1. What is the ideal chest compression:ventilation ratio?
Ventilation : Perfusion Match
Good CPR ~1/4 - 1/3 of normal cardiac output
alveolar ventilation ~1/4 - 1/3 of normal
Additional breaths
“dead space” ventilation
Increase IT pressure

2. CPR ratios Mathematical model Lay rescuers - adult victims 50:2 “best”
This mathematic model demonstrates the competing priorities of blood flow and alveolar oxygen. Since the ultimate goal is oxygen delivery to the tissues, the optimal point appears to be at a compression:ventilation ratio of 50:2.
Why not use 50:2? The primary concern is rescuer fatigue, with resultant ineffective chest compressions.
Babbs, Resuscitation 2004;61

3. Guidelines 2005- Ventilation
Compression/Ventilation Ration 30:2
Deliver each rescue breath over 1 second
Give enough volume to produce visible chest rise
Avoid rapid and forceful breaths
Advanced Airway give 1 breath every 6-8 seconds 1

4. Chest Compressions Only Continuous chest compression (CCPR) G U I D E L N S 2 5
Emphasis 
effective chest compression defibrillation
Chest Compressions Only Continuous chest compression (CCPR)
Shock First or CPR First

5. Survival From Simulated CPR80
73%
70%
24 hr CNS NORM 40
Ewy- Survival from simulated out-of-hospital cardiac arrest due to single lay rescuer CPR. 7%
CC Only IDEAL CPR NO CPR
Ewy et al: Circulation 2005;111:

6. Probability of Survival to Hospital Discharge
Wik, L. et al. JAMA 2003;289:

7. Defibrillation or CPR First
% survival
Wik, JAMA 2004

8. Phases of VF Cardiac Arrest
Metabolic Phase
GLOBAL ISCHEMIA-INJURY
Electrical Phase
MINIMAL ISCHEMIA
Hemodynamic Phase
LOCAL ISCHEMIA
RIGHT HEART V-P
Weisfelt and Becker. JAMA 2002:228;
The three phases cardiac arrest: electrical 5 minutes, hemodynamic 15 minutes; metabolic phase.
During the hemodynamic phase, most important determinant of cerebral perfusion pressure is the arterial pressure generated during CPR. If early defibrillation is not present, major determinant of survival is production of an adequate CPP.
JAMA 2002;288:3035

9. Phases of VF Cardiac Arrest
Metabolic Phase
NOVEL THERAPIES NEEDED
Electrical Phase
EARLY DEFIBRILLATION CRITICAL
Hemodynamic Phase
CORONARY-CEREBRAL PERFUSION PRESSURE
CRITICAL
DEFIBRILLATION
4MINS
CHEST COMPRESSION
HDE
4-10MINS
HYPOTHEMRIA
CONTROLLED REPERFUSION
Weisfelt and Becker. JAMA 2002:228;
The three phases cardiac arrest: electrical 5 minutes, hemodynamic 15 minutes; metabolic phase.
During the hemodynamic phase, most important determinant of cerebral perfusion pressure is the arterial pressure generated during CPR. If early defibrillation is not present, major determinant of survival is production of an adequate CPP.
JAMA 2002;288:3035

10. CPR before Defibrillation
Guidelines 2005-
CPR before Defibrillation
Immediate defibrillation is the treatment of choice for VF of short duration
OOH unwitnessed (EMS) VF, may give period CPR before rhythm check 1

11. Single or Stacked Shocks Pulse Check Rhythm Check2 5
Emphasis 
effective chest compression defibrillation
Single or Stacked Shocks
Pulse Check
Rhythm Check

12. Major RecommendationsG U I D E L N S 2 5
Major Recommendations
Single shock
Followed by immediate CPR

14. 22 seconds after pads placed
1st Shock delivered
22 seconds after pads placed

16. RE-VF 25 seconds after the 1st shock (No Chest Compressions yet)

18. 2nd Shock delivered 34 sec after re-VF
(Still No Chest Compressions)
CPR finally begun after
1 min 17 sec from 1st shock

19. Monophasic vs Biphasic Waveform Shock Efficacy VF
Waveform Energy
1st
2nd
3rd 54
BTE
150, 150,150
96%
98% 48
MTE
200, 200, 360
54%
60%
67% 13
MDS
77%
No waveform consistently related to  ROSC or Hospital Discharge

20. Defibrillation Success Out-of-Hospital Cardiac Arrest
First Shock Results (N=21/61)
Remained in VF- 19%
Shocked into Non-VF 81%
Perfusing rhythm  0%
21/61 (34%) received Defib shock(s)
@TIME RESUME CPR – 45 SECONDS
Kern Circulation 2002

21. Prompt CPR after AED ‘p’ <0.05 Percent 10/18 9/18 9/18 Kern 3/18

22. Will CPR Do Harm Post-Shock
Most ‘post-shock” PEA is “pseudo-PEA” -some pressure generated (~10/5 or 20/10 mmHg) -undetectable as a palpable pulse (Aufderheide/Monday)
Chest Compressions during post-shock organized rhythms does not precipitate re-VF (Hess & White)

23. CPR after Defibrillation
Guidelines 2005-
CPR after Defibrillation
Resume CPR immediately following shock (and while charging)
No pulse or rhythm check for 5 cycles CPR 2 minutes) 1

24. ACLS Major RecommendationsG U I D E L N S 2 5
ACLS Major Recommendations
 Emphasis advanced airway
Recommendation Intraosseous access
 Emphasis ET drug administration

25. ACLS PRIORITIES 2 MINUTE CYCLES- TEAM DYNAMICS

26. ECC – New Course Emphasis
Team Dynamics and Leadership
Outcome is determined by success of team and not the individual

27. ACLS Major RecommendationsG U I D E L N S 2 5
ACLS Major Recommendations
Amiodarone – Lidocaine either
Epinephrine- Vasopressin
ET discouraged
Atropine 0.5 mg - ACS

28. Summary ACLS Emphasis on High-Quality CPR Simplified Algorithms2 5
Summary ACLS
Emphasis on High-Quality CPR
Simplified Algorithms
Recommend expert consultation
Use IV / IO Access
limit ET administration
Limit, defer Advanced Airway Use
Especially endotracheal tube
Primary confirmation of ET- dual method

29. Key studies- Amiodarone
ARREST TRIAL Kudenchuck 1999
Patient group n
Survival to admission
Odds ratio for admission
Survival to discharge
Amiodarone
246
44 %
1.6
13.4 %
Placebo
258
34 %
(p = 0.03)
(p = 0.02)
13.2 %
(p = ns.)
ALIVE TRIAL Dorian 2002
amiodarone 5 mg/kg vs. lidocaine 1.5 mg/kg)
Patient group n
Survival to admission
Survival to discharge
Amiodarone
180
22.8 %
5 %
Lidocaine
167
12.0 %
(p = 0.009)
3 %
(p = 0.34)

30. Vasopressin-Epinephrine
Group n
ROSC
Survival
admission
≥ 24 h
discharge
Vasopressin 20
80 %
70 %
60 %
40 %
Epinephrine
55 %
(p = 0.18)
35 %
(p = 0.06)
20 %
(p = 0.02)
15 %
(p = 0.16)
Lindner 1997

31. Vasopressin-Epinephrine
Patient group
(all rhythms) n
Survival to 1 hour
Survival to discharge
Vasopressin
104
39 %
12 %
Epinephrine 96
35 %
(p = 0.66)
14 %
(p = 0.67)
PEA
n = 95
Survival
to 1 hour
discharge
Vasopressin
33 %
9 %
Epinephrine
29 %
10 %
Stiell 2001

32. Vasopressin-Epinephrine
VF/VT
(n = 42)
Survival
1 hour
discharge
Vasopressin
54 %
25 %
Epinephrine
61 %
33 %
Stiell 2001
VF/VT
(n = 188)
ROSC
Survival admission
Survival discharge
Vasopressin
36.8 %
46.2 %
17.8 %
Epinephrine
42.6 %
(p = 0.20)
43.0 %
(p = 0.48)
19.2 %
(p = 0.70)
Wenzel 2004

33. Patient group (all rhythms)
Vasopressin-Epinephrine
Patient group (all rhythms) n
ROSC
Survival admission
Survival discharge
Vasopressin
589
24.6 %
36.3 %
9.9 %
Epinephrine
597
28.0 %
(p = 0.19)
31.2 %
(p = 0.06)
(p = 0.99)
Subgroup
with PEA
n = 186
N=186
ROSC
Survival admission
Survival discharge
Vasopressin
104
20.2 %
33.7 %
5.9 %
Epinephrine 82
20.7 %
(p = 0.93)
30.5 %
(p = 0.65)
8.6 %
(p = 0.47)
Wenzel 2004

34. Summary BLS HCP Lone HCP- Tailor Sequence ActionsG U I D E L N S 2 5
Summary BLS HCP
Lone HCP- Tailor Sequence Actions
Check for Adequate Breathing
Open airway in trauma patients
Avoid Excessive Ventilation (too fast, too much)
1 breath Q 8-10secs
30:2 compression ventilation ratio
Continuous CPR with advanced airway
Rescuers rotate every two seconds
Push hard, push fast, allow full chest recoil
Pulse check >5  10 seconds