-only CPR 2010 Survival to DC 11.5% 14.4%

37. HP CPR (Pit) Crew  Each rescuer is assigned a specific location, role and list of tasks to perform.  Focus on high quality CPR  Defibrillator is readied while manual compressions are being performed.  Team Leader ensures overall scene management. EMS Can Further Improving Cardiac Arrest Outcomes?

38. Key Elements to HPCPR BLS – the first 10 min are critical to successful patient outcomes Each agency develops roles according to manpower Continuous chest compressions with minimal interruption Use available feedback devices/metronome Alternate compression person every 2 min (200 compressions) Continue chest compressions when charging an AED or manual defibrillator Resume chest compressions immediately after any shock

39. CPR Dashboard Display Rate indicator Perfusion performance indicator Depth indicator Release ETCO2 CPR Quality

40. HPCPR Integrating ALS IO vs IV Epinephrine 1:10,000 1 mg IV / IO After first full round of 200 compressions/defibrillation Repeat with every other cycle of compressions unless in ROSC Lidocaine 1.5 mg/kg IV/IO not to exceed 3mg/kg Refractory VF/VT Advanced Airway – wait until ROSC unless airway compromised, BVM inadequate, or available manpower prevents two hand mask seal Other medications Other potential causes- tricyclic OD, renal failure, narcotic OD Dopamine with ROSC with low BP-STEMI Center Physician Order

41. Key to success: Adapt the concepts to your program

42. POI P1 P2 Position 1 (P1) -Initial Team Leader Initiate compressions 110/min Alternates compressions with P2 at 200 compression When not doing compressions and keeps count of compressions Provides for Passive Oxygenation Insufflation (POI) with OPA Suction airway as necessary Position 2 (P2) Activates Metronome Applies and operates AED if applicable with minimal interruption of compressions Analyze and shock if indicated after each round of 200 compression Provide for Passive Oxygenation Insufflation (POI) with OPA Alternates with P1 at 200 compression ) When not doing compressions, keeps count of compressions AED 2 Person BLS

43. P3 P1 P2 AED/ Monitor Position 3 (P3) BLS/ALS – At patient’s head becomes Team Leader Assembles and manages airway BVM, ETCO2, Suctioning Analyze and shock if indicated after each round of 200 compression Position 1 (P1) – Initiate compressions 110/min Alternates compressions with P2 at 200 compression When not doing compressions and keeps count of compressions Provides respirations on upstroke of 10 th compression and keeps count of compressions Position 2 (P2) Activates Metronome Assists with application AED/ALS Monitor with minimal interruption of compressions Provides respirations on upstroke of 10 th compression and keeps count of compressions Alternates with P1 at 200 compression When not doing compressions and keeps count of compressions 3 Person

44. P3 P1 P2 AED/ Monitor Position 1 (P1) Initiate compressions 110/min Alternates compressions with P2 at 200 compression When not doing compressions and keeps count of compressions Position 2 (P2) Activates Metronome Applies and operates AED /Monitor Ventilates 200-400cc every 10 compression Alternates with P1 at 200 compression /keeping count 4 Person BLS/ALS Position 3 (P3 ALS)– At patient’s head – Team Leader Manages airway BVM two hand mask seal Suctioning - PRN Apply capnography Consider oral intubation if airway not compliant, w/ ROSC or after a minimum of 4 -5 rounds of compressions (10-15 min) – do not interrupt compressions P4 Position 4 (P4 ALS) –outside of the CPR Triangle -May become Team Leader and oversees medication administration Initiate IV or IO access Administer medications Applies monitor- if not done Analyze for shockable rhythm after 200 compression - continue with compression while charging Interacts with Family

45. How long … Stay on scene and work the code until: ROSC for 5 min – transport to nearest STEMI Center (regardless of 12 lead) Refractory V-fib/V-tach – contact STEMI Base Physician for transport to nearest hospital If patient arrest during transport – consider STEMI Base Physician for destination to closest hospital After 20 min of recitation and no response – call the STEMI Base Physician to terminate Consider the auto pulse during transport for the unstable patient Recognize some circumstances will dictate transporting the non- viable patient Exceptions: children and other causes of cardiac arrest i.e. trauma, drowning, OD, etc.

46. HPCPR and Mechanical CPR Devices Mechanical CPR devices have not demonstrated an increase in survivors over manual CPR Goal to minimize interruption in chest compressions during first 10-20 minutes of cardiac arrest is critical, so mechanical CPR device should be delayed Mechanical devices should be considered if transporting unstable or refractory V-fib/V-tach patients

47. How do 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)

48. Cardiac arrest performance data Performance Review: each team member will receive a summary of each code highlighting successes and potential areas for improvement

49. Successful Programs: Measure Outcomes Provide Feedback Continuous Improvement Program Practice regularly

50. Take Home Points Cardiac Arrests Outcomes Can Improve! BLS CPR quality makes the biggest impact Compression rate (110) Maximize compression depth (>2”) Allow for full recoil Minimize pauses (Ideally < 5 sec) Minimize ventilations (1:10) (200cc) Use CPR feedback tools – metronome, capnography Debrief and review performance Practice, practice, practice

51. DEATH TELLING

52. Death telling Assign someone to be the primary communicator with the family Be honest and direct Ask about support/resources

53. Time to practice….